25792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11UILBI\7:-LL„ RA. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NECHANICAI, /� C (�n'
BUILDING PROJEC1'IDENTIFICATION LJ JL
BUIIAINGAU
DDRESS: -- II w SAN 'ARYNO. APPLICATION SUBMITTAL.DATE
- 1?13-1 /,wr44A 11/4- Ci.-L r UNIT. LOT It
OWNS SNAME: PHONE: CON'IRACTO 'S NAME: LICNO: N/C CONTROL#
e_V Q IG�yv 4Qgq
RCIII'IECTIENGINT;ER: LIC NO: ADDREv55�
'CONTACT: PHONE: .1 ,r BUILDING PERMIT INFO
QTTYY. ELECTRIC PERMIT FEE
BO ELECT PLUMB MECII
PERMIT ISSUANCE
LICF,NSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DT:SCRIPI'ION
OCZ 1 hereby affirm that l am liccuwd unJerm
pvisi.ns of Cb:rpmr9(commencing with
00E Section 7")of Division 3 of the Business and Professi C end my license a in PANELS
FtLx�W Lees C132 .`3 � LiiN
uU �7 `� UPT02MAMPS
w Q d Dam Contractor_, 201-1000 AMPS 111 V V
F D5Z ARCHITECTS DECLARATION RA E/SQ.4T.
Zoo,_ I understand my plans shall M used as public records.
OVER 11X10 AMPS 1
OZFW SIGNS ELECTRICAL B� p
Pin1
LiccnccJ Rofessionul P p N
N 'L'QTER
YY vV/
uI OWNIiR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
y�0¢,O I hereby off rat that I am except fmm the Craloodur's License Law for the I
1+131x.y¢ followiri,mawn.(Section 70315,Business and Profecaiom Cash:Any city.,county TEMP.METER OR POLE INST. 11
0.J which requires a permit to construct,alter,improve,demolish.m repair any mamm 1
5n}� to its issuance,also he licam(.,such G.filaitu adsmanaam POWER DEVICES
poor requires pp p<mti gn
aed K Q that he is licensed pursuant to the Provisions of the Connector's License Law(Chapter VALUATION
'ya 9(c.mmrncing with Smion]fl(l0)of DivisionJof Ole Business and Professions Code) SWIMMING POOL ELF,CIRIC
W^y or that he is exampvhcrefrom and the basis for the alleged exemption.Anyviolalienof
F Z_Y Section]031.5 by any applicant for a permit subjects the applicant to a civil penally of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($500).
WtinNEW RESIDENTIALF.LECPR SQ,Ff. STORIES 9'YPE CONSTRUCT ION
KF� ❑ othewrk,andepmpccture isermYemplndeeswithwagesrsalas e( ec,c.mpBusiness
y 3� will Mthe work,and Nc he Cera intended License
Law red
not
apply to an owner
of
and Professions GMC:The Connumors License Luw d«s not apply to an owner of
prnpenywhobuildsorimprovex thereon,and whod«s such work himselfortmough his
cmployess,provided that such improvements menotimendeduroffered forsale.If, OCC.GROUP RES.UNITS
however,the buildingurimpmvemcm is sold within one ycarofcompleuon,the owner- TOTAL:
builder will have the burden of proving Nat he did not build or improve for purpose of
m1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ las he pumeNepmpmy.am Business an Pofietingwithre)Td,Cannoeern
constm,the projem(Sc.. itno Business pe Roh.h.ins mr arp The C.ntmcmr's
Liccnschawd«snmapoyman.wncrofprepertywhosed psoumt to the
omentJ PERMIT ISSUANCE
who contracts Resuch projects with oc.ntrncNr(s)II«nxcd pursuant mNe Comment, ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I am exempt under Sets ,B&P C for This rcmnnOUTSIDE ELLS
BACK FLOW PROTECT'.DEVICE
SANITARY Y N
Ow«r ADRAINS-FLOOR.ROOF,AREA,COND. RECF.IVI'a
WORKMAN COMPENSATION DECLARATION TSCtI00L TAX YN
lei❑ I hereby affirm that l have a emifteam ofchrsrnt to self-insure,.,a certificate of FIXTURES-PER TRAP RECF,IPFN
Workers Compensation lnsumncemacettifedcopy Nemof(Sec.MOD,Lab C.)which PARK PEE Y N
coven all employ GAS INC. OLTLETS RECEPT#
Policy# i; O - � BUILDING DIVISION
FEES
Company �T t0 GAS-EA.SYSTEM-OVER 4(E,) PLANCHECK FEE
❑ Certified copy is hereby fumn'hcd.
❑ Certified copy is filed with the city inspection division. GREASErINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(This section read net lx completed ifthe permit is for one hundrMdollars(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cmifythat in the performance of the work for whiehthis permit is issued.l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensation laws of Culifnmin. Date WATER SYSTEMORIATING Date Receipt#
Z Appbcam
z
NOI ICE TO APPLICANI':If,after making this Cenilicale of Exemption.you should NEW REMDEWIAL PLMB. SQ.FI'. TOTAL:
become subject o the Workers Compensation provisions of the Lobo,Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
C QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
z Ihereby affirm that then is a construction lending agency for the performance of TOTAL: ELECTRIC FEF,
U O the work for which this permit is issued(Sec.3097.0s.C.)
Lender s Name PLUMBING FEE
I"
F Lender's Address QTY. MECHANICAL PERMIT FEE
U U 1 certify that 1 have read this application and state that the above information is �^f MECI IANICAL FF,E na
}' W correct.l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE .--i 11
V) haiddingeonstruction,mal berebyauthmicam,resenkiivesofthis city toenter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilitiea,judgmrnu.costs andeaperxseaw ich may in.ny wayincruart,imisaid City AIR HANDLING UNIT(TO 10.000 CFM)
ce of the grants um it.
ti r��tiq AIR HANDLING UNIT(OVER IO.000 CFM)
wwrc of Applic UConnacmr .,af EXHAUST HOOD(WMUCI.)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) 9 t �` Dam Receipt N
Will the applicant or future building occupant store or handle hmsrdous bashan l TOTAL: .a
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100j"BTU)
Cade,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Ycs ❑No
ISSUANCE DATE
Will the applicamorfuturc building«cupantuwcquipmntmdeviceswhich emit BOILER-COMP IMP OR 1110,000 BTU)
hazardous air contaminants as defined by the Buy Arta Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A ' D
Distnct?
❑Yes ❑No NEW RESIDEM'[M.MECH.-SQ.FL
I face read the licences,onamaN re,mminems order Chapter 6.95.f the NOV 22 1993
California Health Be Safety Cade,Sections 25505,25533 and 25534. 1 understand that
if Nc 1, Id �g d«snot currendy have a tenant,Nm it is my responsibility m notify the
«cups Pt the mxjml; n t hich must b a pnm to issuance of a Certificate ofTOTAL: n C(I*Y Or CUFci r l u vv
Dec y. 3 2
ram on .,cutDare ISSUED BY:
OFFICE