25085 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPENO PLUMBINGMIMMU PFRMn NO.
BUILDING DIVISIONAPPLICATION/PERMIT 2 5
O H 5
BUILDING PROJECT IDEM'OFICATION
BUILDING ADDRESS: rg w�p.� 1 SANITARY NO. APPLICVHONSUBMITTALDATE
2'I891 Cd RZ'E r"t AV BIZ L UNIT LOT# — �� 3
(t RS NAML': PHONE CONTRACTOR'S NAME: LIC NO:
1/�C`' q I Lxxt i1� lfp ,F N/C CONTROL#
• A\\RCHIIF.CDFNGINEER: " LIC NO: T ADDRESS: ❑
CONTACT: PHONE: - _;E . ' BUILDING PERMIT INFO
QTY.':,'i I°X"'`vM',TzECTRIC PERMIT FEE
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBD CRIPI'ION
I herebyaffrmthat l sat m
licensed underprovisionsofatipter9(comemingwith
R 00CZ Smtim IoW)of Division 3 of the Business and Professions CWe,and my license is in PANELS
W tfF--. full force and effect,
FzyVj License Class Lic.# UPTO200AWS ` �J
m G y Date Cantmclor 201-1000 AMPS -]
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS SQ. RAREA $ISQ.FT.
O Z•' I understand my plans shall he used as Public reemob.
a�'Co� I SIGNS ELECTRICAL
Ci�ddLicensed Profession.y�W l
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/IMSC.
O a V I hereby affirm that 1 am exempt from the Contracmrs License Law for the
Saya following reusnn(Smtion]031.5,Business mW Profusions Code:Any rity ormunry TEMP.MEI5RORPOLEINST.
J which requires a permit to construct,alter,improve,demolish,or repair any structure 'V
WP•� prior to its issuance,also requires the applicant forsuch Permit to file a signed statement POWER DEVICES
g'D O that be is licensed pursuanuo the proviaione of the Contm<tors License Lew(CMpter 17 r II
�0.I�' 9(e mmencingwish Sation]WO)Of Divisim3ofthe Businessand PmfasimsCW.) SWIMMINGPOOLELECDtIC ,i u N
iWm or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
iE ,
� Section T031.5 by any applicant for.pemdt.objects the applicant..civil penalty of
Q t more than five hundred dollen($500).
zMzE. n❑ 1,aeawnerofthepropeny,ormyemployeeswiNwage utheirsolecompensation, NBW RESIDENTIALELECB _S PT. STORMS - CONSTRUCTION
y3:!2 will dothework,and the structutairsam Intended Or Offered for 6We(Sec.]044.Business
and Professions Cede:The Contractors License Law does not apply to un owner of
Property who buildxorimprover thermn,and whod...ch vomkirmse fmtluoughhis
own employes,providedthat such improvements.renotimmndedmoffp forsWe.If, OCC.GROUP RFS.UNITS
however,the buildingor improvement is sold withinoneyeerof completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I.mownerofshepropeny,amexclusivelymntnetingwnh Reerzsedcantractarsta QTY,- "'PLUMBING PERMIT PEE Fl.00D zorvE APN
construct the pmjmt(Sec.7044,Business and Professions Cede:)]lie Contractor's
License Lawdm...I apply toenownerofpropmywhabuildsorimprova Nermn,and PERMIT ISSUANCE -DU
whocantrects forsuch projecU with.consrectm(s)licensed pursuant tothe Camracrors ALTER-DRAIN@VENT-WATER(FA)
License Law. FEE SUMMARY
❑ 1 vat exempt under Sm. ,B&P C for this resort BACK FLOW PROTECT.DEVICE
SANITARY OUTSIDE YN
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RP.CEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ibemby.Rrmthatlhsveacenificmcofconxnttowlf-Imure,oramrtificateof RF.CEIPTN
FI%TURES-PLR TRAP
Workers'Compensatian lnsurmceorattnifiedmpY shereapSm.Jg00.Lab C.)which PARK FEE YN
covers vll employee's under his permit. GAS-LA.SYSTEM-1 INC.4 OUTLEfg
RF.CEIPTN
Palmy# BUILDING DIVISION FEES
Company GAS-IA.SYSTEM-OVER 4EA) PLANCHECK FEE
❑ Certified copy ishereby furnished.
❑ Certified ropy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE ,^
(This sectimmadl nmbe completed if Ne permit is(mone hundred dollars($IW) SEWER-SANITARY-STORM EA.2001T. ea�0 ENERGY FEE
or Icu.)
I cerdfy that in the frma sof she work for which Nis permit is issued,]shall WATER HEATER W/VENT/ELECTR
not employ any person N any momrer so as to becomes subject to the Worken' PAID
COmpensaou Lawsof Califomia Date WATER SYSTEM/IREATINO Date Receipt#
Q Z Applicant
Z 0 NOTICETO APPLICANT.If.after making this CeniOcam of Exemption,you Wmuld NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F" fA become subject to the Workers Compensation provisions oflhe Labor Cede,you must BUILDING FEF.
a ; forthwith comply wish such Provisions m this permit shall be deemed revoked.
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ Ihereby off that share is a construction lending agency for the performance of //��
O the work for which this Permit is issued(Sm.3097,Civ.C.) TOTAL: •ek ELECTRIC FEL
Leader Name
D" F I.endele Addreu QTY.`i^- MECHANICAL PERMIT .- FEE PLUMBING FEE O_Qa
LUI comfy drat i have read this apph<ebon end aura that the above infarmnoon is # a r"' ""' MECHANICAL FEG
D. correct.l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE
y building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTIONTAX
V Z above-mentioned property for inspection puryosu. ALTER OR ADD TO MECH.
(We)agree to save,inderardfy and kap hamdeas the City of Cupertino against
,jud ents,msts and pen.whichtna many way vccruevgsinst said City AIR HANDLING MIT(TO IO,BW CFM)
o cq.up c o",a groat ffjjyy..pq��RRtt�—
in co / �7 AIR HANDLING UNIT(OVER 10,000 CFM)
LA
Sitummre of APplicunt/Cmancetor LI Dat, EXHAUST I IOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as de0nm by the Cupertino Municipal Cede,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL: •[�
Cala Section 25532(.)7 VENTILATION FAN(SINGLE RESID)
❑Yes s)aoo
1 - BOILER-COMP(3HPOft 1011,000 BTU) ISSUANCE DATE
Willair choicentmfumre building by the
nBay Ana Air Q.olitcuwhicement PAID
hazardous air mntaminanU as dented by the Bey Aree Air Quairy Management BOILLR-COMP(OVER 100,IXI0 BTU)
District?
a
❑Yes NEW RESIDENTIAL MECH.—SQ.Ff.
1 have read the hazardous materials requirements under Chapter 6.95 of the JUN 07 1993
C.lifomi.lie.lsh&Safay Cede.Sections 25505,25533 and 25534. 1 u.dentsncithat
ifthebuilofdoc resnrentents whicve.tenant,thato is my issuance
eoilirymnficate of C VIIJIMM'I IDIW
cupant of the requircmeme which must h run prior to issuance of a Certificate
of Ci WF
Occupancy.
Ow.m.a duarized agent Date TOTAL: ISSUED BY: 1ALJZJL