25117APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
C ITY OF CUPERTINO .BTIli hLirC I IUCA 1,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CHANIC-AC
IIUILDING PROJK(A IDEN1'114CAI ]ON
PERMIT NO.
25117
BUILDIN ADDRESS : /a
41
LOT It
SANITARY NO.]APPLICATIONSIAINU�ITA1�.�DA'Iti
WNF. SN PHONIi:
CONTR OWSNAMH ,. LCNO:
NIC
CONTROL#
❑
RC1 TE /F,NGINEER: 1 NO:
ADDRESS:
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT UM ACH
(f
✓
PERMIT ISSUANCE, rs
LICENSED CONTRACTOR'S DECLARATION
1 heoehy affirm that l am licensed under Provisions ofatiprer9 (commencing with
APPLIANCES -RESIDENTIAL
UB DESCRIPTION
PANELS
Saban 90(gO of Division 3 of the Business and Professions Cade, and my license is in
full force and effect.
License Claes Lic.4
UP T0200 AMPS
/
Date Contractor
201 - 1000 AMPS
ARCHITECTS DECLARATION
I undcrsemd my plana ship CHbeCT' as public DECLARATION
OVER E
�� FT. FL AREA 1
6t`/ry's��111
g/OSQ. IT.
E
SIGNS ELECTRICAL
TRIC
Licensee norr_aaianal
OWNER -BUILDER
SPECIAL CIXCUIT/MISC.
1 heathy n, the ComTION
that 1 am exempt from the Contractor's License Lew for the
room
TEMP. METER OR POLE INST,
billwhowingaimsa(Scottconstrut,7031.5, aincss and Co da Any city
(Se
ve, demolish, structure
which requires a permit re oamwd, alae improve, demolish, me.,i any
recants far ch od am<nt
comment
prionmssissoancammunt w',
POWER DEVICES
t kims,miftheam,
Liter
of the Cnmmdor's Littnse law (,hepar
Conall License
thin ben xiii, w p Sufi. m the pnwi Division
.,,bar heendngwith Sectioorandthe Division mr.11ceuvinessanmi.A., viola Cade)
Srthat he is exempt tyapplic and f the bmisfmthe tsthedexemptitm. Any violation of
Samisen 703ISby my applicant foraPermit subjects the appli<annoacivil penalty of
SWIMMING POOL ELECTRIC
VALUATION
2�
JJ
OUTLETS - SWITCHES - FIXTURES
re than five hundred dollars ($500).
I,esowncrnfthcpropcny,ormyemployecs with wagcsastheirsolecompcnsation,
STORI .' TY-CONSTRUCI'IqN
NEW RESIDENTIAL ELECfR Q. FT.
willdo work, and the structure is not intended contacted for sale (See 9094, Business
and Professions Code: The Convectors License Law does not apply to as owner of
LE
propcny who builds orimpmves thereogand whodoessachwork himulforthrough hisr-
cmployces,provided that. such improvernw ssre not imendedoroffated fnrsWe. If,
however. the building or improvement is sold within one year ofampletion, the owner-
builder will have the burden of proving that he did not build at improve for purpose of
^ P r— RES. UNITS
Lr✓. I
17;-
QTY. PLUMBING PERMIT _
role.).
❑ I.avawneroflhepmp,rty,,meaWuxivelycmmr:mtingwimlicenxdcontr ionm
zo APN
instruct the project (Sec. 90 PL Hostile,., and Professions Cmlep The Cc ars License law does not apply to an owner ofpm,vmy who builds or improves thmmn,andPERMIT
ISSUANCE A___
whit contracts far such projects with is licensed pursuanuothc Contracmrs
License Law.
FL•E SUMMARY
ALTER - DRAIN&VENT - WATER FA
( )
❑ 1 am exempt ander Ser. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
O T IUF FEES
SAN19'ARY Y N
RIFIPT#
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Iherehyaffvm that l have a certificate ofcomem to self -insure, or a certificate of
orkers'Compcmmion Insurance or a certified copy thercof(Sw. 3600, Lab C.) which
FIXTURES -PER TRAP
RECEIPTp
PARK FEE Y —N—
GAS - PA. SYSTEM.I INC. 4 OUTLETS
covers WI emplayce's under this permit
Policy#
RECEIPT
BUILDI?T, DIVISRA FEES
PLANCHECK IBE
Company
GAS - EA. SYSTEM -OVER 4 (EA)
❑ Certified ropy is hereby furnished.
GREASFONDUSTRL WASTE INTERCEPTOR
GRADINGFF.F.
(:ICertified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTIONFROM WORKERS'
GREASETRAPCOMPENSATION
INSURANCE
SEWER -SANITARY -STORM EA. 20 ',
1re
EN GY
r�qs
(This section need not be completed ifthe permit is forms, hundred dollars($IIXE
WATER HEATER WNENOELECfR
PAID
I nifythfonat in the pernancemlNewark fm which this Femur is issued, I shall
not employ any Person in any manner so as to become subject in the WotAers
WATER SYSTEMITREATING
Com,ricilart Uasof Cnlifomis. Dole
[)all c p
Applicant
NOTICE TO APPLICANT :If, after making this Cenificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
becomeh the rs Compenuthis provisionsoftheened Cade,you must
such
forthwith comply with such provisions or this permit shallbedomed revoked,
comply
BUILDING FBG
CONSTRUCTION LENDING AGENCY
SEISMIC FEE f
1 herehy affiom for here isis construction lending agency for the performance of
the work for which this permit is issued(Sec. 3097, Civ. CJ
ELECTRIC FEELea
Nwnc
QTY. MECHANICAL PERMIT FEE
PLUMBING RE
Lmd's
Lendere,'s Address
1 certify that I have reed this application and eine thin the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL ITE
huilding construction, and hereby auNmim represenmtivesaf this city to enter upon the
slave -mentioned pm,cay far inspection purposes.
ALTER OR ADD TO MECIL
CONS "I RUCTION'1'AX
Ove) agree to save, indemnify and keep hmmless the City of CuPenimc annularliahilitics,judgmenu.
civilians] expcnusw' ay in say way azc ainst sail City
AIR HANDLING UNIT (TO 00.000 CPM)
in conscgncncuo he Atin tho
AIR HANDLING UNIT (OVER 10.00) CI'M)
oat reof ApplicapriCoutingtor Date
EXHAUST HOOD OODUCD
PAID
I IEA'1'[NO UNIT (TO 100,M) BTU)
HAZARDOUS MATE S DISCLOSURE
HAZARDOUS
Dau RT—
#
HEATING UNIT (OVER 100.000 BTU)
TOTAL:
or handle hHealth smaarial
Will adthe ae Ctilstm,Momeiilal Codeng Chapel 9.12,
as Jcfined by the Cupertino Municipal Cade, CTapter 9.12, and she Health and Safety
VENTILATION FAN (SINGLE RPSID) Lit C-3
Colic, Smtimn 25532(x)'1
❑ Ycx ❑ No
BOILER - COMP FHP OR 100,000 81 U)
ISSUANCE DATE
Will the applicant or fuwm building occupanmu equipmem m devitts which emit
BOILER - COMP(OVER 103,0110 BTU)
M1 cardoms t t defined by the Bay Area Air Quality Management
UisUidl air cmn Amman .v m
Cl Yrs ElNo
P A'
NEW RESIDENTIAL MECIL SQ. IT.
I have read the hazardous materials requirements under Chapter 6.95 of the
Cnlie Health Safety Onendsponsi (understand that
JUL
building haven tenant, thin it is my responsibility m notify the
il'the building not haveSectionsX.45535,2 itis
2
a re meatscurrently
of the requirements which man be me prior m issuance of a Certificate of
Occupam
ccupancy.
•a Jr 1 LnIINU
ISSUED BY'
Owner art uulbarb"ed agent Can
sorter