25655 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
IIUILDING PROJECT]DEN'1'IF'ICA9'ION 25655
BUILDING ADDRESS: . SANITARY NO. APPLICATIOON/SUMIBMITTALDATE
V
LOT«
OWNS MF,: PHONE CONTRACTOR'S NAME: LIC NO:
N/C CONTROL«
R 1 LIC NO: ADDRESS: ❑
CONTACT PHONE��9 i
Q QTY. :.J ELECTRIC PERh11T. FEE BUILDING PERMIT INFO
'ly^ :.'..r. BLDG ELECT PLU B MECH
C:�l �`a' Gvl� /•x'G PERMIT ISSUANCE 1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION I hembyafrim that l am licensed under provisbasofChapteril mommcncing with
ts100 Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
<ZC[� License Class full fare aaffect
Uc. /'-7476- UP TO 200 AMPS
til T « A
rn 6 a pale Camsaztm 201-1000 AMPS
ZOt`r'ia� ARCHITECTSDECIARATION OVER I"AMPS SQ.IT.FLOOR AREA S/gQ.Pf.
O Z—C I understand my plans shall M used es public records.
F rn P-W SIGNS ELECTRICAL
Qg Licen dRafesxianol
YY'' OWNER-B exempt
from
the Con TION SPECIAL CIRNIT/MISC.
�B�dd'O y U 1 hereby affirm that I am exempt from the Connector's License 4w for the r ® I
Y13LLyQ following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR PoIJ3 MST. � � I Nil L- (-�
J which requires a Permit to construct,alter,improve,demolish,or rcpur any immune POWER DEVICES 1
tayM prion.it,issuance,alsorequireadus.,icant far such pemouo fil.tim,not statement
9CGO that he is licensed punuanuo the provisions of the Convector's License Law(Chapter SWIMMING POOL ELECTRIC VACUA ON
st I10�' 9(commcncing with Station 7000)of Division 3oFlhe Business and Profesaiom Code)
B'Kj❑y or not he is exempt therefrom andthe basis for da.11eged exemption.Any vlolwonof D
i Section 7031.56 applicant Permit then Meant to a civil d of OUTLETS-SWITCHPS-FIXTURES
�Z G y any app icon pemsi i applicant Penalty
S G nor more than five hundred dollars($50D). NEW RESIDENTIAL ELECfR _SQ.ET. STORIES TYPE.CONSTRUCTION
W m ❑ I.asownerofshepmperty,ormyemployces with wagnutheirsolecompensation,
d will dosbework,and theswaure is not imcndeduroffered formle(Sec.]044,Businwa
and Professions Cade:The Commctoes Licenu Law docs not apply in an owner of
Employ smbmldsorEl,oo,x thereon,and whodoe....hwod,himselforthmaghhia OCC.GROUP RES.UNITS
ownemployees.pruvidedthutsuehimpmvememsmenotintendMd offeredforaele.If,
however,the building orimprovcmem is sold within oneycar ofcompletion,theowner- TOTAL:
builder will have the burden of moving that he did not build or improve for purpose of
mine.
❑)I,mownerofthepmpeny,onsexclusmvelycomncungwitblicensedcanvaeswsm QTY YrYe{ PLUMBING PERMIT FEE FLOOD ZONE APN
conmona the project(Sca.7044,Business and Professions Cde:7 The Convector's pggMlT ISSUANCE
Li can se Into does not apply to an owner of propmy who bei Ida orunproves therenn,end
whimmuacss fmsuch projects with a contoctor(s)licensed pursuant o the Convectora ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
License Law.
❑. I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SI
SANITARY Y N
Owner Wu DI4AIN5-FLOOR,ROOF,AREA,GOND. RECEIPT«
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ 1herebyaffirm that l have a ccnificau ofconsent to self-iresum,or a cenificme ofRECEIPT«
FIXTURES-PER TRAP
Woken'CeeInsurance certified copy thereofatl00,
(S .3Inb C.)which PARK FEF: Y N
Polars ell employee's unJcr Nix permit GAS-EA.SYSTEM-1 INC,4 OUTLETS RECEIPT p
DIVISION
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 RA) PLANCHE.CK FEE
❑ Cmifid copy is hereby furnished.
❑ Cenifiedcapy is fill with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need our becamplad ifthepemdt iafa....hundreldollars(5100) SEWD AMTARY-STORM EA.2WFT. ENERGY FEE
or los.)
Iccrtifyliminthepe-fomunceofthework forwhich Chia permit is issud.INdl WATER MATER W/VrNT/ELECfR
not employ any person in any rammer so as to became subject to the Workers' PAID
Cion,mmionlnwsof Cdifomia. Data WATER SYSTEM/TREATING Data Receipt«
Q z Applicant
O NOTICE TO APPLICANT:If,after makiag in.Certificate of Exemption,ya.should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
FIn become subject to Ne Workefe Comparrandon provimanof the Labor Code,you must
> foMwlth comply with such provisions or this Permit shell be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that then is a construction lending agency for the performance of
the word,for which this parrot is issued(Six.3097,Cu.C.) T �/ ELECTRIC ME
Lender's Name
LL �' PLUMBING FEE
I C) F Lender'a Address QTY m MECHANICAL PERMIT FEE
W1 certify that l have read this application and state them the above information is " MECHANICAL FEE
correct.l agree to comply with all city and county ordirmces and sum laws miming to PERMIT ISSUANCE
-' � buildingconavuaion,and herby authorise representatives ofthisciry menterupon the CONSTRUCTION TAX
V Z shove-mernm ed property,for inspection purposes. ALTER OR ADD TO MECH.
(We)since to save,indemnify and keep hamdess the City of Cupertino against
ISI liabilitiesjudgmems,costa and expenseswhich may in any wayaccme against add City AIR HANDLING UNIT(TO 10,00)CFN)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signaure of Applicam/Contactor Data EXHAUST HOOD(WIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Das. Receipt«
Will she applicant offuturebuildingo.cupamatomorhandlehva usmaunel
ua defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TAI-:
Cade,Section 25532(x)] VENTILATION FAN(SINGLE RESID)
El Sea ❑No
ISSUANCE DATE
Will sheapplicunmrfurvrebuildingaccupam useequipmcnmrdevices which emit BOILER-COMP(3HPOR 100,000 BTU)
hazardous oil contaminants as defind by the Bay Ara Air Quality Managemem BOILER-COMP(OVER 100,000 BTU) � '
District?-
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 hnv the hezvJous mat requirements under Chapter 6.95 of the OCT 2 01993
ColiPomie iealth Safety Code,S�01�1,13mmll!5511. lundeotend that
if the hu, ibe nm cunendy haponsibility m nmify the 'j •CI T Y u UUI' I I /
cupent of menu whitnee of a Certifi'me of
Occupan
Owner. au Data TOTAL: ISSUED BY:
OFFICE