25591 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - .L L^rRIC PERMITNo.
APPLICATION/PERMIT PLUMBING-MF:CI{pNICAI, n C C(�
13UILUING DIVISION ^ BUILDING PROJF,CT IDENTIFICATION L J J J
BUILDING AJyyRISS: _ ^, v-�sPa �/�ITk LOT# SANITARY NO. GPPWCATION SUBMITTAL,DA'll
OW RSNA ':/✓I�I/V_` �p/1 ru`(/CCONTRACTOR'B NAyygs LIC NO: •I��
'A" // •_\. 7r+ NIC CONTROL#
RCI BTEC ANEE LIC NO
. : ADDRESS:
ts+ ❑
o-.1#[ONTACT: PHONE: BUILDING PERMIT INFO
- .. + QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE fS/ E:] ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nwz I hereby affirm Nal l arthemsed underprovisiornof Chapmr9(commencing with JOB DESCRIPTIO
{400 Section 7")of Division 3 ofthe Business and Professions Code,and my li«nu is in PANELS
aUt full force and effect.
N?N Lt...oClass Lic.If Contmcmr - 201TOIW0AMPS
Z O,— ARCHITECTS DECLARATION OVER IOW AMPS �'D"LC�I�f�q E/SQ.FT.
C Z—C 1 understand my plans shall be used as public records. yYl'VJ,Ir ��\\YY,,
P!n F W SIGNS ELECTRICAL
Qy�J Licensed Professional 1pI.�[
5K=< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. y �
WHO, I hereby effort,,(Sethe 1 ant exempt from the Convanor's Licenu Lew for the • I
If 70< following reason,Permit to Co3L5.Bodo r.imp Professions h,Or re repair
city smacrum TEMP.METER OR POLE BJST, P71
F m J which requirtz a permit to cmnswcb alter,improve,demolish,nr repair any strucmrc
f u�ul+l}M prior to its issuance,also regairea Ne applicant for such permit to file a signed statement POWER DEVICES
eG p
that he is licensed pursuant to the Provisions of the Convacmr's License Law(Ompter
n-XOLL 9(cononencing with Section 700D)of Division 3 of the Business and Pmf,ssiom Cade) SWIMMING POOL ELECTRIC VALUATION
µ)_v, or thatSectio 7031. by therefromandthe basPermit s theallegedthedexemartto civiny l
of OUTLETS-SWITCHES- ��
F-.Z> Section 7031.5 by any droddantforapemtit subjects the applicwnoecivilpwalry of FIXTURES �J
X40 t thanftvehundrcd ny.ormyemp.
NEW RESIDENTIAL FlEt.TR SQ.PI'.
Kyo the wrk.andeestrucy.ormyempended manhood
became
comprnssimaron, STORIES TYPE GDN$TRHCTIOf
1'3= w doth,sions andthestructuremences not License
ofw does not apply to
owner of
d Professions Code:The Commences License Law such
not apply to rt owner of
property who builds or improves thereon,and whodocs such work himselfor through his
Own employees,p building
or improvement
is vldwitammt earofCmoffcred fonownr- ACC.GROUP RFS.UNITS
however,the buildinguimprovementissoldie did not yewofcompledon,theowner- TOTAL:
hue.). will have the burden mf proving that he did not hutted or improv<for puryou of
TOTAL-
safe.).
❑ Las the project
Sec.property,4,Business
and Professions
wird de:)Iedcommaorse QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
ovwct the project(Sec.omi Business and Professions Code#lite Conoacmrs
who contrace,
Law d«snot h pplymwoh actu scronsy whosedpamimpro the Commacand PERMIT ISSUANCE.
wicenseecm fonuch projectswiNacontractor(s)Iicensedpurswnno the Contrecbrs ALTER ( )
License law. WATER EA FEEISIDE Y
❑ 1 am exempt under Sec ,B&P C for this moon BACK FLOW PROTECT.DEVTC12 OVI'SIDE FF,T;S
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
. an WORKMAN COMPENSATIONDEC selfaw re SCHOOL.TAX Y N_
❑ Ihcrtbypem.fiaffam hatlhav,ecenifecam of conummml(Sec. ,o,Lab C.)w which
FIXTURES-PERTRAP RIiCtorn..
Worken'Cnmpensation hmurenee oracenifiedcopy thereof(S«.38W,Lab CJwhich PARK FEE Y_N
rsnll employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-LA.SYSTEM-OVER 4(EA)
❑ Certified copy is hereby famished. PLANCHItCK PEE
❑
Certified copy is filed with the city ins#«dondivision. GREASEnNDUSTRL WAS TE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
INSURANCE
(This action need not be completed ifthe permit is forms,hundred dollars 1$100) SEWER-SANITARY-STORM EA.201 ENERGY ME
or le".)
I candy Nat in Ne Informative of the weak for which Nis permit is issued.)shall WATER HEATER W/VENT/ELECIR
not employ any person in any manner so as to became subject to the WorkersPAID
z Compeneationlawsof California. Date WATER SYSTIIPREATING Date Receipt
zC) NOTICE TO APPLICANT.If.after making this Ceniftcate of E,empdon,you should NEW RESIDENTIAL PLMB. SQ.Fr TOTAL:
r (10 become smbjecnothe Workee,Compensation provisions oldie Labor Cal,you most
forthwith comply with such provisions or this permit shall be deemed evoked. +
fY, 7 BUILDING FIiE
yQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a«nsWction lending agency for the perfmmaame of
U O fle work for whichlhis permit is issued(See3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
0 U LendeA Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 cenify that I have read this application and stile Nat the above informa0on is
F.0. romct toga«to comply with all city and county ordinances and slate laws rclalingm PERM IT ISSUANCE MECHANICAL.FTiE
_ buildingconxtmcdmn,and hereby authoriu mprcscntativn ofthis city mercer upon the
U Z above-mentioned property,for inspection purpous. ALTER OR ADD TO MECH. CONSTRULTIONTAX
(We)agree a save.indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs anile itch may inanywayace ,against 'd City AIR HANDLING UNIT(TO 10,OIIp CFM)
conuquen« cV Vi permit /y
N{, AIR HANDLING UNIT(OVER 10.000 CPM)
Si nuwrc of licwt/ ntracmr a EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE M
UNIT(TO Bill"BTU) Date Receipt#
Will the applicant of future building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety UNIT(OVER 100,000 BTU) TO
Code.Section 2.5532(u)1
❑Yes ❑No N PAN(SINGLE RESID)MP(3HP OR 1 00,000 BTU ISSUANCE DATE
Will theacomarmtorfuembufnedby uhenBay Ar Amir Quality Management7Dionemua air«maminwts as defed by the Bay Arta Air Quality ManagementMP(OVER 100.000 BTUUisWn? )Lbildin,
Yes ❑No NTIAL MECH. SQ.ELmnJ the hazvdous mamdels rtuiret«nm under Chapter 6.95 of the ���
wllh&Safety Cale,Sections 25505,25533 and 25534.I understand that 8
g does not cimendy haveoncon .T hal it is my rtsomsibili,m notify thethe rcyuimments which must be met prior a rssaance of a Ccrtiecme of ClI rNosxcJ agent Dam TOTAL: ISSUED BY: e�T���<; J Moo!
OFFICE