25496 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO 11 ILUING-ELEC'1'NICAL PERMIT NO.
APPLICATION/PERMIT PI,UMB Z-MECHANICAL 25496
BUILDING DIVISION BUILDING PROJECT'IDEN'I'IFICA9'ION
BUILDING ADDRESS: yam,} SANITARY NO. APPLICATTIIONSS---UBMHTAL DATE
/ 0 3 3-3 a�/O ��s(T! UNITN 1 LO?'s
jg&bOWNERSNAM���E: PHONE: CONTRACTOR'S NAME:: T 1 CNOO: NIC CONTROL
RCTITTECT/TIIJG�NELR: �Pr2C LIC NO: AUU ESS: v ���c
6 Sf
CONTACT. PHONE: BUILDING PERMIT INFO Oj � QTY. ELECTRIC PERMIT FEE
JAvga J H IiLECT PLUMB MECH
V PERMIT IS ANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES- IiSIDENI'JAL JOB DESCRIPTION
GszIhemhY affirm that lnot licensed underpmvisionsofChepsr9(commencing with F�L.A�P F)ei SdJ"n
00 Section 7")of Division 3 of the Business and Pmfessiort-Code,and my license is in PANELS
� 0Wfull fineeandeffea. f� io Cb ,&r tsly-h
�ZW License Clues 8—� Lica q_ ._S 6 S .J_ UPT0200AMPS New PW7�0 CG P.�/P`.
oj< - Date Cnmrecmr 201VER-IOOIIAMI'S /i•
F yzq ARCHITECTS DECLARATION SQ.F1'.FLOOR AREA $/SV FT.
'LOvs— I understand my plans shall be used as public records. O 1000 AMP$
SIGNS ELECTRICAL
Q $j Licensed Professional
are W< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
x'06 V I hereby affirm mm I am esempl from the Contractor's License Law far the
W>LLy l olbwing manm.(Section 70315.Homes and Pmfic,mrs Code;Any citynrco.a,, TEMP.METER OR POLE INST.-.1
f¢0� which reclaims a permit to commua,alter,improve,demolish,or repair any suumum
E'�Y� priorm its i.sxua.ce.aEo requires the.ppiterm for such petmitm file.signed stmemem POWER DEVICES
� a0 that he is liccnsul punuanl mthe provisions of the Comructor's License Law(Chapter
❑ SWIMMING P00L F,LECIRIC
d e . 666
that heisesemng ithSatioonstar0oe basisibn3ofthebalBuse.cssand.Any Professions VALUATI
cut—y nr@m M1c is cannpnhcmfrom end the bssisfor the alleged cxemplion.Any violation of FIXTURE
hZa Section 9031.5 by any applicant for a Permit subjects the applicant a civil penalty of OfffLETS-SWITCHES- �J1
nor more Than Eve hundred dollars(8500). NEW RESID TIAL EC 5
C � ❑ T,mowneroftheprtpery,ormyemployeeswiNwagesmfficirselecomcemation, - STORIES TYPE CONSTRUCTION
y3— will do the work.andthe structure isnot mbendedoroffered forsale(Sec.70us4,Business
and Professions Cade:The Combustors License Law does not apply to an owner of
property who builds.,improves lherenn,and who does such work himsdfor through his I b n n U RES.UNI"IS
own cmployers.pr.videdth.l such improvemLn
culsme not madedor offexdforsula If, - Y V Y �' '
however.the building or improvement is sold within on yes ofe mpletion.the owner- TOTAL: III UTE Rbuilder will have the burden of proving that he did not build or improve for purpose of IUUU
sac.). PER' Il O fyVfij APN
❑ 1.as.wnerofthepmpcny,amenclusivelycontmningwiNiicensedcontmctorslu QI'Y. PLUMBING AT EF � tL)G
construct the pmjem(Sec.?UM,Business and Professions Code:)The Cadmium's
License law does not apply manownerofProperty whobuildsor improves thereon,and PERMIT ISSUANCE
who contracts for such Noicets w'nh sconranlmr(s)licensed pumuam m the Cmumemes
License La '
Ls. ALnIR-DRAIN&V ENT-WATER(EA) FEE SUMMARY
CI 1 am exempt under Sr,. ,B&P C fm this reason BACK FLOW PROTECT.DEVICE OUT.'IUh FEES
-_ SANITARY Y N
-� Owner Dam DRAINS-FIAOR,ROOP,AREA,COND. RLCEIPfp
WORKMAN COMPENSA'T'ION DECLARATION SCHOOL]AS Y N
❑ I hereby affirm ohm l have v certificate ofeonsem to self-insum.or a cenificme of FIXTURES-PER TRAP RECEIPTp
WmIsers Compensulfon lnsutanceor a certified copy tGeteof(Sec.3800,Lab C.)which PARK FI?E .Y N
covers al I employee's un cr t is RECEIPTp
. d h` Bib zl�_ GAS INC.40UTLIiTS BUILDING DIVISION ERGS
Catkin s F•asA1
Company GAS-FA.SYSTGM"OVEN 4(FA) PLANCIIECK FEE 4.
❑ Certified cop,is hereby famished.
❑ Certilled ropy is fled with the city inspection division GRIASE/JNDUSTRL WASTE INTERCEPTOR GRADING EEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ItiE
COMPENSATION INSURANCE
(Thix,womm neednot In,compleled tithe permit is for one hundred dollars(SiW) SEWER-SANITARY-STORM EA.2(XIFT. ENERGY FGE
or less.)
I certify that in the performance ofthe work for which this permit is issue,l shall WATER HEATER W/V NT/ELECTR
and cm,I.y any penam in any manner,an as to Income subject to the Workers' PAID
Cnmpensmi.n Lawsof Califnmia. Dam WATERSYSTEM/IREATING Dale Receipts
O z Applicant
z Q NOTICE TO APPLICANT:If.aftermAi.g,hia Cerificme of Exemption.you should NEW RESIDENTIAL PLM B. SQ,FT. TOTAL:
,Gbecome subject to the Worker's Compensation provisions of,he Labur Code,you..at BUILDING FEE l�
a fodhwlth comply with such provisions.,,his permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC EEE
1 hereby affirm that there is a construction lending agency for the performance of
U z TOTAL: ELECTRIC HE
O the work for which this permit is issued(Sec.31199.Cis.CJ
Leashes Name PLUMBING FEE
lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that I have rend this application and swat that the above information is MECHANICAL FEE
>" f2J comcf. Iagrcemcomply with all city and county ordinances and natelawsrelming to PERMITISSUANCE
E" building conswmion.and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION]AS
U z above-manionol properly for inspection import". ALTERORADDTOMGCH.
(We)agree est Ness,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNTI'(TO 10,Y00 CFM)
in comerponce of the ginning of this pernit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signamm of pxmo`Cunuactoram EXHAUST HOOD(WNUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Rocedd a
Willthevpphemut or future buddin,occina,n store or handle humanism,mvtenal TIIiAI'ING UNIT(OVER IW.UN)lil'U) TOTAL:
m defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
C .Sorb.25532p)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE,
Will the Licant orfuturebuildin tux ent ordevices which emit BOILER-COMP CIHP OR IW,000 BTU)
app d by than AreaA
haaallous air contaminanu as defined by the Bay Area Air Quality Mmmgcmcnt BOILER-COMP(OVER 100,000 BTU) pp
Distinct? C3 yet 13 No NEW RESIDENTIAL,MECH.—SQ.FT. P a'4 1
I have mad the hev,doas materials m,uimmems ander Chapter 6.95 of the AUG 26
fmcbuil buiHirlding
do,norr yCnde.3eeions2550h2553Jv,ad repo a 1unde maid that y�(� �a.�
actmarilofthe resnotcunes which
amnae that it is mymmorce hility tomai fythe y 3
cupant of the reyvircmems which most be met prior to issuance of a C<nificam of C
it Occupancy. I/�
Owner or authoriecJ agent Uum TOTAL: ISSUED BY:
OFFICE