25341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'PINO '-
APPLICATION/PERMIT PING R OJEC7 IDENTICAL
FICATION
BUILDING DIVISION BUILDING PRIIJF.(T IDENTIFICATION
BUILDING ADDRESS. r(( {{ � 1/r SANITARY NO. APPLICAnOON SU�BMfITAL DAT
10916 • FR /--..J b&vF_ UNIT# LOT# /� n—g 5
OW -ROS NAME S / PHONE: RA NAU6 LIC NO: N� CONTROL#
ARCIIITECT/ENGI F.R: /rV/ LIC NO: ADDRESS: f(VV^.•• ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
@LIR'i ELECT PLUMB MECII
PERMIT ISSUANCE �I�Ir
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nyZ I hereby affirm that teem licensed underprovisions of Chapter9(commencingwith � TOB DE$CRIPf10F1
=x100 Section a and e f Division J of the Business and RoPossionx Code,and my littnu is in PANELS � , l
CVF fall fso Cladeffect. L,
1¢<a_ Licenx Class Liv.kaCmar UP T0200 MPS
m?y Una Commcmr 301-1000 AMPS
zOyZ ARCHITECTS DECLARATION OVER IT3oo AMPS I 97n
g/SQ.IT.
I understand my plans shall be used as public records 1
OZ_M
PF_�� MCNs ELECTRICAL e nn r_
Y21=e4j Licetscd Prnfusinnel
d'�KQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. u v a v
KO W U I hereby affirm that l am exempt from the Containment's License Law for the
W 3 a y following reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
Fi0 G which requires a permit to concoct,alter,improve,demolish,or repair any structure D E
K.}M prior to its issuance,also requires the aWlicent far such patent to file a signed statement POWER DEVICES
WW<0 That he is licensed pmsunnl to the provisions of the Contmcmrs License Law(Chapter
a c.o� 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VAL^ /��/
ATION
W_w or that h7031.5 by therefrom and the basPermit sbeascgedexlicantn.Any violation of OUTLETS-SWITCHES- )�Uw``�
HZQ Section,than byanydreddrintfor apcmmitsubjeathe applicemmacivil perWryof FDCTIJRES L V -�
not more than five hundred dollars($500). NEW RESIDENTIALELECIR S .FT.
Co ❑ hasownerofthepropmy,ormycmployeeswithwagcsastheirsolecompensation, Q STORIES 'TYPECONS'TRUCTIOI
y3_o wil l do the work,and lheswcmre is not intended or offered for mile(sce.1044,Business
and Pmfes nom Code:The Cmurama 's License law does not apply to an owner of
prnpeny who builds m improves thereoa,and who does such work himsalfmidroughhis
own employes,provided that such improveranor sum not intended or offered for sale.If, OCC.GROUP RES.UNI TS
however,the building or improvement is%old within one yemofcompletion,dmowner- TOTAL:
builder will have the burden of proving that he did not build or improve for propose of
sale.).
❑ I.mowneroftheproparty,amesclusivelycantrnctingwiNlicenxdwntrawmw QTY. PLUMBING PERMIT FEE F1 ODD APN
construct IM1e project(Sec.7044,Business and Professions Code:)The ConVacmr's
License law does not apply to an owner ofpropeny who builds or improves lLerson,and PERMIT ISSUANCE
whocamreas for such projects with aeon metaO licensed pursuant o the Coneramnrs
License Law. ALTER-DRAIN&VENT-WATER(EA,) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDIi FE6
SANITARY YN_
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECF.I T_#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ en'Cc)ma nsmth lmury a oracenifi co Wthmof(Se 3i fid acenifcate of %TURES-PER TRAP RF.CCIPTp
Workcrs'Campensation Insurance oracenifiW copy thereof(Sce.3g00,LabCJwhicIt PARK FEE Y_N
covers all employee's under this permit RECEIPT p
Policy# GAS-EA.SYSTEM-I INC.4 OUTLETS
BUILDING DIVISION FEES
Company
El Cenifed copy is M1<rcby famished. GAS-P.SYSTEM-OVER 4(EA) PLANCHIiCK FEE
❑ Cenifed copy is filed with the city inspection division. GREASFy1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
phis section need not becampleard ifthe pemtit is for one hundred dollars($100) SEWER-SANITARY-ST'ORM EA.200FT'. ENERGY FEEoflessJ
I cenify that in the performance ofthe work for which this permit is famed,I shall WATER IIMTFR W/VENT/ELECTR
not employ any person in tiny manner w as to become subject m the Workers' PAID
Cmapeasatiom Lowsof California Use WATER SYSH-M/TREATING
zz Applicant Date Romig,#
0 NOTICE TO APPUCANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F to-ow subject no the Worker's Compensation pmbo
visionsofthe lar CWe.you most
7 forthwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE _.saaa
1 CONSTRUCTION LENDING AGENCY SEISMIC IEE I1
= z 1 hereby nffinn That them is a construction lending agency for Ne perfarmvm a of C/
U O the work for which this permit is issued(Sce.3091,Civ.C.) T ELECTRIC FEE
Lenders Name
p U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
} L1-I I cenify that 1 have tend this application and state that the above information is
Q. coteot.I agree 10 comply with all city and county exuberances and state laws alining to PERMIT ISSUANCE MECIIANICALFEE
building construction.and hereby emanate rcprescntadvesof thiscity to enter upon the
U z above-mentioned property for inspection prpoxs. ALTER OR ADD TO MECII. GONSI'RUGTIDN TAX
(We)agree to save,Indemnify and keep hunt the City of Cupertino against
limulitien,judgmma,costs and expenses which may in any way accae against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I food CPM)
mgnamteof ApplicanUComeactur Date EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO I 00.000 BTU) Uaa Receipt#
Will the applicant or Iumm building u:cmpam more or handle hmardous manual
as defined by the Calton-Municipal Cale.Chepar 9.12.and the Health and Safemy I(EATING UNIT(OVER 100,000 BTU) TAL:
Calc,Seelion 25532(x)?
❑Yes El No VENTILATION FAN(SING LE RTSID)
Will the applicant or future building wcupant useequipmcm ordevices which emir
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
harommal all ammeminents as defined by the Bay Area Air Quality Mnuagemem BOILER 100.000 BTU)
District? P A Y
❑Yea ❑No NEW RESIDENTIAL MECH. S
1 have read the hazardous o ncfinls requirements under Chapter 6.95 of the AUG ._3199
California HcaRh&Safety Code.S 305,25333 and 23534.1 understand That
ifthehuiliiagdoe motcueremlyiux, anam,that it ismy responsibility m notify the
occupant of the iremcnts whit un be met prior m issuance of a Cenific re of
Oewpaney. �L CITY OF CUPtMI IIVU
Owner or
prized agent Date
TOTAL: ISSUED BY:
0 FI