25656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILDID I7.—LLEIIR1 APERMITNO.
APPLICATION/PERMIT FLUMRING-MBCHA WALL /J C C[S
BUILDING DIVISION IIUILDING PROJEC'TIDEN'1'IFICATION G J J U
LNG ADDRESS: ' SANITARY NO. APPLICATION SUBMITTAL DAM
ZOIOS iVo2iNwT/�y` G UNIT# LOT# 6,28.!.(3
OWNERS NAME: }� PHONE: CONTRAMOR'SNAME LIC NO:/'^ 111
�m '/✓ SO eN M- CDNS/mit( IeIkI SS4-0 NAC ( CONTROL#
RCIII'I'F,Cf/IENGIN[ER: LIC NO: ADDRESS:
oz e -GE DC . S . cA9�i3
ONTACT: PHONE.: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LDC ELECT PLUMB MECH
PERMIT ISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
LOB UISCRIPf10N
MxZ Iloobyam ffrIlia,lam licensedtndia-Em kimetACTeprer 9(commencing with
�JJ00 Scc,ion]00(pnf Division3nncssa
t,hc Busind Professions Cone,and any license is in PANELS
m
e deHeel. SSe3
<7 ic<nse Classt49
Lic.p OPT02a0AMP5
vo< Dam Coal. 201-i"AMTS
Fern ARCHITECTS DECLARATION SQ.FL FLOOR AREA S/SQ.FT.
y:C OVER 1000AMPS
Z )w— 1 undersland my plans shall be used as public records.
Fy E-uw1 SIGNS ELECTRICAL
7,,j Licensed Professional
�a'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ax'OaU 1 hereby etfrm Ihut I sun exempt from the Contractor's License Law for me
u1'�+rr-eFii following normal.(Section Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F I!-O< which requiteapermitmronslrun,.Intdemolish.,
i,improve, repant
air any,vac
ENt1}y prior to its issuance,also re tracklhe applicant for such permit to File a signed ointment POWER DEVICES
W <O than he is licensed pursuant In the provisions of the Contractor's license Law(Chapter
6�Oo 9(enmmencingwitli Section 9o00)of Division 3oflhe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
or that he is exempuherefrmn and as basis Rothe alleged eacmp,ion.Any violation of OUTLETS-SWITCHPS-Il%NRPB
tKy Section'/031.5 by any applicant for a Penni,subject applicant the applicano a civil penalty of '
not more thin Iii.hundred dollars f55IX0.
=2❑ NIEW RESIDENTIAL ELIECIR SQ.IT. STORIES 'IN Piz CONS'fRUCTION
CFo ❑ Ldsownerofthepmpeny.ms not imoyeeswithwagesasthci See.compensation,
y3.° win do thesions analMm Comisnm imendede wiffervil Law
not apply to an,Business
and rmreasmna coae:'rne cammemra License W w acted not apply la an owner or
,rotary who builIke,impruvesthene i,und who dassuch work himselfomhrough his I r II ^� ' I I OCC.GROUP RES.UNITS
own employees.provided than such improvementare not inlendedoroffemd haste,If. P — —
however,the building or improvement is sold within one year ofcompletion.the owner- I TOTAL: I •'4
builder will have the burden of Forcing that he did and build or improve for purpose of
one.)' QTY. PLU BINC PERMIT J a 8 �FLOODZONE APN
❑ Lases a pont lh(Sec.7 FJ Burin sivery Professor.
Code)The
morsm
conmmm IM1e pmja,(Sec.7044,Business and Profnsicins Code)The Contracmrs
Liccnu Wwdues not epplyto anownerofpropcnywho builasorimpmva,hereon.and PERMIT IS.DANCE pglE
who contracts for such project with aconlmc,or(s)licensed pursuant to the Convacmee ALTER-DRAT9rVENT WATER(EA) FEESUMMARY
Licrao,Law.
❑ I am exempt under Scc. .B&PC for this reason BACK FLOW PROTECT.DEVICEO 'SNE EELS
SANITARY Y—N
Owner Dam DRAINS-FLOOR.ROOF,AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have ecernficale ofconsenno self-insum,oraccnilicamo! mic Ell-too
FIXTURES.PER TRAP
Workers'Cumpensnion lnsuraaremisceeo
nified copy Nerf(Sec.3800.Lab CJ which PARK FEE Y N
rs RECEIPT a
all employee's under,his permit GAS-EA.SYSTEM-1 INC.4 OU ILETS
Pot icy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifiedcopyillorebyfumished.
❑ Ccnifed ropy is tied win the city inspectiondivision. GREASEJENDUSTRL WASTE INTERCEPTOR GRADING FEE
CF.RTIIICA'I'JOE IE%BMFI'ION FROM WORKERS' GR17ASETRAP SOILS FEE
COMPENSATION INSURANCE
((Tis sec,ionnccanm be completed ifthe permil is porcine hundred dollars(5100) SEWER-SANITARY-STORM EA.2WIFT. ENERGY REE
less.)
I cell ly that in the perfmmance of the work for which this pcmlit is issued,I shell WATER I IFAIHR WNENT/ELECR
not employ any person in any manner so as to become subject to the Workers PAN
Compensation Wwsof California. Date WATER SYSTIEM/IREATING Dale ReriPle
Oz Applicant
zO NO OCE TO APPLICANT:If.after mrdimthis Certificate of Esemp,ion,youxhould NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
E-t br,masc ubjccl to Or Workers Compensation pmvisionsoffle tabor Code,you all
FF" forthwith comply with such previsions or this permit shall be deemed revoked. BUILDING FEF. /a
7
0.Wi Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
U
I hereh fF,.thea mere is a cmrstratnt n lending agency for the folhor me,,of'z' the work for which this R—it is issued(See 3097.Civ.C.) TOTAL: ELECTRIC FEE
U Lenders Naas PLUMBING FEF.
Lenders Address QTY. MECHANICAL PERMIT FEE
U 1 eerily that 1 have read this ap,Iicati.a and sane Ihm the above information is MECHANICAL FEE
>,�" W coned. give to comply with all city dna county oNinances dna mmedewa relatingm PERMIT ISSUANCE
y buildingcomwto comply
herebyl Cityassrepaseatavesof suis city laws rupon to CONSTRUCTIONTAX
U Z shove-mcmioncd property for inspection safove.. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep haanless IM1e City of Cupertino again,
liubililies,judgnom a Land expe}smpea/wmrhich theyin' yl y accnto,ininm said City AIRBANDLINGUNIT('1'G 10.001 ciMp,
in Consequence 11 il. �`
AIR HANDLING UNIT(OVER 10,OCFM) /—y
guature of Ap Iicant/Cnntramo, D10,0100ate (EXHAUST I IOOD(W/DUCT)
PAID
IIALARDOUS MATERIALS DISCLOSURE IfPTING UNIT(TO I0L00B BTU) Dae Rettipl a
Will thc applicant or future building occupam store or handle hauMous material TOTAL:
us defined by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety IIfiATING UNIT(OVIER 100,000 JIM)
Cash.Section 25532pd? VENTILATION FAN(SINGLE RESIU)
❑Yes ❑No ISSUANCE DATE
Willthcapplicam or future buildingoccupant vseequipncnlmdcvlccs which emit BOILER-COMP(3HP OR 100,000 BTU) P barardcus air contaminants as defined by the Buy Arca Air Quality Management A I
District? BOILER-COMP(OVER I W,f100 BTU)
❑Yes ❑No NEW RESIDENTIAL.MF.CJL SQ.FT. ®CT 2 01993
I have read the bevardme,materials oNt,iremems under Chapre,6.95 of the
California l Ica da&Safly Code,Sections 25505.25533 and 25534. 1 umlerslavd that
if the building does nm currently have a auction.that it is my responsibility to notify the tiIIY ur wretllllVU
occupant o1IM1e requirements which must be me,prior to issuance of a Cci ifcme of
Occupancy.
Owner car oriented Join, Dee r TOTAL: ISSUED BY:
OFFICE