25863APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
- - •
PLUM BING-MFICHANI
Pit RMITNo.
25863
BUILDINGBUILDINGPROJF60' IIIN:NTIFICFICA'I'ION
BUILDIN DDRESS:
t
UNIT# LOT»
SANITARY NO.
APPLICATIONSUBMfITALDATE
O R. AMI?: ed, aHONE:
ueo ass'
CONTRAR'S NAME: LIC Nq� �
C—
N/C
CONTROL
AR CTR' INFER: LIC NO:
'CON]
-J
ADDRESS:
'ALT: PHONE:
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LICENSED CONTRACTOR'S DECLARATION
1 herebyuffinn that I sat licensed underprovixionsof Cheprcr9(commrn<ingwit
QTY. PERMIT FEE
TIAL
n
BUILDING PERMIT INFO
BLDG ELECT DMB MECH
❑ ❑ ❑
IDB DESCRI ON
[�
Scnion]tNp)of Division of the Business mdProfeuion Code, and mylicrnuia in
f.ieen.�ci �`I "36 see.» SIiS
Date f [ —Q V Convenor
a AARCHTfECTS DECLARATI
I understand my plana shall be used as public mends.
PANELS
GPToz AMIM
201 -1000 AMPS
OVER IOW AMPg
SQ. FT. FLOOR AREA
5/SQ. FT.
SIGNS ELECTRICAL
® B 1�1
p INo
0Vwhich
hprior
E FR
j Licensed Professional
OWNER-BUILDER DECLARATIONSPECIALCmR
hereby affirm that 1 am exempt from the Convessorb License Law for the
following reason.(Section]031.5. Business and Professions Code: Any city or county
requires a Permit to construct, alter. impove. demolish, or repair any structure
to its issuance, alsorequius the applicant far such p Moto file a signed statement
5 that he is licensed pursuantto the Provisions ofthe Canouctors License Lew (Chapter
9( commencing with Section7OW)ofDivWmtWineBusinessandprofession.Code)
Or that he is exempttherefrom and the basis for the alleged exemption. Any violation ofSection]031.5 by any applicant fore permitsubjeea the epplicont m a civil nalty of
f mare then five hundred dollars (SSW).
❑ I,Asownerofthepropeny,ormyemployeeswithwegesmthcir.olemmp nsadon,
will do the work, and thestrunureis not imendedaroffered fnrsale(Sec. 7044, Business
ITMSC.LE
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FIX'URES
M
NEW RESIDENTIAL ELECTS _SQ. PT.#SMWRIMT"ECONSTRUCTION
A
and Professions Code: The Contommes License Lew does not apply to an owner of
property who buiIds orimprovestherwn, andwhodsuch work him eIforthrough his
hoemplaytts provided Nat such improvememaere nm imrndcdorofferedforsale. IL
wever, to building orimprovement is sold within one yearofcompletion, theowner-
builder will have the burden mproving that he did not build or improve for of
TOTALCale.).
RFS. UNITS
purpose
❑ Las ownerofthepmNe y,amexclusivelymnoecting wit licenudcontmetors m
con ovct the project (Sec. 7044, Business and Pmfesxious Code) The Contmcmrs
License Lawdrcanot applyman ownerofpropetty who buildsorimprovestereon,andsw—
QTY. PLUMBING PERMIT FEE
TLPERMIT ISSUANCE
APN
who contracts fru such projects wit a comracror(s) licensed pursuant to to Commences
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
ALTER - DRAIN & VENT- WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUl'SIDE FEF9
Owner Date
Y N_
RECEIPT#
WORKMAN COMPENSATIONDECLARATION
❑ en'Co afftrmiminsat I veeorafineofcanunt tnof(Sec.38 Can
Workers Cropl.,&. orerthiscermit. ificdcopy tercof(Sec.JBW,fabCJwhich
,UbCfics, ofhich
ell employee's under thio permit.
#
DRAWS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS-f?A.SY$TFN-I INC.40UTLETS
Y N_
RECEIPT#
VPA�ME
Y_Ncnvcrs
RFCEIPT»Policy
UILDING DIVISION FEES
0 Ca
Cmifiedcopyishertbfundted.
GAS -EA. SYSTEM -OVER 4(E,O❑
❑ Certified cagy is filed wit to city inspection divi.ion.
GREASPONDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASRTRAP
ILSFEE
(This section need nm becomplmed Ron, permit is hunts, hundred dollars(SIW)
or leas.)
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
I cert y that in to perfcrm. of to work for which his permit is ban Ishall
WATER HEATER W/VENT/ELECIR
nm y MY pecan m Any manner so as m bac t L-!?
C oration ofLelifomj�/�` _�7 `rs
pplictnt A ..
you
WATER SYSTEMIUREATING
PAID
Date Receipt#
NOTICE TO APPLICANT: If, After making this Clufficar, of Exemption, should
become subject m to Workers Compensation provision of to Labor Code, you must
foMwit comply with such Provisions or this permit shall Its dented revoked.
NEW RESIDENTIAL PLMB: SQ, FT.
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm thv them is a Constrction lending agency for to performance of
SEISMIC FEE
ELECTRIC FEE
the work for which this permit is ist (See. 3097, Civ. C.)
Lenders Name
Lenders Address
1 cCmY that 1 have reed this application and sate that to above informmian ie
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
correct. I agree to comply with all city and county ordinances and sive laws islating to
building Conswotion. and hereby authorize representatives of this city starter upon the
above-mentioned property for inspection purposes.
(We) ago to save, indemnify and keep harmless the City of Cupertino against
Iiabilities,judgments,cosisand expenses which may in any waysccrue against said City
in ... staisafiaw mdr. grunting tispermit.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TD 10,000 CFM)
'
MECHANICAL FEB
CONSTRUCTION TAX
// `%f. - _ . I ,` W -9C/ AIR HANDLING UNIT (OVER 10,aW CFM)
Signa ppbcamucontracmr s' ---IDate
EXHAUST 14MD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 1," BM
Data Receipt#
Will the applicant or future building Occupam sorra M handle hazardous materiel
n defned by the Cupertino Municipal Code, Chapter 9.12, and to Ilealt and Safety
HEATING UNIT (OVER 100,000 BTU)
Code. Section 8532hq?
13 Yes 0 N
VENTILATION FAN (SINGLE RMID)
Will the applicant pair
nBay
BOILER - COMP (3HP OR 100,IXq BTU)
ISSUANCE DATE
ult as defined by theA reality Management
District? air cnntaminonts as defined by to Boy Arca Air Quality Management
Distrix?
BOILER -COW (OVER 100,000 BTU)
Cl Yes ❑ No
NEW RESIDENTIAL MECH. SQ. PT.
I have mad the ham dour materials requiremcros under Chapter 6.95 of the
California Health & Safety Cade, Sections 8505, 25533 and 25534. 1 undersand tet
if the building does not currently have a tenant. that it is my msponsibility to notify the
Occupant of the requirements which must be met pour to issuance of a Certificate of
Occupancy.
tY
����
BY:
Owmacrintharudagent Date TOTAL: 1
ot-mut a sir VV"CI ,