25144 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILII -ELE6 RI AL PFRMUNO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJEcrBING- ID
IANIOAL 25144
IfU1L111NCs 1'INt IJEC'1'IIIIiN'1'IISICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
VJ�� rr ` ✓(�(fe— � UNIT# LOT#
OWNI?R_N.AM : 1'1 N" CONT �D LIC NO: N/C CON'I'ROL1#
ARCHT'TECf/ENGINEER: LIC NO: ADDRESS: wo ❑
CONTACT: PHONE: BUILDING PERMIT INFO
10110 �J T��� QTY, ELECTRIC PERMIT FEE
-pG ELECT PLUMB MECII
PERMIT ISSUANCE. El ❑
LICENSED CONTRACTOR'SundpwDECLARATION APPLIANCES-RESIDENTIAL JO DPSCRIPPION
qay Ihereby affirmlhatl 3 ofan th B semis and profesioCCode,and
my brcing with
❑100 Seninn]WO) IFDivision lsf the Business and Professions Code,and my lices¢c is in PANELS
Ld E full Grtce mJ effect l% r' �/
¢Vzu Licenu Class— Lic.x �yx5rzz? UPT02fq AMPS
ria pram Contrector 201-1000 AMPS
?-- Z A HITECTg DECLARATION OVER I"AMPS S T.FL(1fQR AREA $/SQ,Ff.
OZ-N' I understand my plans shall be used us public records. 1
Q4ff--:: SIGNS ELECTRICAL t //�► Q
� Licensed Professional yk O
�d4'W OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISQ VV
OyU 1 hereby
affirm that 1 inn exempt from the Communes License Law for the —
m34y following mason.(Sect Business end Profcssiam Cade:Any city or county TEMP.METER OR POLE INST.
which rcyuires it Permit In ceromet,aIle,improve,den I di,or repair any snucture
f'n>,� prior it)its issuance,also permits the applicant for such permit file a signed statement POWF DF.VICIS
pj 5 Q O that he is licensed pursuant to the provisions of the Contram
cfs License Law(Chapter
611. 9(commenting with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VAI TION
or that he is exempttherefrnm and the huis forthe alleged exemption.Any violation of
�Q Section 7031-5 by anynpp1aaot for a Permit subjects the applicam to a civil Penalty of OUTLETS-SWITCHES-FIXTURES
aEa� nm more than its M1andbe dollsrs($500). NEWRESIDENTIALELECTR S .IT. V
Co ❑ I,asownerofthepmperry,ormycmployecswith wagesu theirwlecampensation, Q STORIES TYPE CONSTRUCTION
x300 willdu the work,andthe emscmin is not imendedoraffered farde(Sec.7044,Business
and Professions Code:The CovuacroEs License Lew docs not apply to an owner of
property who buildsaeimpowesthereomund whodoeswch work himselforthroaghhis OCC.GROUP RES.UNITS
own employees,provided that such iniprovemen¢am not intended or offered for sale.If,
however,he building or improvement is sold within one ycuofcomplerion,the owner- T I
builder will have the burden of proving that he did act build or improve for purpou of
sale .
❑ I,
as uncrofthe Property,am exclusively contracting with licensedcontmetora m QTY. PLUMBING PERMIT FEE Fl.00D ZON APN
construct the Project(Sec.71$4,Business and Professions Code:)The Cnn ovelm's pPRMI'1'ISSUANCE
Liceme Law does not apply to an owner propertyolwho builds or improves thereon,and
who contractsforsuch pmjwts with a contmctor(s)Iicensedpuramnttothe Coneacmh ALTER-DRAIN@VENT-WATER IPA)
License law, FEE SUMMARY
❑ I am eumpt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE. SANITARY Y D N
Owner he DRAINS-FLOOR,BOOS,AREA,COND. RECEIFI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby efftrm lhmlheve accrtificue of eanumto self-insart.on cmifiwte of FIXTURES-PER TRAP RECEIPTN
Workers'Coan emation lnsuonceora ccnific,copy thcrcof(Sce.3800,Lab C.)which PARK FEE Y N
covin all employees under this permit. RECEIPT#GAS-EA.SYSTEM-1 INC.4 OUG.ETS
Policy p BUILDING DIVISION PBlig^
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE /t']
❑ Certified copy is hereby famished w
❑ Cenifiedcopy is Bled with the city inspection division, ORE- SFgNDUSTRL WASTE INTERCEPTOR GRADING ME tI
CERTIFICATE OF EXEMPTION MOM WORKERS' GRFASETRAP SOILS FEL?
COMPENSATION INSURANCE
(This section need not be completedHthe permit is forone hundred dollais Dita0 SEWER-SANITARY-STORMG 2000, ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/F.LpR -not employ my person in any manner so as to become subject to the WorkersPAID
Compermlimlawsnf Crdifomit. Date WATER SYSTEMITREATING Date Receipt
Z Z Applicant
C NOTICE TO APPLICANT:IL after makingthis Certificate of Exemption,y ushould NEW RPSI DENTIAL PIAS. SQ,FIL
o TOTAL:
Z ) became subject to the Woheh Compensation provisions of theeCadc,you man
fonhwi@comply with innm
such provisions or Permit shell his dmed invoked. BUILDING FEE /a
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby affirm that hem is a construction[cutting agency for the performance of
V O the work for which this Permit is issued(Sec.3097,Civ.CJ TOTAL: eLECTRIC FEE
Lenders Name
L7. Lender s Address QTY. MECHANICALPERMIT FEE PLUMBING FEE O
L) 1 certify that I have mrd this appluairm and state that the above information is
s� 4 careen.Iagree tin comply with all cit,md county ordinances and state laws relating to PERMIT'ISSUANCE r�MECHANICAI.FIy
Vf-' fn building construction,and hereby authorize representatives ofthiscily income upon the CONSTRUCDONTAX
q above-mentioned property for irmpection purposes. ALTER OR ADD TO MECIL
r7 (We)ug.to save,indemnify and keep harmless the City of Cupertino against
fielallhael,judgments,costs and expenses which may in any way accrucaguinst said City AIR HANDLING UNIT(TO 10,000 CPM)
inane¢ gruntin of th's noir. TT AIR HANDLING UNIT(OVER 1030001 CFNB
VuN�
Signature of ApplicanUContmmor ll Date / EXHAUST HGOD(WNUCf) p,s"
HAZARDOUS MATERIALS DISCLOSURE IIEAI'(N,UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or ftuure building oceaPantiame or handle humorous material HEATING UNIT(OVER 100,000 BTU) TOT
as defined by the Cupertino Maniacal Code,Chapter 9.12.and the Health and Safety
Code,Section 25332,17 VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
Will theepPlicanmrfmuin building occupant useeyuipmenmmiBOILER-COMP(3HPOR 100,01 Bl'U) ISSUANCE DATE
rdevices whiche
I V
hazardous air contemins as as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 10J."BTU)
DistrinT
❑Yes ❑No NEW RESIDENTIAL.MECH.—SQ.Ff. P A
I have mud the barbarous Coci materials requirements under Chapter 695 of the �V��� ����
iftheuil Iftedth ng chaff Safety Cade,Sectionssm,d,l it is and 25534.1understand that 08
if the building thatitismyresponsibility ronotifythe
occupant of Ne requimnents which most be inn prior to issuance of a Certificate of
Occupancy. - Ca T r
Owner m mmhmiud a,cut Data TOTAL: ISSUED BY:
,