25430 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 1 DIN -LLL 'IRI AL PERMIT NO.
APPLICATION/PERMIT PING PROJECT
CM IDENMCAL 25430
BUILDING DIVISION BUILDING PROJECT IDENTIFlCA'r10N
HUILQfNQ ADD ES _ SANITARY NO. APPLICA'HON SUBMITTAL DA'II:
111TJ OTR r-
O CON MAMA: \� kti �{C
vY/L l/lV`VS(� V sem' _-,'NIC CONTROLM
•ARCHITECT/ENGINEER: LIC NO: A DRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MHCII
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1-1 El El
I Lerch 1'llrm thud um licensed under ICh. t l gwi OB DESCRI 'ION
OC% yit Prove onto parnd mmenens th
WOO_ Sectforeand ofect.Division Business and Professions Code.nnJ my license is an PANELS
y,11-- full fora and effect.
� FGW License Class Lic.p UP T02l0 AMI5
y jy Date Caamemr 201-1000 AMPS 5 .11:50R A EA 5/SQ.FT.
%Otoz ARCf11'TI?CTS DECLARATION OVER HXXAMPS
O'Lr-G IundemnnJ my plans shall be used as public rccmJs. LE ® I N s
W SIGNS ELECTRICAL
Q�d�,,j Licensed Pmfessimad
1y+ Q OWNER-BUILDER SPECIALCIRCUII'/MISC. �� c �U TER
1
N 1 hereby affirm that I see exempt from she Contractors License Law for the „ „
W�+14 following moved.(Section]031.5,Business and Professions Code:Any city nr county l'EMP.METER OR POLE IN ST, a
F'LL O< which requires u Permit to cans ma,alta,improve,demolish,or repair any stracture t'
>� mit,i...anee,uhrine thea licant for such t1.File.si d,umancnt POWER DEVICES DATE
prier quires pp pm gee
0,'m that he is licensed pursuant to the provisionsnnhe Gmtmcwr's License haw(Chaeta
C y SWIMMING POOL ELECTRIC
ad ti m ila,hencingwithomfeardSection it aDivision3nftheed!ixem and Professions Code) VALU
or Nat hcis euby any.fromund the ba,lafodacts the exemption. civiny l Penalty of OUTLETS-SWITCHES-FIXTURES osx
not mo than
by hundred
dollars($500). the epplicanuoecivil Penalty of
not more than f vc hundred dollen(5500).
�Sp NEW RESIDIiNT1AL ELECIR -SQ.FT. STORIES TYPE CONSTRUCTION
❑ oche wnanDbe Pr someoormycmpendedo rdered fairshei(sole eontpensmion,
a'3� will Pathework,and the he C.o is not intended Law
do,no,apply 7M4,Business
and Pmfussinns Crde.The Convector's I iccnse Law docs not apply It,an owner of
property whohuildsar improves mcrcon,andwhodwssuch work himselfor through his OCC.GROUP RIS.ON]1:S
employees,ldin iJWthat con mid
within mol intendedopleti n.the owner,
M1uilder ..the building ori en of moving
is sold within one yw of completion,the owner- TOTAL:
builder will have the burden of proving that he did not buil)or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ m
I,as owo -ofthe prapery.am exclusively contracting with licensed contractors to r
'mstmet the project(Sec.IlW4,Business and Profession,Code:) Me Contractor's
License Low th<e not apply ronnnwna nfpmpery who builds orimprmes thereon.and PERMIT ISSUANCE
whocomrads forsuch projects with acontractor(s)Boosted pursuant to the Convadors ALTER-DRAIN&VENT-WATER
License Lsw. (EA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&PC for this mason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE DL HI N
Owner Date DRAINS-PhOORROOFAREA, RECEIPTp
, . , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have.cenificam ofconsent to self-insum,ora certificate of FIXTURES PIiR TRAP RECEIPI'R
Workers'Compensmioa ln,mancem.certifiedcopytheeeof(Sex.3800.1.1,C)which PARK FEE Y N
emomstill employees under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT R
Policy R BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Cenilicd copy is hereby lnmishcd.
❑ CeniticJ copy is filed with the city inspenian Jivieinn GREASMNDUS'I'RL WASTE INTERCF,PPOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
(This section need not her completed ifthe Permit is for one hundred dollars(S100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lesa.)
I cenily that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT'/ELECrR
not employ any person in any nounct,s.a as ,,become subject to the Wnrits, PAID
Z
Compenmimi Lawsof Califoman. DateWATER SYSTHMOREATING Data Reccid#
� aot
NOTI :
NOlicantTO APPLICANT:If,afro making this Certificate of Exemption,you should NEW RESIDPNTIAL PLMIL SQ.IT. TOTAL
1Z~" become subject to the Worker's Compensation provisions of the Labor Chair.you muss
> forthwith comply with such provisions or this permit shall her clamed revoked. BUILDING FEE , 110a (] CONSTRUGr10N LENDING AGENCY SEISMIC FEE I
z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097.Civ.C.)
Lender's Name PLUMBING FEE
u' F^ Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 cenily that 1 have mad this application and state that the above information is MIiCI IANICAL FEE
correct. Isame in comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building coarructinn,xnd hereby oulhoraxe reprcsenmtive,of this city err toleration the CONSTRUCTION TAX
U Z above-mentioned property forms i ALTER OR ADD TO MECH.
(We)agreeindemnify and ka les.the City of Cupertino against
liabiliue, ass.Ve uundexpensesw cl yin wayacemeagainstsaid Cary AIR HANDLING UNIT(TO 10,000 CFM)
a. o it.
AIR HANDLING UNIT(OVER IU,000 CFM)
Signnl App sunu EXHAUST HOOD(W/DUCq
atu PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam RmciptR
Will the applicant or future building oaupad store or handle hazmdous mammal HEATING ON IT(OVER IOO,gIO BTU) TOTAL:
as defined by the Cupertino Municipal Cede,Chapter 9.12.and the Health and Safety
Code,Section 2553200? V ENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMPOHP OR 100,000 BTU) Iy$UANE�7A7Y3
Will applicant minant as defined
by her
Area
Quality
which train PAI
u
hazardous air contaminants m defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100.(1(10 BTU)
Dis n1
❑Yes ❑No NEW RESIDCNI'IAL MECH.-SQ.FT. AUG 9 19Q3
1 have read the ha,emous materials requirements under Chapter 6.95 of the V
Califamia l lcalth&Safosy Gdn,Sections 25505,25533.md 25534. l understa id that n 1114U
if the building does not currently have o tenant.that it is my responsibility to notify the !^iIIy
Occupant of the rcyuirements which must be met pour to issuance of a Certifiwm of V
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE