25172 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E1'RI,AL PERMI I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 25172 C'I ��]
BUILDING PROJECTIDENTTFICATIDN J1 G
BUILDING DDDRRRES�.S'N�,$) SANITARY NO. APPLICATION SUBMITTAL DATE
Iv ✓ UNIT# LOT#
*RCHIH7
ERS NAME,: PHONE: CONTRACTOR'S NAME: LICNO,
6 Z N/C CONTROL#
TIENGINEER: L.IC NO: C DRESS: ❑S/ /f -I r!iTACf: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
az Iherebyaffirm that l am licensedunderprovisionsofChapter9(commencing with JJOB DESCRIPTION
00 Section 700m of Division 3 m dod Bmiuna and Profession Code,end my license is in PANELS
M tWoC full force and effect V
FG Licdnseflt"Ic Lid.# �"/ b UP T02(O AMPS ^ m
y<N Data (CN/ Conuacmr 201-Uggil AMPS +ate
ZO z ARCHrMCCS DECLARATION OVER IW0AMP5 SQ.FT.FLOOR AREA S/SQ.FT.
oz—p
1 undersmnd my plans shall be used os public recmds. I
h SIGNS BLECTR'CA"
Licensed Professional
^d' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIS
XOy1. 1 hereby affirm that 1 am aedmpt from the Cnmrectora License law for the
W 3 a following reason.(Section 7031.5,Business and Professions Code:Any city memory TEMP.METER OR POL
which requires a pem,it to construct,alter,improve,demolish,or repair any structure
`�Y pnonniu ixxuance,also requires the applinmt forsuch pemtit to fileesigned xtutement POWER DEVICES
<0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
`X°� 9(rommenaingwithSection 7")ofDivision3,aftheBusiness and Professions Code) SWIMMING Poo
LEC RIC VALUATIONg%yn
W_y or that heisexempuberefrnm and Ne hula for the allege)aemption.Any v...saunof OUTL[r -SWITCHES-FIXTURES
Z G permit Section 9031.5 by my applicant for a subjects the applicant o a civil penalty of
A not more than five hundred dollars($50m. NEW NISIDENTIAI.ELEC'IR S .Pf:
m ❑ 1,usowneroftheprnperty,ormyentployecswithwagesasibeirsolecompensadon, Q STORIES TYPP.CONSTRUCTION
y will dmhewons and the structureisnot immense Law does not
1014.Business
and Professions build,
or i The improve,
donates nd who Law does oat apply if an owner of
property who builds vi improves thereon,and who does such..,it Lor offerer through his
n employees Provided that such improvements arc
vementsnntimendedoraffared far It.If. OCG GROUP RES.UNITS
however,the building or improvement is sold within one year .ofcnmpldtinn.the owero.
builder will have the burden of pmving that he did not build or improve for puryose of TOTAL:
S81l QTY. PLUMBING PERMIT FEE FTAODZONE APN
p ❑ uct'he project
(See eny,amesclucivdyconvactii...C li,1 Th Comodeme.
S construes the oared(Spa.oano Business and Professions Coded The Contractors PERM["f ISSUANCE
1 License Lnwdforsucapplytoanoh a corapmpery whobuil purmanpro theves Courrthereogand
whacs Lo w.tracts foreuch pmjdmswithecbnhumar(s)licenanl puuuantmrhe Commctors ALTER-DRAIN&VENT-WATER HA) FEE SUMMARY
License law.
❑ I am dsempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY TY N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMANCOMPIiNSATIONDECI,ARATION SCHOOLTAX YN
affirm
❑ Ihercby thmlhnvea cenificme ofconsenno self-insum,orncertificemofRIiC[IPI'#
orkers'Compenvsu
tion lnranceora unified copyflo,ouf(See.3800.lab C.)which FIX'I URRS-PER TRAP PARK FEE Y N
vers all empo ee':y����Jrty1 GAS-PA.gYSTEM-I INC.4 OUTLETS RECF.ln#
Policy N 1 t Y y BUILDING DIVISION FEES
Compmty Q CQI� GAS PA.SYSTEM-OVER 4ILA) PL.ANCHP.CK FEE
❑ Certified copy is hereby furnished,
CYCertilied copy is filed with the city im,ecton division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
/� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEB.
COMPENSATION INSURANCE
('Phis section need not be completed Hired permit is for one hundred dollars(Sim) SEWER-SANITARY-STORM EA.20017. ENERGY MH
Idea.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HFATP.R W/VPN'T/ELECfR
and employ any person in any manner so as to become subject to the Workcri PAID
z Compensutioniaesof Culifamia. Date WATF.RSYSTEM)TRIATING Dam Receipt#
Applicant
O NOTICE TG APPLICANT:H,aper making this Cenificou of Exemption,y..should NEW RESIDENTIAL PI.MB. SQ.PT. TOTAL:
become subject to tire Workers Compensation Provisions of the labor Code,you must
a 1 forthwith comply with such Provisions err this permit shall be deaned revoked. BUILDING IM!
aGQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z I hereby affirm that there is a construction lending agency for the performwce of
the work for which this t' issued 309'/,Civ,CJ 'TOTAL: ELECTRIC FEE
L) Or panni ue issue _
U Lenders Name
tenAI eAddress QTY. MECHANICAL PERMIT' FI?F. PLUMBING FEE
CJ 1,I gr that 1 have read this ityanmiou and sum that the above information is MECHANICAL WJE
corten.lagree to comply withall city,unJ county ordinances and state laws relating to PERMIT ISSUANCE.
Ln building consounion,and hereby maborir<representatives ofthis city to enter upon the - CONSTRUCTION TAX
U y above-mentioned property for inspection puryoses. AL'1'ER OR ADD TO M FCI I.
^�
We)agree to save,indemnify and keep hmmless the City of Cupertino against
IinM1ilitin,judgments.costs and expends which may in any way accrueagvnst said City AIR HANDLING UNIT(TO 10,000 CFM)
in concyue of the ranting of Chia permit.
l A R HANDLING UNIT(OVER IQDO CFM)
I,
/ / G,P-93
Si OwofApliant onhactor Dam. EXHAUST HOOD(WB)UC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW."B"DD Dam Recciptk
Will the applicant or future building occupant store or handle hazmdom materiel HEATING UNIT(OVER 100,(100 BTU) TOTAL:
as dc0ned by the Cupertino Municipal Code,Chapter 9.12,and the Ileaeh and Safety
Code,Section 15532(x)7y� VENTILATION FAN(SINGLE RESI D)
❑Yes Id No
/ BOILER-COME LIJLP OR 100."BTU) ISSUANCE DATE
Will tair cou tamair future building by themase equipment Quality Manageemit
)Ntrulun air comuminentx m define)by the day Arca Air Quality Management BOILER.COMP(OV RR 100.000 BTU)" p�
)Ixtrlcf! 6 P A
❑Ya 7' NEW RFSIDENTIAL MECH. SQ.FT. b
1 cave read the haromlelyC u.materials 5505,255 3 under Chapter 6.95 of the08 19i,the Hcuph&$atity Cale.Section 25505,33533 and 25534. 1 undersmnd that ;J 140819
iftheh If loo not currently have atcntnn,that it is my responsibility to notify the u
o ccu a n r e requi cents which be met prior to issamed ads Certificate of �
omhorizcJ Uma TOTAL: ISSUED B W