25514 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CLPERTINO BUILDING-RLKCI'RI(AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MRCHANICAI. A C [v aI /I
I{UII,DINC DIVISION BUILDING PROJECI'IDEN I'IF'ICATION' L J J 1 4
BUILDING ADDRESS: ///�/ / SANITARY NO. APPLICATIONSURMIATALDATE
6 14�r/OV V O O UNITN LOT#
OWN' S MFk O PIIONH =-� CONT@ACf00.'S NA LIC NO:
'/'LN# ,(✓.v /w
NC CFOMROLa
*ARCIIII'IiCI'/IJJGINEER: LIC NO: ADDRESS: ❑ L V�
CON I'ACI'; a PHONE: Ql'Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE B_Ij)G RI 1:� pLUM MI;CIi
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
�y,Z Ihereby affirm that l am licensed under provisionsol'Chapter9(commencing wish JOB DESCRIPTION
�00 Section7NB of Division 3 Ofthe Business and Professions Code,and my license is in PANELS
yWad full Lamp Classe and effect. �71�s
f yy/ Littnx Class Lich UP T02W AMPS
m Q 5• Dam Conwmor 201-1000 AMPS
FyZ ARCHITECTS DECLARATIONSQ.IT.FLOOR AREA $/SQ.FT.
ZOm l understand my plans shall be used as public records. OVER IOW AMPS
O'Z—O /
P rn t W SIGNS ELECTRICAL
Q,y:Fqq
; Licensed Prufcsvional
q W�yI< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X
OyU I hcrcby n.Se that 1 3L exempt from IM1e Contractor's License law for 0c
W3u-vFi .1hichingmason.(Senionportio Business and Pndbssioe Code:Any ciryorscantyr.ou. '1'IiMP.METER OR POLE INS'f.
which«m is..u permit m conswa,ulmr,improve,Je �y'ttrucmre
aas—
prior to its iasuantt,also requimsthe npplicant forxuch rno s sat -POWER DEVICES
K p thvt be is licensed pursuam m the pmvisioas of the Conl or's Liremse pt S L%L=
IC�
aao� 9lrommenchng with Section 7")of DivisinnJ ofdmR Pro CadVALUATION_
w^y or that he is exempt therefrom and the basis for the ell<6 ' . .An v atioa `O �^G
HZY Sectio 703 LS by any applicant fora permit subject I pplicanuoa .alt L S-S r L/` 1`�j.�{`
ASO¢ ore than fiva hundred dollars($500L ee
a!= I,asuwnera thcpr., y.ormyemployecewiflivew�WthgI. •c. as .W I r /�' STORIES TYPE CONSIHUCI'ION
W3,p.
will she work,and mcxnuaure ban,imendedoroffcred for
and Professions Cade:The Contractor's License law does nor apply I.anmw nf of
pmpeny whobuildsorimpmvesthercon,and whod«s such work himI;I , ur his f OCC.GROUP RES.UNITS
hoemployees,provided that such improvement me not immndedoreffemd forsale.IL r
wever,the building or improvement is sold within one year ofcompletion,the owner. /n
builder will have IM1e burden of proving that he did not build or improve for purpose of 1/
.arc.). .
E] Las owner of the pmperty,em exdusivdy cantmaing with licensed conteamQTYPLUMBING PERMIT FEE
s uh FLOOD ZONE AI'N
entrance,the project(See 0014,Business mad Professions CWe:)The Convenor's
I1iccnw Lowdcesnm apply to an ownerafpropeny whobuildsorimprovesthcrmn,end FERMI'r ISSUANCE
who contracts for such project with aconvaamr(s)licensed pursuant totheCommetor's Commetor'x
License Law. ALTER-DRAIN&VENT-WATER(IA) FEE SUMMARY
07,
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE RES
SANITARY Y N
Owner RECEIPTN DASCt00LTAX Y
NWORKMANCOMPENSATIONDECLARATION , ,
'❑ Ihercbyvff,.th.1haveacenif,.m.fconsentloaelf-imum,orattnftcmeof IIXTGRES-PER TRAP RECEIPT Js
Workers Compamsnion[mummies.cenified copy,him.f(See.3900.Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS IVISI
DRT p
Policy p BUILDING DIVISION FEES , y
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE MA v`0
❑ Ccnitinl copy is hcraby lumishal.
❑ Cenilicd copy is fled with the city impaction Jivisinn. GREASNINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP ! SOILS FEE O
COMPFIJSATION INSURANCE
(This acaiun need not he completed lf,he pontis is fora..hundred dollars(SIW) SEWER-SANITARY-STORM EA.2 I• ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is Issued,Isbell WATER HEATER W/VENT/ELE
not employ any person in any maauer so ss to become subject to the WorkersPAID
Compreattionlawsof California. Dale WATER SYSTEMtrR Data Receiptra
O Z Applicant
z NOTICE TO APPLICANIU If.after making this Certificate of Exemption,you should NEW RESIULNTIAL PLM . SQ.Ff. TOTAL:
17 . haarmembjccl to the Workds Compensnuom provisions of the Labor Crane. mr most
� > forlhwi,h comply with such provisions or this panni,shallh deemed revoked. y. BUILDING FEF,
W [� CONSTRUCTION LENDING AGENCY SEISMIC IEIi
ulc
z,
1 hereby affirm that there is a construction lending agency for the perELECTRIC PEE lo mence of (AP0
tot,U O IM1e work for which this permit is issued(See.JIN],Civ.CJ
Lenders None TY. MECHANICAL FERMI'T FEE PLUMBING FEE
Lender's Address Q
C) I.miry that I have mail this application and stat that the above information is MECHANICAL FEE
cortwt. legree mcomply with all city and county ordinance and state laws relating to PERMIT ISSUANCE
F-' building consmaction,and hemby amborim represenmuscsofthis city in enter upon theCONSTRUCTION TAX
ry
O Z above-mentioned property for inspection pupae. LTER OR ADD TO MECH. 2
(We)agrtc to save,indemnify and keep harmless the City of Cupanino against
liabilitiaa.judgrufn�.cros endeapcnxs which mnyi any way ucmcagainstsaid Chy AIR I IANDLING UNIT(TO 10.(010 CFM)
onseyaehmeaft agremi.g.f,hisperou. a AIR HANDLING UNIT(OVER I0,000 CPM)
tiigivucof Applicanl/Campachr Data EXHAUST HOOD(W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE U E4UNG UNIT(TO I00,000 BI'U) Dam Receipt#
Will the applicant or future building«cupral strafe or handle hazardous material TOTAL:
as dcfi.ad by,h.Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I1EATING UNIT(OVER I W,W BTU)
Coda,Section 25532(e)7 VENTILATION FAN(SINGLE RISID)
❑Ycs ❑No
ISSUANCE DATE
Willtheapplicanmrfoture building«cupam uxequipmemmdevittswhichcmit
BOILER-COMP(3HP OR IW.W0BTU) (A,I
haza dous air conterminous as definad by Lha Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P M
�Dionaf n
❑Yea 0 N NEW RESIDENTIAL MECN, SQ.FT.
8 y
1 have read,hefty Code,
materials requ5505,25533 under Chapter understand
of thethat
993
if the uil ingdHealtM1&Safetyurently Seas ons255115,25533 andsponsi (understand that a7 _C
Ifthchuil alnt Jovanot cumes which amna,met ii ismyssuanceoilieymificat the cl�+ (Jf- �
cenpnni of the myulmnmms which moo M mar poor ah issuance of a Cmlfiame of Vf�[/•1 1Y
O«upanuy.
Owner or authorized agent Data ISSUED DYq:
OFFICE