25403 _ APPLICANT TO FILL IN.INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II......'G--FLECfRICAI' PERMITNO. 25403
� A /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CENTI- 2540 �{
HIIILUINI:PROJECT'IDEKfIFICATION L 'T V
BUILDING ADDRESS: r^s))nn (ID SANITARY NO, APPLICATIONSU4MITTALOATE
1 30 ',VC / W UNIT# ^ LOT# C
OWNS SNAME: L� PHONE: 4ADDHIS
CfOR'S NAME: [..-'� .1 O�O
D I�[/� l NIC CONTROL#
49ARCHITECTIF INFER: LIC NO: :
CONTACT: PHONE: ia BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE X 1i
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affirm that l am licensed under p (commencing with JOB DESCRIPTION
Oa'Z Y Prd Professions
and
If=
POO Section a and of Division 3 of the Business and Pmfeosiom Code,end my license is in PANELS
�UU full force and efrec /
T„ZIY License 1 Lic.# 7d UP T0200 AMPS O�
m Q ti €6�Cantmnm 201-RNp AMPS
ZOyl' ARCHITECTS DECLARATION OVPJ11000 AMPS
SQ.fT.FL AREA $/SQ.FT.
p 1 understood my plans¢hull ha used as public records.
F y�tsl SIGNS ELECTRICAL
gg�� Licensed professional ' IN ALE ® I IV B
OWNER-BUILDER DECLARATION SPECIALCIRCUTTMISC.
KOiF I hereby affirm that 1 am exempt from the Connacmis Lian¢e law for the
W 3 W m following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. OMP I l
I='O j which requites a permit to construct.alter,improve,demolish,or repair any structures
dd gY2 prior to IN issuance,also requires the applicant for such permit o file a signed statement POWER DEVICES
_<Oz that he i¢licensed pursuant to the Provisions of the Contractor's Limns Law(ChapterDATE
W eLL 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC p N
yYj_y onhat M1e is<x<mpt terefmmend the besiifor the alleged exemption.Any violation of OUTLETS-SWRCHES-FIXTURES
�zQ Section 7031.5 by any opplicnm fmapennit eubjene the upplicenuoacivil penalty of
not mom than five hundred dollars($500). NEW RESIDENTIAL ELECFT.
E S .
W � ElI,asowneroftepropcny,ormyemployeeswithwagesastheirsolee mpcnmtion, Q STORIES TYPECONSTRUCTION
d will prnc�wmk.undo: he Cotiactornmmledmofw does ., poly I.an Business
.. and professions Code:The improves
hereon,Liana Lew docs not apply m an owns iof
s
ownpropenywhob,Mviior im ntesthimpmvdwhadmssuintendch orofff for0e.hrough his OCG GROUP RFS.UNI'T'S
wnemployaa,progorimpr improvement
within
neyear fco#tenon,the own If,
hoverer,the
have
the
burden
ofpmem is sold within one year or improve
the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for pugose of
C3
❑ I,aeowncra0he property,em cxclusivelymntmning wit llcrnsal conlmcbntn QTY. PLUMBING PERMIT FEE FLOOD ZONE pPN
cnnswcl the project(Sec.7W,Business and Professions Cod")Too Contractor's e
Licenselawdaman snot apply ownerofproperry who builds.,imrapvm temao,and PERMIT ISSUANCE
who contracts for such projects with a comracor(¢)licensed pursuant o the Commcmis ALTER IFA
License Law. ) FEE SUMMARY
I] 1 stn exempt undo Sec. B&PC for this reasoBACK ROW PROTECT.DEVICE DT'ID."Mn
SANITARY Y N_
Owns Dam
WORKMAN COMPENSATIONRECF.IPI'#
DRAINS-FLOOR,ROOF,AREA,COND.
DECLARATION Y N
❑ Ihereby affirmthat l have seenificam ofcom<nnoself-Insure,oraartifimroof FIXTURPS-PER TRAP RECEIPT'#
em
Wnrkec'Compensetion lnsurenceoracenifieJ cnpyl of(Sa..3800,Lm CJwhlch PARK FET? 'Y N
e Ile ployRe's4upp 11si+gGAS-EA.SYSIEM-IINC.4OUTLETS RECEIPT#
Policy p .L'— /1/YS T`"��V BUILDING DIVISION FEES
Company — - GAS-EA.SYSTEM-OVER4 GIA) PLANCHECK FEE
❑ fled copy is hereby famished.
Certified copy is filed wit to city inspection division, GRBAS RNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOUS FEE:
COMPENSATION INSURANCE
(Thissuconnced not the completed ifte Permit is Toon hundred dollars($100) SEWER-SANITARY-STORM HA.200FT. IS_O ENERGY FEE
or Iwo
I certify that in the perrormunce ofte work for which this permit is issued,l shall WATER HEAT ER W/VENVELECTR
not employ any person in any sumer sec on to become subject to the Workers PAID
Cm,musmionlawsof Califomia. Data WATER SYSTEM/IREAGNG Data Receipt
0 Z Applicant
0 NOTICE TO APPLICANT:If.after making this Ccnifiate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
CA become subject m the Worker's Comparram m provisions of the labor Code,you..at
7
forthwith comply withsuch provisions or this permit shall be decontrol revoked. BUILDING FEE
0. Q
CONSTRUCTIONemisacLFNDING AGENCY SEISMIC FEE
UZ I hereby hickaffirant that there is i construction lending.C.) for the Performance of
0 Lhe mderk far which this parotin I.issued(See.3097,Civ.CJ TOTAL: ELECTRIC HE
0 � Lenders Name
0 dIa Address QTY. MI?CIIANICAL PI?KNIT FEE PLUMBING FEE Q
1 certify tat I have rend this application and stem that the mM1twe Information is MECHANICAL FEE
�-' AW., wrt<n. lagree mcomply harebylcityand coumyaNinan<mand state laws,upon the PERMIT ISSUANCE
F" Z abocangcotioned mend forinspetonureprsentatives aflhi¢cily mercer upon the CONSTRUCTION TAX
U Z strove(We)a am,1.
and pu,lwses. ALTER OR ADD TO MECH.
(We)agate nt save,indemnify and keep harmless to City of .at.a a against
incoitaquedgmend",good"mdexpenseswhich may loony wayecerme at said City AIR HANDLING UNIT(TO IO,l100 CFM)
in<nnsequena of to granting of tis penult.
9, AIR HANDLING UNI'T(OVER 10.(X10 CFM)
gfA ,Beam/Commcmr Data EXHAUST HOOD OVIDUCT) PAID
HAY.ARDOUS MATERIALS DISCLOSURE HEATING UNIT('I'0100.00 BTU) Dam Receipt If
oat ,(
C1the applicant or furore building occupant mate or handle hrrardom,material HEATING UNIT(OVER 100,000 BTU) TOTAL: 3d.D
as defined by the Cupertino Municipal Code,Chapter 9.12,and to Ifealth and Safety
Cade.Section 25532(e)7 VENTILATION FAN(SINGLE RHSID)
EI Yes
Will tea licamorfumrc brildingoccu BOILER-COMP DIP OR 100,000 BTU) ISSUANCE DATE
pr he Bay Are.Air Quality Management
PAID
. Dounlous air cnmvninenrs es tlefined by the Bay Area Air Quality Munegcment BOILER-COMP(OVER 100.000 BTU)
DI¢V Ct7 C [y1.AUG
❑Yes NEW RESIDENTIAL.MECII. SQ.FT. /{ -C2 1J(]J3
1 have read the humorous matenuls requiremems under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand tat
ifl building docsnm currently have a tenant,that it is my responsibility Inanity the CIIY UF CU1-Cn 1114U
cu ant of the regal, ems which must he met m issuance 0f.Certificate of t'
ra onudagem Date TOTAL: ISSUEDBY: �1�G