25483 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINOBUIT.15TNO—TITC I RICAL PHRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 5 A OO
J 4 o J
BUILDING ADDRESS: rSANITARY NO. API'LICATIONSUBMITTALDATE
6�o D n �1 UNITE LO'fp 50
0RS A 1:: PHONE: C N QR'S NAM& LIC NO:
WZT0 h � Z/T-K.l /kakWI A qh A NIC CONTROL a
AR H TECT/EN EIB: LIC NO: DDR SS: y
k a 3-6 El
CONTACT: PHONE: QTY.' n.ELECTRIC PERMIT FEE BUfLDING PERMITINPO
BLDG ELECT PLUMB MECII
PERMITISSUANCEEl
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Qmz Iherebyaffnm that l vat licenxm
dmiler powisio .fChapur9(commeng
cinwith
{+100_ Seen=
rceandofectvisi.n3of the Business and Professions Code.and my license is an pANpUq
t-UF full fame and effect.
FZW Licenu Conor UP TO 200 AMPS �
mad Dme Contractor 1) 201.[BOB AMPS rT„'r
zco l ARCHITECTS DECfARATION OVER 10M AMPS
SQ.FT.FLOOR AREA
CZ—CI I understand my plans shall be used as puhhe am.. _
Py SIGNS ELECTRICAL r np`ppJ
Q Licensed Professional I u V ALE D,
NN OWNER-BUILDER DGCIARATION SPECIAL CIRCUIT/MISC. V
11
X001 V 1 hereby affirm that 1 em exempt from the Comencmrs Lic ms,Law for the (� n
W 3 R'N following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST, L�, �I IIy
�Om g which requires a permit to construct,alter,improve,demolish.or repair any structure
¢� prior to its'ramace,shoo requims theapplicam 0.".1,pematto Ne a signedmomoo POWER DEVICES
p' p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
9(commencing with Section 7000)ofDivision 3 oldie Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Moo or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURFS
C < Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
an,more than five hundred d.U.(SSW).
K � ❑ 1,mownnofihepropny,ormyemplomwithwagesmtheirsolecompensadom, NEW RPSIDPNTIAL P.LECIR _SQ.PT. STORIES TYPE CONSBUCI'ION
a 3.- wdldo the work,andthesmunumis not mtendialmofferad fersale(Sec.7044'Business
and Professions Code:The C.mrzcmrs License Law does not apply to an Owner of
property who builds or improves thereon,and whodoes such work himself.rohrough Ns
on employees,provided thatsuchimproveems menot imm�dedoroffeted formic.If, OCC.GROUP RES.UNITS
hom
wever,the building or improvement is sold within one yearefcompletion,the owner. TOTAL:
builder will have the burden.(proving that he did not build or improve for purpose of
vlcJ.
❑ I,uocorer.(thepropeny.amexetmivelyconbeningwithlicensedconwemrstu QTY. PLUMBING PERMIT FEE FLOODZONF. APN
construct the project(Sec.0044,Business and Profeasams Code:)The Contractors
Limnos Lawdnea rat mpplym anownerofpr.peny whobuildsorimproveatherton,and PERMITISSUANCE
whocommns fmauch projects wish a rontractor(s)licensed pummmuo tiro Contmctoes
License law. ALTER-GRAIN&VENT-WATER(EA,) .FEE SUMMARY
❑ 1 nm exempt under Scc. B k P C for thio reason PACK FLOW PROTECT.DEVICE ID• •EES
SANITARY YN_
Owner Dale RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.BOOP.AREA.COND. SCHOOLTAX Y N
❑ I hereby affirm that l have acenificncodranxm toself-insure,oraccrificateof RECEIPT
Workers'Campcnsation huumme ora cenified copy thcreof(Sec.380/,Let,C.)which FIXTURES-PER TRAP PARK FEE Y N
covers all employee's under this permit GAS-FA.SYSTEM.]INC.40IITLETS RF.CETPT#
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PIANCHGCK FEE
❑ Ceniped copy is hereby furnished.
❑ Certified copy is fletl with rhe city inspection Division GRPASFIINDUSTRI.WAS'I'F.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ORFASETRAP SOILS IMF.
COMPENSATION INSURANCE
(This section mmmm he completed ifthe permit is(oras hundmldolhn(SIM) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I certify that in the perfom .of the work forwhich this Pewit is issued,Ishall WATER HEATER WNFiNT/ELECfR
not employ any person in any manner so m to become subject to the Workers - PAID
z Compensation Luws.f Culifomiu. Darn WATER SYSTEM/TREATING De, Receipt#
Applicant _
O NOTICE TO APPLICANT:IL after making this Cerifictte of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) become subject in the Workers Compensation Provisions of the labor Cade,you must
> forthwith comply with such provisions or this Permit shall be deened,voked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC IEE
I hereby affirm that there I,.conswction lending agency for the performance a(
V O the work for which this pmmit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
LI. 6 Lender's Name 1
0 Lenders Address QTY. MECHANICAL PERMIT - FEE PLUMBING FEE
1 certify that 1 have mrd Nis application and ata a Nat the above infom inion is
correct.Iagree to comply with all city and county ordinances and Stam laws relating to PERMIT ISSUANCE MECHANICAL PER
F-' TA building construction,and hereby auodrt, reae
pntadvas ofthis city menter upon the
V 7 above-mentioned progeny for inspection purpose. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree to'ive,indemnity and keep ha leu the City of Cupertino again
liabilities,judgments,costa vn ep:nsu which yinanywey xcr eegninst said City AIR HANDLING UNIT(TO 10.0010 CFM)
in amxq np���pppf the grumr f this p:mi t.
�� � ��� ��� �� AIR HANDLING UNIT(OVER IO,fg10 CPM)
7
Si Imre.(Applicon/Contimen / Dme EXHAUST HOOD(WMUC) - PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt
Will the applicant or boom,building owupam store or handle hvzuchus materiel , BEATING UNIT(OVER 100,1100 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Senior 25532(u)'t
❑Yes ❑No VENq'ILATION FAN(SINGLE RF.SfD) �a
ISSUANCE DATE
Will thea licantorfutmbuildinoccuant nacqui BOILER-COMP(3HPOR 10LWOBTU) f�n p M f D
PP g P pmentnrdevices which emit
• haamdou'air contaminants as defined by the Bay Area AG Quality Management BOILER-COMP(OVER 1M,M0RTU) '
District? AUG❑Yes ❑No NEW RESIDENTIAL MECII, SQ.FT, A 2 41993
I have read the hazardous materials requirements under Chapter 6.95 of the
Culifomiu HealthSirnot
cDentlyhveato255(15,t itis and25534, 1itytontif that CIIY Lir vu/^r--7/� 5
i the.1ifor is Healtoea nm curCode have 25505,t 533 and 2553aib1 un m stand the
Occupant.(the rcquiremm�ts which mart be met prior m Issuance of a Cenificete of
Occupancy. I L/ .
Owner or authonov!agent Data ISSUED BY.V'