25813 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOTRI:DINC- .Fti PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n C O'1
BUILDING PROJECT IDEN"I"IFICA'1']ON G J o 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOTH \-�..s(.Jan
OWN AME: P O NT I' R'S NAM LIC NO: C—
F. Elk
N/C CONTROL#
ARCHItT fldVOINE LICNO: DDR S: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FIiE BUILDING PERMIT INFO
BLDG ELECTP UMB MECH
PERMIT ISSUANCE 13 El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyz I hereby offirmthut l nen licensed under provisionsofarpter9bommencing with TOB DESCRIPTION
[400 force and
Section of Ne Business end professions ions Cade,and my is in PANELS
t.
QFyw License Class List,# UP TO 200 AMPS
m xiy Date Contractor 201-1000 AMPS
ZOy3ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O z O 1 undersand my plans shall be used as public records.
(=rnFplu SIGNS ELECTRICAL
QY2� Licensed Frofessionvl
�KL'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
MV 1 hereby affirm that 1 um exempt from the Contractor's LicenseLaw for the
Fwl- following reason.(Section 1031.5,Business and Pretensions Code:Any city or county TEMP.METER OR POLE INST.
oe I which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permute-file a signed shipment POWER DEVICES
a s Q O that he is licensed pursuanuo the provisions of the Contractor's License Law(Chapter
p
9(marnencing with Section]000)of Division 3 ofthe Business and Pmfusiotu Code) SWIMMING POOL ELECTRIC VALUATION
Q Moo or that he is exempt heufrom and the basis for the alleged exemption.Any violation of
EzY
Section]031,5 by any applicant for x permit subjects the applicant 0 a civil Penalty of OUTLETS-SW
Wort IF11*14%mr,IN
Jpd�ofcvomrs
than five hundred dollars(S500).
rty, NEWRESID �R� STORIES TYPECONSIRUCTION
e work,and the swcture is not intended or offered for sale(See 7041.Business
Code:'ITe Contrumor'a License law aces not apply re-an owner of
whobuildsorimpmvestherson,and whodoessuchwrk himselforthmughhisOC .GROUP RES.UNITS
eyeee,provided that such improvementsarenot itnendc l m afferW forsnle.If,
however,the building or improvement is sold withinone yearofcompletion,th ovater- TOT L:
builder will have the burden of proving that he did not build or improve for purpose of
s0QTY, PLUMBING PERMIT FEE FLOOD ZONE qPN
❑ I,asownerofthe proPeny,emeadusively convecting wish licensed wnlrecmrsto
aamuum the our,,(So..1044,Business send Profaeiom Cadet)no Commit1,imnu LawdoesnotapPlymanownerof propertywhobuildaw improves framarm,and PERMITISSUANCE.
,beer Intent fm such projects wi ih n corttractan(s)licensed Forsworn tothe Contractor's
License law. g1:fER-DRAIN&VENT-WAHill(IA) FEE SUMMARY
❑ 1 am exempt under Sec. .B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FhOOR,ROOF,AREA,GOND. SCHOOLTAX Y N_
❑ Iherebyel Erm nhatl hoveecettificem of nmunno sal Ginsum,ora certiFcere of RF.CEIPF#
Workers'Com FIXTURES-PER TRAP
pcnxtian Insurance oracmified copy thereof(Sce.3800,Lab CJwhich PARK FEE Y_N
covers all employee's under this permit. GAS-RA.SYSTEM-I INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished,
❑ Cernfied copy is filed with the city inspxuondiviaion. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nal he completed H do,permit is farone hundred dollars($100) SEWER-SANITARY-STORM G.200FT ENERGY FEE
or less.)
1¢nity that in the pefformertce of the wart her which this permit is issued,100 WA Ilyl TER W/VENT/ELECTR
not employ any person in any manner so a9 m become subject to the Workers' PAID
ZCompcnstiion Lowsof Califomia. Data TER SY /IRFATING Date Receipt If
Applicant
� O NOTICE TO APPLICANT.IL.fur muting this CertiBcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
TO FAL:
(/J become subject to the Workds Compenxdon provisions of the labor Code,you must
forthwith comply with such provisions or Permit shall be deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 z
1 hereby efftrtn that there is a construction lending agency for the pert x.co of EI,ECIRIC FEE
V Q the work for which this Permit is issued(Sec.3091.Civ,C.) to
I nddrs Nanta
Lea
O F Lend AdIdress QTY, MECHANICAL PERMIT FEE PLUMBING FEE
L) certify that 1 have read this application and sure Net the above information relatiis
correct.lagrxempty with all city and county ordinances and state rclering ngto PERMIT ISSUANCE MECHANICAL FEE
�+ y building construction,and hereby authorize representatives ofthiscity roamer upon the CONSTRUCTION TAX
L.J z above-mentioned Fmpeny for inspection purposes. ALTER OR ADD TO MECI I.
(W,)ague,to save,Indemnify and kap harmlex th try of Cupertino against
liabilhies.judgmetis.cos ndexpcnseawhchn any ray me against said City AIR HANDLING UN ( 10,"IT 'O IU, CFMI
ce of theg ri gohhispermii. me iAIR HANDLING UNIT(OVER 10,000 CFM)
ignawreo ApplicanVC t w ja� /1 EXHAUST HOOD(W/DUCT) PAID
IIA ZA US MA RIALS DISCLOSURE ) •!� HEATING UNIT(TO 100.000 B'N) Datc Rccciptp
Will the applicant or from building occupant snore or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety BEATING UNIT(OVER I W,OW BTU) T
►��
Code,Section25532(e)P
0 Yes ❑No IVEMA9'ION FAN(SINGLE RISID)
Will theapplicrmorfmure M1vildingcecupam useequipmemordeviceswhich emir
BOILER-COMP LHP OR 100,000 DTU) ISSUANCE.DATE
huaurdoos air contaminant.as defined by the Bay Arra Aif Qualify ManagemeRl BOILER-COMP(OVER 100,000B'IU)
tem ❑Yes C1 No NEW RESIDEM'IAI.MECH. SQ.Pf.
I have read the hazardous maunials requirements under Chapter 6.95 of Ne
California heath&Safety Code,Sections 25505.25533 and 25534. 1 understand that
®�
if the building does not currently have a report.that it is my responsibility to notify the 30
Ocupant of the requirements which must he met prior to issuance of u CeniOcam of -
ccupancy. cffy!t -:;rte
I4
Owner or authorized agent Gam TOTAL: ISSUED BY:
OFFICE