25425 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUn.mb,i- PERMfr No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25425
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS:\ ��/ (� SANITARY NO, AAPN1C�ATI NSU�BM'ITTALDKIL/O / S� a UNIT# LOT# -r'yf�1 ti
\\J OW AMC PHONE CONLIC NO: N/C C(N9R0,#
NE_� VO #✓
ARC141FECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
ELECT P If
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL 1 D
CXz I hereby offitmtbm l um licensed under provisionsol'Chapler9(commencing with
�W00 Sedincurred of Dlvieinn3nl the Business and Professions Code.and my license is in PANELS
<,tu fall Lionse andeffem.
6FZW hiccnse Clan Lic.# UP T0200 AMPS
,,,<aor Dale Contrxmr 201-1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
ZOsoz ARCHITECTS DECLARATION OVER I"AMPS
09—O 1 understand my plans shall be used as public member.
SIGNS ELECTRICAL
Licensed Professional
C
a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KO L V 1 hereby a.offiron(Se that 1 stn exempt from the Co stats a License 1<w for the
W 3 W h follow leg reason.(Section 703 L5,Business and improve,
do to l Code:Any city or county TEMP.METER OR POLE INST.
��.�� witch rcyuirasap,emit In construct,slier.improve.demnli.aM1,or repair any structure
C }5 prim to its issuance.oko requires the applicant for such permit to file a signedsummem POWER DEVICES
WC<p that he is licamel,utsuom drift,
provisions of the Contractors License Low(Chapmr SWIMMING POOL ELECTRIC
c.°ie(�y 9(cnmmencing with Setion]OW)of Division3of Ne Business wd Pmfusiona Cade) VALUACp(J�py��
WM, or that he is exempt therefrom Sea .. nd the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES ��
F Z Q Stion 7031.5 by say applicant for a permit stibju th
ace applicant to a civil penalty of L
�re than five hundred dollma(E5W).
f=D NEW RESIDENTIALELECTR _SO.FT. STORIES TYPE CONSTRUCTION
K L-o asowncr done pope"E'aryemployees with wagestertheirsolecomperuation,
63°0 illd he work,andthenmeone Isom intended oroffcred forsale(Sec.701 .Business
and Professions Code nor Committee's License Law des not apply to an owner of
property wbo builds or improve,thercmn,and who doer such work himself or through his
¢mpinyees,proviJed Ilaboabimpmvementsareirm intended oroffered fa,sle.If, OCC GROUP RES.UNITS
however.the building or improvement is sold within one yearofcomplction,barrister-
builder will have the burden of proving that he did not build or improve for purpose of
'°I`)' QTY. PLUMBING PERMIT FEE
❑ Lar owneof the propenY.ant exdusivelycontr�ting with licenud mntracsorsm FLOOD ZONE APN
construct the project(Sec.]W4,Business and Professimm Code:)The Consracmr's PERMIT ISSUANCE
Licens,Low docs not apply to an owner of peoperry w ho bui kk or improves thereon,and
who contracts for such projects with a conhacmr(s)licensed pursuant o the Contraemr s
License Law. ALTER-DRAIN&Vf:NT-WATER(EAJ FEE SUMMARY
❑ I am exempt under Sec. .B&P C for this reason [;ACK FLOW PROTECT.DEVICE OUTSIDE fES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOP,ARIiA,GOND, RECEIPT,
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y N
❑ Thereby affirm tint)M1uveecenif,,,ifi comemtoself-insure,or a certificate of FlXTURFS-PFR TRAP RECEIPT#
Workers'Compensation lruurance ora ccnifiW coDY thertof(Se.3800,Lab CJ which 6 i i PARK FEE Y N
vers all employee's under this permit. GAS-EA.SYSTEM-111�C.0 OUTLETS � RECEIPT'#
Polcy# T
eI BU
ILDING DIVISION FS
Company GAS-EA.$YSTEM- VER A n
❑ Cxrifiedcpshrebyfuished. I i
❑ Certifiedcopy is filed with the city inspeefion division. GREASFJINDUSTRL WAS ISJTERCEPTOR s GR D ZFi
CBRTIFICKI'COF EXEMPTION FROM WORKERS' OR
TRAP
, COMPENSATION INSURANCE
(This section necdnot be completed if Ne permit is for one hundrWdollars($100) SEWER-SANITAR -S'I.OR 'A. ER0Y 1'IiIT
or less.)
I cenify Nat in Ne pem(armnna of the work fm which Nis permit ixissued,lshall [—.
WATERHEATER FNI'/ELECI'R
nm employ ad,person in any mumer m as to become subject to ted Wmmuv PAID
Compenmtion Lawsof Califomia. Das, WATER SYSTEM/IRE- TING Date Receipt#
CZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. TOTAL.
0 NOTICF.TO APPLICANT:14after making this Ccnificam of Exemption,you should
F-' hemer,a.bjen m the Worker's Compensation provisions of lha Isbor Cade,you must #
forthwith comply with such provisions or his permit shall be darned revoked. BUILDING FEE
d Q SEISMIC FEE,
CONSTRUCTION LENDING AGENCY
z 1 hereby affirm Net Nem is a construction lending agency for the performance of AL
U O the work for which this pstanit is issued(Sec.309],Civ.C.) ELECTRIC ItiE
Landers Name MECHANICAL PERMIT I FEE PLUMBING FEE
0 (•' lamders Address Q
L1 I cenify than I have mead this applicatimn and stale that he above information is MECHANICAL PEE
correct.I agree to comply withal)any amid county mrdimunes add state laws relating to PERMIT ISSUANCE
E-' building construction,and hereby authorize representatives ofthiscity m enmrupon be CONSTRUCTION TAX
U � above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabillines.judgments,cases and expenses which may in any way acemeagainstsold City AIR HANDLING UND(1010,WO CFM)
in consequence of the granting of this permit.
y� AIR HANDLING UNIT(OVER 10,0110 CFM)
cwVConl he Y ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATa LS DISCLOS HEATING UNIT(TO Ino,"BTU) Dam Receipt#
Wil the
Cupertino u builal Codscupamstomor and the
Hardousd Safety
HEATING UNIT(OVER 100,000 BTU) TOTAI'
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Salety
Crate,Seed x)7
El ye, C3 No
VENTILATION FAN(SING LE RES ID) \
❑Yea
ISSUANCE ATE
Will the applicant or future builiingoempant oucyuipmemordeviceswhichemit BOILER-COMP(311P OR 100,000 BTU)
haunches,air cnntaminsats as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.00)BTU)
District] C3PAID
❑Ycs No NEW RESIDENTIAL MECtI. SQ.FT.
1 have tend the by udmu,motions re05,25533 under Chapter ame of the
Californiabulding oe%SafetyQdy have ons ant,that
it is and 255�.sponse 1 ity to nand that
ifthe buildinge resnotcurrentlyhaveatenant,thatitis my responsibility to ifica the AUGr�
occupant of the requirements which man be mm prior to issuance of a Cenifieam of
Oavpancy. 1
•_ IYU
Owner or authorized agent Dam �� TSS UF.D BP
OFFICE