25071U7N
G
14
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - ' CAL
APPLICATION/PERMIT PLUMBINGROJECTECHANIFICA
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
PERMIT N°' 25071 I
1
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATR
{ S K4 UNIT N LOT N
OW SNAME: PHONE:
DG'FrL T
C ACTOR'S NAMI: _ LIC NO: ^
SG 0 /Q0)
7,✓a/
N/C
COjM/%I!R{OLA
V
rII ARCHIT?CT 'NGINEh' IT/Al e,ICNO 0
i(,t1
A D ESS: � L�y `
CONTACT': PHONE:
I os
QTY.' ELECTRIC PERMIT TEE
BUILDING PERMIT INFO
BLDG ECT LU MEC
a
Se.G Q
PERMIT ISSUANCE
LICENSED CON'TRACTOR'S DECLARATION
I hertby Nfimr thmlam licrnsW undtt provisionsafChapmr9(wmmencing with
Section ?").(Division 3 ars, Businessland Prof,sions Code,sndmylieenseism
full force and effeec , 3 3
License Lic. p
APPLIANCES -RESIDENTIAL
TOB DESCRIPTION
�AG Q..:ti nI
PANELS
UP TO AMPS
4,
Date Cuntmcwr
ARCHITFCT`S DE TI
1 understand my plena shall be used m public records.
201 - 1000 AMPS
OVER-
SQ. ff. FLOOR AREA $/SQ. FT.
3S
SIGNS
SIGNS ELECTRIC
Licensed Professional
SPECIAL CIR ISC.
1 OWNHR-BUILDER DECLARATION
I hereby affirm that I am exempt from the Comr.nors License law for the
TEMP. METER OR POLE INS .
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires n Ixnnit re coaatmn, aper, dmforsu demolish, urea sir swcmre
: priormiu issuance, also requires the applicant(orsuch pcmuno file eeigned statement
ed
POWER DEVICES
j that he is ndng w p Smtion the provisions of the Ce Bu inm License Lew (Chapter
f 9that heisandthe Division 3oftheed exemption, Any violation
or that 7031.5
031. byan,mpt therefrom end the pesisfurthe ts,hedexemption. civilplority.f
taubJeeu the applicant toecivilpwalry of
SWIMMING POOL ELECTRIC
VALUwAT/ION j�p
�i {�I/ (JV
�V V
OUTLETS - SWITCHES - FIXTURES
cantfor$200).
outnomthan36y hundred
not mort than five hon rod my,lan ($500).
❑ I,asownttofthepropeny, ormyemployece withwegesazthciraolecompemetion,
/ f70
NEW RESIDENTIAL CLECIR _SQ.
STORIES'
TYPE CONSTRUCTION
WiIIJ. Ne wo,k,..d the Ncoca elanolimeaded or OBcRd froode($K. 7D4d. Business
and Professions Code: The Contractor's License Low dues not apply to an owner of
_
property whobuildsorimprovesthmon, andwhodoes such workhimselfortivough his
wnemploymes, provided that such improvements urenolintende iorofferedforsals. If,
OCG GROUP
RFS. UNI'T'S
however. the building orimprovemem is sold within oneyearof oundetion, the owner.
builder will have the burden of pmving that he did rat build or improve for purpose of
QTY' PLUMBING PERMIT FEE
sale,).
❑ I.ms nerofrhepropeny,amexclusivelycoatrecdngwidlican ,.o mum
FLOOD'LONE
APN
construct the project (Sec. 7W, Business and professions Code:) The Comosetor's
License law does not aMlymenowserofproperty whobuilds mimproves therwn,and
PERMIT ISSUANCE
whoccrimnsforsuch projects with acommactm(s) licensed punuanttothe, Convactore
License Law.
ALTER-DRAIN&VENT-WATER (EA)
)
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICEO
I E
Owner Date
DRAINS -Fl 000.,ROOF,AREA,COND.
SANITARY Y N_
RECEIPfp
WORKMANCOMPENSATION DECfARAT10N
❑ Ihcmby nffirm lhaU hove accniFlcem of conawuo self-ineore, orncertiliaa of
�Vmkm.'Compensation lnsuranceoro ceniftedeopy there0((SecJg00, Lab C.) which
SCHOOL TAX Y N
RECEIPTp
FIXTURES PER TRAP
PARK IEE Y N
. S TE N UTI T
covers all employee's under this permit.
Policy at
BE ?IPPA
BUI INO DIVISION FEES
Company
11 aimE [A)
-
PLANCHECK f•E'
❑ Certified copy m hmby fumphed.
❑ Certified copy is NM with the city impaction division.
! G E S I AIR
GRADING CS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRP.ASI?
SOILS D �a
EN
(This secticstmadma becompletM ifthepennitis for one hundred dollen( 100)
or less.)
WATER ITUT17R W/VENT/T.LECTR
WATER SYSTF.M/IREATING
PAID
Date R cip ` 1
I certify thutin the performance ofthe work for which thispennitis issued, I shall
not employ on pe n rn any menta, wast to Ne Workers'
Compensation Celifp�s. Dotk 7tl_/
c /-
L �I s��
NOTICE this Certificate
NOTICE do, Worker's
after Compensation sof of Labor Tonle, youshould
become subject m the Compensation pmvit shalof the Labor C you muni
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
such Pr
forthwith comply with such Provisions or this penult shillhdmnM rtvoked.
ak
BUILDING FEP.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is ismed (Sec. 3097, Co. C.)
Lender. Name
ELECTRIC FEE
Lenders Address
I certify dal I have read this up,timuma and aur, that the .hove infennon m ds
ee
correct. l agree to comply with all city and county ordinens and store laws miming to
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE L
PERMIT ISSUANCE
MECHANICAL FEE
construction, and hereby authodu representatives of this city m enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) ogre. to save, indemnify and keep barmlen the City of Ca,umms .gains,
liabiliti. judgmenu, casu andexpenseswhichmayinanywayaccrue.gumZ ,10ty
AIR HANDLING UNIT (TO IBM CFM)
encu the gree ins elft .permit.
50
AIR HANDLING UNIT (OVER 10," CFM)
gn urcof Applican/Contra mar pate
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO 100,1100 HTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt It
Willthe applicant or future building occupant arum or handle laardous rrumd.l
a defined by the Cupmino Municipal Cods. Chapter 9. 12. and the Health and Safety
HEATING UNIT (OVER 1041,01,10 B'lT0
TOTAL:
VENTILATION PAN (SINGLE RP.SID)
Cade, Seciloa 25532(.)7
❑ Yes ❑ No
Will theapplicanwrftnumebuildingoccupentusee to anderamdevieeswhichemit
-aNous air comaminams as defined by the Bay Area Air Quality Management
BOILER -COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
9D Iq
BOILER - COMP(OVER 106,C00 BTU)
❑ Yea ❑ No
have read @e harardeue materials requiremcne under Chapter 6.95 of the
AUG
{�4G
NEW RESIDENTIAL MECH, SQ. PT.
Calif -mi. Health & Safety Code. Secpona 25507.25533 and 25534, 1 undersmnd that
if the building does not currently have. roam that it is my responsibility to amity the
Cl/ i �r I p
occupant of the reyuimmems which ..at he met prior to issuance of. Certificate of
Occupancy.
,._ up
ISSUED BY:
Owner ser ewhoduJ ugem Dom
T
Urrwt