25091APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO U11111.oli KLHi,"IRTCA .
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- .ME'HA NICAI.
BUILDING PROJf:CT IDf1Y1'IFLCA'1'ION
PERM[] No. O I
1
BUILDING ADDRESS'.
SANITARYNO.
APPLIGTIONSUBMTT['AL DATE
r LLINITO LOT
OWNERSNAMh: PIIOWi: —
ems. \\ ¢ r ( - Z
NTRACTO "NAME, LIC NO:
lSo
N�
❑
CO R LI
ARCHIIiLT/ENGIN[ER: LIC NO:
DRESS:
A. AulzSAM
CONTACT: tPHONE:
\ -V
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
RLD ELECT PLUMB MIiCH
LLLLLLiii ❑ ❑ ❑
PERMIT ISSUANCE
LICENSED COM RACfOR'S DECIARATION
hereby affirm (hut 1 am licensed under pmvisionanf Chapter9 (commencing withSection
APPLIANCES -RESIDENTIAL
LOB DESCRIPTIONI
PANELS
UP TO 200AMPS
7(M) of Division 3 of the Business and Pasfeuions Cade. and my license is in
full forst, and cffcet.
License Clna-� o ., �GY ,.
Contract.,
onuacmr
- 1 AMPS
DEC tic Too ON
-' CHIbe used
1 undcrstmA my plain shell be axed o public records.
OVER I
OVER 1000 AMPS
SQ. FT. FLOOR ARG
fISQ. FT.
SIGNS ELECTRIChL
Licensed professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 an empt form she Conlrvnnr's License Law for she
TEMP. ME'PER OR POLE [NST.
following reason. (Section 703 LS. Business and Professions Cade: Any city or county
which requires a permit to construe,, alter, improve, demolish, or repair any structure
priarl. it, marince,.h negnim.Nealy,ficarof.. much pernit,, filea5iood statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Comractar s License Law (Chapter
9(commencing with Section 70(0)uf Division 3 afthe Business and Profusions Code)
SWIMMING POOL ELECTRIC
ON
or that he in exempttherefrom and the basis for the alleged exemption. Any violation of
Section?031.5 by any applicant fora permit subjects Neupplicant m aeivil penalry, of
�pVALUA
I �/ /(l _o�
OITII,ETS- SWITCHES - FIXTURES
n mammon five rofihe ro ny.os yemp.
n❑
soshei(Set.(AlBsiron,
wrk,
NEW RESIDFNTALELECIR SQ. FT.
S'1 ORIES
TYPE CONS I' RUCTION
andcpmpanymrmyemtendedwi.Priedth
will colic work. and,he is not is a
olio W 9044.13us'ineof
and Ilse w do . not a(ploy.
o Contractor Lie e not apply to an owner
License Lew
artyProwhi.ns lit..,Cado
such
property whobei door improvesthereon, andwho mo sac t work himse1fed f orughhis
ot,therems, is
lhm ouch in,provemema nrcnm intended ondkmd fnrsale.IL
OCC. GROUT'
RLS. UNITS
TOTAL:
hoempinywa,provided
wever, the building or improvement is sold within one yearofcompletion, the owner-
builder will have she burden of proving that he did not build or impasse for purpose of
QTY. PLUMBING PERMIT 'FEE
matey
I,nu,wnu of lbcpmpcny..mexdusivdy cmm�cting wiN rimmed c.ntrudora to
El'
construct the pmjmt (Sec. 70,14, Business and Professions Codenm
:) TIm Comor's
Licenselaw does not m m ownerofpeu
ropeny whobuildsorimproves Nern,and
FLO DZONE
N
APN
PERMIT ISSUANCE i
II V
who dmlrucla for such pmjcns with a camractug.) licensed pursuant athe C.nlroatora
License Law.
tl
ALTER VF-WATtlRitsss�(
�'
FEE SUMMARY
❑ 1 am exempt under Sec. , B A P C for Nis mason
BACK FLOW PROTF,CT. 13VICE
OUTSIDP FEES
SAN["LARY Y N
RECLIPI'N
Owner Dam
DRAINS"�T,�"� CC'�
WORKMANROOF,Ay/YT{¢U.
WORKMAN COMPENSATION DECLARATION
XJL Y N
❑ IM1crtby effitm Nall M1uveaccrtificare of conxmmself-insurt,oxacenifcae of
Work. Compcnwtlon lnmumnce to a ceniEulcnpy Ncrec((Sca 31 Lab C.) which
IIXTUR1iS-PER' A
RECEIPT
PARK FEE Y N
v rs all employee's under this permit
Policy N
GAS - G. SYSTEM -1 INC. Y OffILLTS
RECEIPT N
BUILDING DIVISION IBES
Company
MS - G. SYSTEM -OVER 4 QA)
PLANCHECK FEE
�Cenified copy is hereby famished.
GRESSEANDUSTRI. WASTE INTERCEPTOR
GRADING FEE:
❑ Cmified copy is filer wiN Ne city impecsion division.
CERTIFICATE OF EXEMM[ON FROM WORKERS'
COMPENSATION INSURANCE
ORGSE'IRAP
SOILS FEE
SEWER - SANITARY - STORM E.A. 200FT.
ENERGY FEL:
(ntis section needinal be completed ifthe permit is forone hundred dollara(5100)
r tins)
WATER HATER W/VE[dTryLECIR
I cenify that i nshe perfarra eeof the work for which shin perout is issued,I hal
not employ any person in any manner sou to become subject an the Workui
PAID
WATER SYSTENETRGTING
Dine Receipt
Compensation Lawsof Califnmia. Dae
Applicant
NOTICE TO APPLICANT: If, afsir making this Catifiam of Ememption, you should
become subject to the Worker's Compensation provisions of the labor Cade, you must
NEW RESIDENTIAL PLNIB. SQ. FT.
TOTAL:
fanhwisb comply with such provisions or this permit shat l he deemed revoked
BUI LDING FEE
�1
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 hereby affirm Net,hcm is a connrucsinn Icnding agency for she perfin.men of
the work for which this .it is issued (Set. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lenders Nm
lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that I have mud this eppliceion unit state that the above information is
correct. Iagree to comply with sell city and county ordinances and stale laws minting to
PERMIT ISSUANCE
MECHANICAL FEE
buildingmnstrvcsiun, and hereby station. mp excired,em ufthis city wester upon the
ubovo-mentional property far, ir,Fcmi.n purposes.
ALTER OR ADD T'O MECI I.
CONSTRUCTION TAX
(WO ugme m save, Inde ify an cp harmly�lhe City of Cupertino .gains,
liabilirit,s.judgmcnts,cwtsa pe w' ins /('any way acervugunv aid City
AIR HANDLING UNIT'010,(gp CFM)
fT
in con I m of 11.
s/
AIR HANDLING UNIT (OVER 10.1%10 CFM)
O
1
Sin umof Applic t� Trus r Dale
EXHAUST HOOD(W/DUCI)
PAID
HEATING UNIT(TO Hal BTU)
Doc Receipt 0
HAZARDOUS MAT12RIAM DISCLOSURE
Will the applicant or future building occupant store or handle huoardicus material
sea defined by the Cupertino Municipal Code, Chapter 9. 12. and the Ileallh and Safety
❑EATING UNIT (OVER 100,0(a], BTU(
'TOTAL,
�•. VV
VENTILATION FAN (SINGLE. RFSID)
Cs.le. Section 255J2(u)
0 't Yen 11 No
Will the applicant err future buildln which
gbythenlay
tir
BOILER - COMP (311P OR Me,1%10 BTU)
ISSUANCE DATE
PIA i D
k stNoua air contaminants as defined by ,he Bay Arta Air Quality Management
Arm& Quality
BOILER - COMP (OVER I W,pp BTU)
❑ Ycs ❑ No
I have tend the haivdous materia[. requirements under Chapter 6.95 of the
MAY 19 u��
NEW RESIDENTIAL-MECH. SQ. IT.
CaLfomia I lealth A, Solely Gale, Sections 25505, 25533 and 25534. 1 understand that
Rine building dace not currently have a mount, that it is my rcapomibility to nmify the
CI I Y LJr VVI" Cf) I IIS V
occupant of the requiremutts which must be met prior to issuance of a Certificate of
Occupancy.
ISSUED BY: V`
Owim,ro.alhoriaed a,., Date
TOTAL:
VrrIVC