25155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ROtLllmrt',--F',LEL'TRrcal, PERMIT NO. S
APPLICATION/PERMIT PLUMBING-MF.CIIANICA I, 'LJ
BUILDING DIVISION BUILDING PROJECF IDENTIFICATION
BUI TNG ADDDRESS: pa SANH'ARYNO. APPLICATION SUBhurn AL DATE
/0300 L/`, UNIT# LOT#
OWNS 'NAME: PI li: ONTRACfOR'S NAME: LIC NO: `P ��••//
OI. , NEC CON'IROhp
RC l'CfryNGINI'(ft: LIC NO: ADDRESS: K/ ❑
CONTACT: PHONE: } a' `arer BUILDING PERMIT INFO
QTY:.•p+�' EEE(eTRIC PERMIT..: FEE
BLDG ELECT PLUMB MECEl II
PERMIT ISSUANCE w ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p yZ, I hereby affirm that l am li«msedunderpravisionso(cham
pter 9 pomen<ingwith BOB DESCRIPTION
{as00 Seeden 70mPof Division Sof the Buxinesamd Professions Cde,and my license is in PANES
ae U F full force and effect. '1 �. L \ • " —
FZm License Class Lica UP T0200AMPS i/
LA6 d Date Commmr 201-1000 AMPS
F
is, ARCHITECTS UECIARATION SQ.FT.FLOOR AREA fl/SQ.IT.
ZO«— lundersmnd my plans shall bused os puM1lic recants. OVER IWOAMPS
Py F w SIGNS ELECTRICAL
Q E,, LianseA Professional
�ya'Q OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
C
L) 1 hereby notion that 1 um exempt from the Convector's License Low for the
m3aN following reason.(Section]0315,Business and Professions Code:Any city or county TEMP.METER OR POLEINST. J
which requires.permit res construct.after,improve, reW demolish,or it anY aW<nurt /G
}� prior in its issuance,also reclaims the applicant for such Pennant to file asignMsoemem POWER DEVICES
K 0 p thin he is licensed formation to the Provisions of,ha Contncum's License Law(Chepttt SWIMMING POOL ELECTRIC v
4%0E 9(command,wiilt Section 7M)).f Division 3ofthe Business and Professions Code) VALUA ON
,_y onha he is exempt lMrcfmen andthe basis for thealle,m]exemption.Any violation of SWITCHES-
FZQmol nomadism Eveun
Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS- FIXTURES
ocSp thdred ma doll (S500L
NEW RENIDENTIAL SLECrIt _SQ.FT. STORIES 'IYYE CONSTRUCTION
C f-o ❑ oche wnttafthepopecyrormulimanyecswifewed forthei(sole c0m Business
will olbewons Codec arucmreanor's Lienee Law
of apply 1B 14,Business
and Professions Code:The Contractor's License Law d«s not apply to an owner of
property who build ormanowestherean,and whodoessuch work Nmselforthrough Na
DEC.GROUT' RES.UNITS
own emfloyees,providalthat
rovsuch improvements sold nthin nse carr fcmofrema thmale.If,
mildhowever.the
ave the burimpmvemcntishathe idnoney<a or improve
omm efor theawncr- TOT
M1uilder veil l have the burden of proving than he Jid not buil)or imprme for purpose of
avoclm the profif amct
eecluslvelycontrang n with licensed emarcmto QTY. PLUMBING PERMIT FEE FLOOD LOM: APN
sal
Attract the project(See.7D44,Business and Professions Code:)The Contractor's
kh,inLawdoes not applyto anownerofpropertywho builds or improvuthumn,and PERMIT ISSUANCE
M1uu contracts for such projects with acmntraemr(s)licensed pursuant o the Contractor's ALTI?R-DRAIN&VENT FA
('-WATER
License Law. ) FEE SUMMARY
❑ 1 am exempt under See. ,B&P C for this reaon BACK FLOW PROTECT.DEVICEUT.IDs FEES
_ SANITARY Y N
F Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, SCHOOLTAX Y N
❑ 1hereby aft that l have a<emificateofemerenttoself-inaare.m ..rlGcatn or FIXTURES-PER TRAP RECEIPTa
Worken'Compensmian lnmranccar a certified copy thereof(ge<.3g60,Lab G)which PARKFEE Y N
eovenallemploycdaunderthopernit. GAS-EA.SYSTEM.I INC.4 OUTLETS ' RECEIPTp
Policy If BUILDING DIVISION MES
Company GAS-EA.SYSTEM-OVER 4(EA) PI NCIIECK FEE
❑ CenifiW copy is hereby funished.
❑ CenifieJ copy is flet with the city inspection Jivisina GREASE(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF MMMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(This section need nudist completed ifthe Permit is foresee hundrd dollan($100) SEWER-SANITARY-STORM EA.206FT. ENERGY FEE
or less.)
I certify that in fee performance ofthe work fmwhich this permit is iscd,l shall WATER HEATER WNENTpiLECTR
not employ any person in any mama so as to become subject to the Workm' PAID
Compensaaiontawsa(Caliromie. Dam WATER SYSTENUREATING- Dae Receipts
zz Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PL.MB. SQ.FT. TOTAL:
E-' f,f become subject to the Wmkefs Compensation Provisions of the Labor Code,you must
7 foMwilhcumply with such provisions or this permit shall W deemd rnvokd. BUILDING FEE
G Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
a z Ihereby aft that hem is a construction[ending agency for the performance of - TOTAL: ELECTRIC Ell
U Q the work far which this pcmtit is issued(See 3091.Civ.C.)
Lender's Nmae
O"' F lenders Address - QTY. - MECHANICAL PERMIT FEE PLUMBING IEE
O U 1 eerily fear I have read this application and state that the above Information is
correct.Inarce to cam with all cit and ordinances and state laws relating PE RM I ISSUANCE' MSCI IAN ICAL Riff
Teams, comply yam county g to
I"^ hW-Fcitionenion.andhercbynmbmi purples. vas of this city to enter upon the CONSTRUCT ION FAX
U z. ubve-mm�aio.popery almonifyand purposes. ALTER OR ADD TO MECH.
(W.)agrm nt sive,indemnify and hie mayhimein a the City co Cupertino against
liabililies.jm enb,cost anJexpenuswhich may in any weyacerve against said City AIR HANDLING UNIT('1'O LO,6IXI CFM)
in cnnmecom the romongaf this reit.
AIR HANDLING UNIT(OVER 10,000 CFM)
ac EXHAUSTHOODOYMUC)
PAID
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 10h,M)BTU) Dam Receipt a
Will the applicant or future building occupant store or handle M1anrdous material Ttyl'AL:
as def ned by the Cupeniam Municipal Gide,Chapter 9.12,and rhe lEidth and Safety HEATING IONUNIFAN
(SI IDLE RESID
Code.Section 25532(.)? VENTILATION FAN(SINGLE RISIDl I
❑Yes ❑No
ISSUANCE DATE
Will rheapplicant«foram buildingoccupant useWuipmentordeviceswhich emit BOILER-COMP LIHP OR 100.000 BTU)
havordnus air comantinants as derined by the Buy Area Air Quality Management BOILER-COMP(OVER 160,0(10 BTU)
Uistrim? �a A
❑yes ❑No NEW RESIDENTIAL MF,CH. SQ.IT. r g!
I have read the hmzrdoas mate ods requirement,under Chapter 6.95 of the
OJirnmiC loans&Safety Code,Section.,25505,25533 neJ 25534. 1 undersand Nm J
if the building does not currently have a tenant,than it is my responsibility m notify the U��,
131997
.
occupant of the requirements which must b mel prior to issuance of a Certificate of (s
Occupancy. Cl jr
Owner or Womiecd agent Date TOTAL: ISSUED BY: .