25956 APPLICANT TO FILL IN INFORMATION WITHIN REP LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DI I PERMIT'NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL. 25956
y' sµ-BUIh;IIING I'ROJhG'I'IDEN'1'IF1LA'1'IUN_,
BUILDING ADDRESS���I�+�,�\�'`• SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT' LOT
If NA e P' L� 1 _ PEON Sec ats-C R' N M L_I�,['4 0 N/C CONTROLp
RCHITFCf/ENGINEF,R: f-lI1 LIC NO: J A `TJ ❑
Y
VONTACT: PHONE:
QTY. ELECT IC PERMIT FEE BUILDING PERMIT INFO
B G ELELT X 'CH
LICENSED CONTRACTORS PERMIT ISSUANCC f��r,
'SDECLARATION APPLIANCES- A
b nffitm Ne'Iamlicensed under onsolCha[ 9 JOB DIiSCRIPTION
paZ Tey ndPro per and my]let.wish
+{100 Lion 7o00)of n3of the Business end Prafessima Code,and my liceueis in
r fnrw ea eerfa a S'Z�O16.5
— z Ps 420
l
<y Licenre Cl Link
y< Dose Connaztor
ysy7J. a ARCI IITECTSDEC RATI � 30EIIOOOA PS . AR EA $/SQ.Fr.
O'L^D ..l understand my plans shall he used as public records. /VT's/ �—
Pl Ln L W S ELECTRICAL
4�Yd '� Licemed Profes,haral
frJ CG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ip(,Oy I hereby affirm that I am exempt from the Contractors License Law for the
m 3 wy following...,(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
priorm its momace,alaorestricts the applicem forsuch permit o filauignedraprorm POWER DEVICES
O that he is licensed pursuant to the Provisions of Ne Connectors License Law(Chapter
L e� 9(c.mmencing with Sec'ian]OW)nf Divisi. Sof the Business and Profeseione Code) SWIMMING POOL ELIiCTRIC �- ] VALUATION
yo urthat 7031. by yapplimandra bermefor allegcAcxemptian.Aivil Peation of LTS-SWITCHES-FIXTURES
�Z¢ Section 7031.5 by any applicant forepermit aublu applicant toecivil penalty of
O not more than five hundred dollars($500).
❑ 1,mownerofthepmperry,ormyemplo mswithwageautM1es pemation, NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
I'Ly3$ will JON.work,and LL.
imcndW a ficardfarame(Sec.]and Pbowssim's Code:The Crs Lice. Law does not apply to an.w neorproperty who buildsarimprovon,andw does such workhimu orthroug is
wnemployees,providcd Net provema see no,i nded orals agile IL OCC.GROUP RL'S.UNITS
however,the building or improis sold uhin ane yea lel' aw r.builder will have the burden. g Net did not build. v�apurpo of
ode.).❑ Lmowne,.ftheprepanclusi lycomme� ensed cppmmetor t. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.] sine and Prnressio :)The C.nacLicense Lawdues nm applysoer.( openywhobuildsar prove .own, d PERMITISSUANCEwhncnntrads fur such projectmn ucmrts)licensedp uylonwemlx pLTF.R-DRAINffi VENT-WATER(FA)Lt.Law. FEE SUMMARY
❑ 1 am exempt under Sec. P C br this re BACK MOW PROTFM.DEVICE D
SANITARY Y N
Owner te DRAINS-FLOORROOFAREA. RECEIPTN
WORKMANCO ENSATIONDECIV TIO , , . . SCHOOLTAX Y N
13Iherebyaffrmthutlhavesc Ificaeatest u inure,ora certificate e / RECEIPTM
Worked Compns
eation lnva Ceara certified copy the OO�b C.)whic X'fORES-PER TRAP PARK FEE _ Y N_
'oversell employee's under d spe'mit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPI'p
Policy M BUILDING DIVISION MI;
Compony GAS-PA.SYS'TF.M OVER 4(FA) PIANCHECK FEE
❑ Certified copy is hereby fmdMwd.
❑ Certified copyis filed with the city inspection Iv 'm. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WOR GREASETRAP - SOILS PEC
COMPENSATION INSURANCE
(This sectummidom becompletedBNe permit isfor one hundreddollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY ME siss—iss
or less)
I certify that in the performance of the work for which this permit is issued.)shall WATER HEXrHR W/VENT/CLECIR al assass,
nm employ any person in any meaner so as to become subject to the Workers' PAID
Compeasaion Lawsof California. Date WATER SYSTEM/TREATING Data Receipt#
Applicant
O0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLAHL SQ,FT.
TOTAL:
> becomesubject
comply the Workers Compensationprevisionssh.11 ft he Labor Code,you must
� ; fnnhwith comply with such provisions or perhii'xhell be deemed revoked. BUILDING FEB
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^a I hereby affirm that hem is a construction lending agency for the performance of
U Oa-s the work far which this pends is issued(Sec.3090,Civ.C.) T �^ ELECTRIC FEE .tea
V. t-' Landers Name PLUMBING FEE
O U Lender's Address QTY. MECHANICAL PERMIT FEF, r
1 certify Nat 1 have mad this application card sow that the above information is
ILL carxanL Iagree'.comply with dl city and county mchr casandsm¢lawarelatingto PERMIT ISSUANCE M[CIIANICAL FEE r^'
building construction,and hereby authorize represent 'v sof Nis city center upon the CONSTRUCTION TAX
(� z above-rmmimed property for
urposes. ALTER OR ADO TO MECH.
A2!M_'.Z'a=fn.
o save,indha Ic she City of Cupertino.gains'
ts, stnnoic y in any way acme against said City AIR HANDLING UNIT(TO 10,000 CPM)he ansinit AIR HANDLING UNIT(OVER W.000 CFM)
41 een/ moor Dat EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE If EATING UNIT(TO 100,0110 BTU) Data Reccap,#
Will the applicant or future building occupan mre or handle haurtlou material HEATING UMT(OVER 100,000 BTU) TOTAL:
u defined by the Cupertino Municipal Code,Chapin .I2,and the Health and Safety
Code.Seen..35532(.)?
❑Yu 13 No VENTILATION PAN(SINGLE RESID)
Will[be applicunmrl'uwrebuilding mcupmt use egoipmentordevittswhich emit
BOILER-COMP(FHP OR 100,000 BTU) ISSUANCE DATE
hturdom.4 comatninanu u defined by the Bay Area Air Quality Manegetnttll BOILER-COMP(OVER I W,WO BTU)
!,e'
Disti.t?
13 Y. EI No NEW RESIDENTIAL MECH.—SQ.FT.
' O 1 have reed the heurdous materials requirements under Chapter 6.95 of the J�`. 8,9California I leStalwartsth A Safety Code,Se25505,25533 and 25534. 1 undcrsmnd that 8
/a I r s
a ffthe
ptionofillding eounot
rrents yhhmue a stkLNmiiismymanceNfoCenmifyNe C/��.`r 1994
occupant of'he requircmcnts which most be mm prior m issuance of a cenificme.f
Occupancy.
Owner or uuNoduJ.gem
Data T ISSUED BY: / g
OFFICE