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25575 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPF.RTINO .-IB:F.CTRME PERMITNU BUILDING DIVISION APPLICATION/PERMIT PING PRO0-MRCHATI IC 25575 11111LIsiNC PRf1J1?CI'111NY1'1PICATIk1N BUILDINQAAYDDRE.SS: n '/L µA SANITARY NO. APPLICATIONSUBMrrIALDATE .11 I r'�o5 /J 5 UNIT N LOT I OWNERS AME: PIIONI' �-�S/T CON RACfOR'g NgME: L,1'C NIJ; N/C C✓O_NTRGOLM\J ARCHITRCf/FNGINF:IiR: LIC NO: S„7 AD t': JJ Mr S.� �I�O�YC ❑ CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELECT PLUMB MECH PERMIT ISSUANCE 1:1 ❑ LICFNSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Mo4z IherehyaffimUhat l am licensed underonevisioas of Chapter9(commencingwiN JOB DESCRIPTION 11400 Section 70(1 Division 3 ofile Business and Professions Code,and my license is in PANELS qWV� fail furceandeffect. LicenUP TO 200 AMPS �A 66 L,W se Class Lic.p Nay Dalt Commctor 201-1000 AMPS Z�O,R. ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.IT. CZ-0 l understand my plana shall horsed u public retard.. OVER 101X1 AMPS < t W SIGNS ELECTRICAL yM Licensed Professional Cq 0., u OWNER BUILDER DECLARATION SPECIALCIRCUTT/MISC. X 00. I hereby affirm that I um exempt from the Contractors License law for me W 3 4 y fidlowing reason(Section 7031,5,Business and Profession.Cade:Any city or county TEMP.METER OR POLE INST. (=0 which requires a patron to consumer,eller,improve,demolish,or repair any suucmre KWQ� m its issuance.also requires the optician for such permit file a signed statement POWER DEVICES poor i pp pennt g W LL G 0 thro he is licensed pursuant to the pmvisim s of the Commnnr's Lwouse Law(Chapter 0. p� 9(commencing with Section TWO)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION µj❑y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWTfCFIES-FIXTURES tKQ no 7031.5 by any applicant for a permit subjects the applicam to a civil penalty of E 0 not more Than five hundred dollar(1500). K ❑ I,aownerofthProperty,mmyemployecswithwgnurhrwlenNEWREIDENTLELEI S .F . TYPE CONSTRUCTION y3— will ought,work,and the stmcture isnm intondedmoffered forsale(Seo.7044,Business and Professions Cade:The Cantmcmrs License law does not apply It en owner of r 1 Property whobuildsorimprovesthemon,mdwhodaeaeuch work himselforthmugh his ES.UNITS em ,p ployeesrovidedthatachimerepmvemcn,. net intendedmoffered forsale.If, ALED howcverJhe building or improvement is sold within one yemofcnmplelion,the owner- R:� % 6^a g II T q builder will have the burden of proving that he did not build or improve for purpose of YLL �Vp 7p 1 Bale.). QTY, PLUMBING PERMIT FEE 11.3Oy1/ AP ❑ Les the pmjoO(See. 7044, nous and ntrscgiions Code:) d Co mmtsto �T construct the project(Sec 7D44, aero fp and Profession Crim The Cen , rs License 4wdocsnol apply man ownero(propenywhobuildv orimprovntheswn.and PERMIT ISSUANCE E whocontmets for such projects with aconaacmr(s)licenced pursuant an the Commons Licensee Law. ALTER.DRAW&VENT-WATER(FA) FEE SUMMARY ❑ I am exempt under Sec. .B&P C for this reason BACK PLOW PROTECT.DEVICE OUTMUME—S SANITARY YN Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_ ❑ Ihercby affirm rhmlhuveu ceniOceM of consenuo self-insure,ore cedificme of 1:1%TURES-PER TRAP RE CEIPI'M Workers'Compensation Insurance or a codified copy thereof(See.3800,Lab C.)which PARK FEE Y N covers all employee's under his permit. GAS-FA.SYSTEM-I INC.4 OUTLETS - RECEI". Policy a BUILDING DIVISION FEES Company GAS-EA.SYSTEM-OVER 4(IA) PLANCHECK FEE ❑ Codified copy is hereby famished. ❑ Certified copy is Bled with the city inspection division. GREASFIINDUSTRL WASTE.INTERCEPTOR GRADING HE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (This section need not he completed iffle permit is for one hundred dollars($IN) SEWER-SANITARY-STORM IIA,200FT. ENERGY FE.E ns) I codify that in the perhurnamoofthe work for which this permit is issued,Ishii][ WAl'ER HEATER W/VP.NTd:LECTR not employ any person in any manner an m in became abject to the Workers' PAID Compensationlawsof Califomia. Date WATER SYSTEMTREATING Date Receipt# O z Applicant 0 NOTICE TO APPLICANT:If,after making this Canificale of tem you should NEW RESIDENTIAL PLMB. SQ.FT. z poo de, TOTAL: I~ y becomeh comp to the Worker.Compenstian provisionofthe Labor Code,you moat a ; forthwith comply with such provisions or this pvmigshill be deemed invoked. BUILDING FEE rrFWz CONSTRUCTION LENDING AGENCY SEISMIC FEE - 1 berehy mf firm that here is a co..card n lending agency for the performance of U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE L2. tr Lender's Name O [U-q Lender.Address QTY] MECIIANICALPERMIT FEE PLUMBING FEE 1 certify that 1 have read this applicedan and sage that the above information is >" OW., cormm.Iagr«in comply with all city ata county ordinmces and n.M laws.taring to PERMIT ISSUANCE MECHANICAL FF.E �-' IA building commuction,and hereby aralumeareprexntvivesofthis city minter upon the C.) Z .have-romahmed Property far inspection purposes. ALTERORADDTOMECIi. CONSTRUC IONTAX (We)agree in save,indemnify and keep hermlos the City of Cupertino against lishilities,judgment,embandespens hichmay i.my way merueegalnamid City AIR HANDLING UNIT(TO 10,0(10 CFM) in qct ce of rhysfri 1 -- AIR HANDLING UNIT(OVER 10,000 CFM) Si turc Applicant/Contractor ,are RXIIAUST IIOOD(W/DUM) PAID HAZARDOUS MATERIALS DISCLOSURE IIBATIN0 UNIT(TO 1011,000 BTU) Dam Rj"I.X Will the applicant or future building occupant store or handle hmurdous materiel Ilp-A'I'ING UNIT(OVER 100,000 BTU) TOTAL: as defined by the Caperton Municipal Cade,Chapter 9.12,and the I lcalth and Safety Cale.Section 25532(a)? VENTILATION FAN(SINGLE RRSID) 13Yes ❑No Will the applicant or building occupant use equipment ordevices which emit BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE hmurdous air contaminants as defined by the Bay Area Air Quality Management BOILEiR-COMP(OVER 100,000 BTU)It y� � ' o ? rrt ❑Yes 11 No NEW RESIDENTIAL MCCIi. SQ.FT. 1 have read the hazardous materials requirements under Chapter 6.95 of the SEP 24 1993 LSlifomie Health&Safety Code,Sections 25505,25533 end 25534. 1 undersand Not if the building does not currently have a Mian.Our it is my responsibility to notify the a.I '1r ` �r occupant of the requirements which must be met prior to issuance of a Certificate of C V C flay Occupancy. Owner m mmorized.gem Dam TOTAL: ISSUED BY: OFFICE ' 1 I o � a .ate © og ti pp[�ry n V VVV v J i CO ' o I Z 0 C9 y !1�#11Iry1'J'1, I 1 I i 1 � I l I LL U Q 1 I � I V ,sill Q I m