24751 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HI LDmG-ELL 'I RICAL PERMIT NO.
APPLICATION/PERMIT TNG PROJECI IDUANICAL
FICA n /I 7 5 1
BUILDING DIVISION nun,DlNr.rltoAF,Cr a»:NnFlCnI'IOY LSF J
HUILo D 1)9` UNITa LOT a SANITARY 0. APPLICATIONSUBMITTAL DATE
rq"a
OWNERS NAMIi: PIIONIi: COKI'RACT'OR'S NAME: LIC NO:
10 O Ips ��-• /7_
N/C COMI'ROI,M
RCIIITF,CT'/FNGINEER:
LIC NO: l— ADDRESS: GI` ❑ ��\^
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF:
e,nf\ M(s /l,�fk/x �!1c I�C� �J CT PLUMB MT❑CII
_CoM U� 5 1 [� PERMIT ISSUANCE
LICENSED CON"TRACT ORS DECLARATION APPLIANCES-R HSI DCNTIAI.
�yrP I hereby affirm that l am licensed under provisions ofChapter9(commencing with JOB DESCRIPTION
WOO Smri.n lltlyJlof Division 3of the Busiacaand Prafessions Code,and my license is in PANELS /g —_
yW_ full force and affect. UPT02W AMPS (_y •Ap,{_/ `s e_
Fyty License Class Lie.p
to Q c• Data Contractor 201-I"AMPS
❑'OSU.I.T.FLOOR AREA SISQ IT.
,Z FON_ ARC]IITECTS DECLARATION OVER 1000 AMPS �k
dat
O _C I understand my pans sbe
d plans owd.l as public records
MM ^+■ 41,
SIGNS ELECTRICAL
Q Y ,� Licensed Probational �TS�
tat a,e[Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOaU I hereby affirm that 1 am exempt from the Contractors License Law for the
•W S a y following reason(Scctaun 7031.5,liusincss and l'mfcasinns CWa Any city or county WIMP.METER OR POL°1 :T.
whichregaares apenniuo constram,almp improve,dere ish,of repair any aructure
KNQ� to its issuunce, koro Nen licunt forsach 'u.file asi medstaemend POWER DEVICES
prior yuires pp panto y
Wp50o that he is licensed pursuanuo Ne provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
m p,o 9(eoma
menng with Section90X1).1 Division 3of the Basinasund profession,Code) VALUATION
yKj_y or that he is exempt herefmm and the basis for the alleged exemption.Any violation of �
FZ_a Section 7031.5 by any applicant for u permit subjects the spplicanu.acivilprnaldy of OUTLETS-SWITCHES-FIXTURES k
fd-,he"'work.
en ftvc hundredd.11ars($500)
NEW R65IDENTIAL T:LECfR _SQ.FT. STORMS TYPE CONSTRUCf10N
KowneroDhepmpcny,nrm,employees with wvgesuathcirsolcatmpensaion, 1
y3_e and the structure is not intended proffered forsake(Sm. Business A e
s nv Gde'ITe Convactnr's License Law Joos not apply m an owner ofobuildsor improves themnn.andwhodoessuchwork hinnelforthrough his
own employros.provided that such improvemennare not intendelar offered forsale.lf, p (7 OC60 1 RFS.UNITS
however,the building.,improvement is sold sithirimu,vanufmar,delion,thewnr-
oe �� 11 J
builder will have the burden of proving that he did nm build or improve for purpose of
sale). n 'N
QTY. PLUMBING PERMIT FE
❑ I.asa roftbeproKc y.umcaclusivelyconiraating`+'iNliceveJ...uacmom FDAIE O O
instruct the project(Sec.70ad,Business and Professions Cale:)The Contractors '
Uccnwlaw Jocsnotapplytoanowncrofpmo nywM1nbuiids.rimprovcsthcrcnn.und PERMIT ISSUANCE
who enmmets for such projects with a commewsrod licensed puua
rsnuo the C.mmctors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I um exempt under Sec. .B&P C for this reamn BACK FLOW PROTECT.UIiVICE OUTSIDE'MIS
SANITARY YN
Owner Dae DRAINS-FLOOR.ROOF,AREA,COND. RECRIPI'p
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IM1emby uffrm Na]haveacenificam of conwnun selfdnsurt.oracenificam of pIXTURES-PF.R TRAP RECIHPI'a
'W.rken'Contpenwti.n lnsumnee.racenifed copy Nereuf(Sec.3gW,Lob C)which PARK FEE Y N
rots all employeesunder this permit. ECElPTq
GAS-HA.SYSTEM-1 INC.4 OUTLETS BUILD ,DVISION FEES
Policy a
Company GAS-M.SYSTEM-OVER 4(EA) PLANCHECK FM
❑ Certified copy is hereby famished.
❑ Cenified copy is Bled withthecity inspection division. GREASE4NDUSTRL WASTE INTERCEPTOR GRADE'
CERTIFICATE OFF.XEMPTIONFROM WORKERSGREASETRAP SOUS FEE
COMPENSATION INSURANCE
('1'hissection need not he completed Blue permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM G.20AFT. ENERGY FEE
or Tess.)
I coni fy that in the performance of the as arkfor which this permit is issued,l shall WATER HEATER W/VENT/ELECIR
mat employ any person in any manner ao as m become subject m the Worker' PAID
Compen.n.ionlawsof California. Dam WATER SYSTENDEREATING Date Receipt
Z A licunt
PF NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
2 NOTme subject to thCANT:IL after Compensation sCisions of
Labor Code.
You must
f- .�. become subject to the Worker's Compensation proviaians.f Neemed revday.0 must BUILDING FEE
a , forthwith coin ply with such prnvumna.r this permit shall be deemed rtvmkcd.
OW. Q CONS'[RUCION LENDING AGENCY SEISMIC FEE
1 herebybfinn that Nem is a construction lending agency for e pcerfommce nof
z TOTAL: ELECTRIC FEE
thmec
e work for which this pcth is issued(S .3097,Civ.C)
U C) lender's Name
" F lemdves Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
I"'
0 U I certify that I have read this application and awte Nat the above information is MECHANICAL ITE.
7" W corce. legrccmnnnply with all airy unJ nnuny ordinances and state laws rdmingm PERMIT ISSUANCE
con" building construction,and hereby authorize amesentatives ofnis city Deme,upon the CONSTRUCTION TAX
U Z abme.ame dined p perry lot inspection purposes. ALTER OR ADD TO MECH.
(We)agree c,and mfy and keep harmless he City of Cupertino against
liabilities,jud if rstsu enpc"w"dich I in any wayacemm against said City AIR HANDLING UNI'T(TO 10,0(0 CFM)
in consic in f dlhi _
AIR HANDLING UNIT(OVER 10,000 CPM)
Sign' re � pplicaml ,actor Daa EXHAUST HOOD(W/DUCT)
PAID
MALAR UOU SMA TER IA LS IIISCLOSURE HEATING UNIT CFO 100,(100 BTU) Data Receipt#
Will the applicant or future building wcupsm nma.r handle haixhms material TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Ilwlth and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Seaton 25532(#)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑N.
BOILER.COMP CHIP OR 100,000 BTU) ISSUANCE DATE
Will the applicant random buildingoccupant use eyuipmenmrJeviceswhich emit �a''pp pp
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100.000 BTU) P A I D
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT.
I have read the hazudaus materials requirements under Chapter 6.95 of the MAY 2 51
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the hudding)nes not currently have a tenant,that it is my respamibility to notify the
occupied of the rtquiremenm which must be met prior to nuance of a Ceniticicii—
ate o1' CI I I Uf w sit,'G.
Usurers,nuthnrineJ ngcnt Dole TOTAL: ISSUED BY:
OFFICE