25513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'PINO IBR, 6.soC-E1'HCTRI�"' PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PIAMBNG-MF.CHANI25513
111111.DING PR(1dR(TI'IDN:N'I'IFICFICA'1']ON
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITI'ALDATE
1 /- If1�Nrrx LOT# Ul2 I.
+ OWNER NAMfi: PHONE: CONTRACTOR'S NAME LI 1 •!
1 N/C CONTROL p
\RCI 11ITCOENG INIBBL LIC NO: A KESS: kyd ❑
CONTACT: PHONE: faT _g 1 ^*$a 1
QTY?'f,-t a,` ELECIRI PERMIT. FEE BUILDING PERMIT INFO
n 3 k VNNr!d*t Y.#t BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 11 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
0.'Z l hereby union that l am licensed underprovisimsof Chapter9(conmmcingwith
00 Section 700h of Division 3 of the Business and Professions Code,and my license is in PANELS
U�
lull form and affect.
F Licenx Clns LIC.# UP TO 200 AMPS
m h Dale Comrecmr 201-1000 AMPS SQ.PI'.FLOOR AREA $/SQ.IT.
ZOy'� ARCIIITECCS DECLARATION OVER 1t00 AMPS
Q I undersland my plans shall be used as public re cords.
ryn , SIGNS ELECTRICAL II ® l
Q Licensed PmfeseimmI J
tY IN
OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MISC. 'S
EMU 1 hereby affirm that I am exempt from the Contractors License Law for the I[I L✓
tr13 4 aai following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE LOST, h V p IIII
t�Om.] which requires a patent m co estrva,after,improve,denalish,or repair any ametma 4 ��
�raN�a11}2 Prior la in issuance.also requires the applicautfor such pemdno file a signed statement POWER DEVICES (� 9i
Om met he is licensed pursuant m the provisionsofthe Commucmrs License Law(Chapter SWIMMING POOL ELECTRIC
r'XCLL 9(commencing with Section]0)0)af Division 3 ofthe Business and Professions Cade) Al.V
—00
,:2,, orlhat he is exempt floorboard and the basis for she alleged exemption.Any violation of I
F-Za Section 7031.5 by any applicant for a permit subjects the applicamm.civil penalty of OUTLETS-SWITCHES-FIXTURES
�Z not mom than five hundred dollars(5500).
Q
❑ 1,asownaoftM1epropeny,ormyemployerswith wegesestheirsolecompensetion, NEWRESIDENTIALELECTR _SQ.FT. STORIES '1'YPECONSTRUCI'ION
i3 will do The work,and the structure is not intended or offered for sale Sec.7w,Business
and Profcsnions Cobe Use Cmoram is License Law does not apply m an owner of
property who buildsnrimpoweallureon,and whodues suchwors druselforthroughbis
I provided that such improvements areaot inmirmoroffered fnrsale.IL DEC.GROUP RLS.UNITS
own amp thecs,pmvi
bowevemdmavo llocla improvement issold within oneyeatofcompletionthe owner-
huilderwill hove lM1e burden of proving[hal he did not build or improve for puapnx of TOTAL:
W..).
❑ I,as nwncroftba property um exalusivelycomuctingwLhlieenseJconvaa rsm gfyY } X ,PLUMBINCPERMITFEE,(- FLOODZONE APN
construct the prgjeal(See,7044,Business and Professions Code:)The Contractor's
License Lawdoes not apply to an ownerofpropeny whobuildsmurnproves Mercon,and PERMIT ISSUANCE
who comrnets forsnch projects with acontructuds)licensed pursuant to the Coronas
Licroso Law. ALTER-DRAIN&VENT-WATER UPM - •FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE CUTS IDE FEES
SANITARY Y—N
—
Owner Data DRAINS-FLOOR,ROOF,ARECOND. RF.CEIPTx
WORKMAN COMPENSATION DECLARATION A, SCHOOLTAX Y N
❑ Thereby affirm that l have acenificamofconxnttoself-insure,oracenificateof FIXTURES-PER TRAP RECEIPT#
Works.Compensation lnumucaora certifiWcopy Nereof(Sec.3800,Lab C.)which PARK PEE Y N
rovers ell employas's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECHIPE 4
Policy# BUILDING DIVISION FEES
C pmY GAS-EA.SYSTEMOVER 4(EA) PLANCHECK FEE
Certified copy is hereby fumishaL
❑ Certified copy is filed with the city iaspection division. GREA MNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ITE
COMPENSATION INSURANCE
(This section need not he completed ifthapermit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I comynal in the performeneeof the work for which this permit is issued,Isbell WATER HEATER W/VENT/F.LECI'R
not employ any person in my manner so as to become subject to the Workers' PAID
Compensation Lawsnf Culifomia. Dam WATER SYSTEMRREATING Date Receipt It
Q z Applicant
z C) NOTICE ID APPLICANT:If,after ranking this Cenificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT, TOTAL:
V3 become subjectto the Workers Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. - BUILDING FEE 0/a
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is is construction leading agency for the performma of
that wars for which this tis issued(Sec.J09],Civ.C.)
O Permit TOTAL: ELECTRIC FEE
Lenders Name
u"' F 1enJerx Address QTpY,i�';i. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have rod this application and sum that the above information is x' - MECHANICAL FEE
correct.l agree m ate comply with all city and county ordinances and slaws relating to PERMIT ISSUANCE
1--' pj building construation.md herby anhmim representativesofthisciry mcnter upon the CONSTRUCTION TAX
V Z aemb
bove-mered pnose.prdy for inspection purpALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino again
Iiabilitics,judgmenu.cosuand expenses whichmay in my way xcreagaimi said City AIR HANDLING UNIT(TO IR"CFM)
h
I te gmming of Nis peamil.
in consrgycncco f AIR HANDLING UNIT(OVER 10,1100 CFM)
+ Art a rn Ln 4EXHAUST HOOD UVMUCD
Signatumm of of Applicant/Commctnr T Date PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Beretta Of
W III the npplicnnt Or furore building ocemam stere or handle hvardous material ]RATING UNIT(OVER 100,(X10 BTU) 'f0'1'AI,:
m define]by the Cupertino Municipal Code,Chupter9.12.and the Health and Safety
Codd,Section 215320)? VENTH.ATION FAN(SINGLE RLSID)
El Yes ❑NO
ISSUANCE DATE
Will theapplicanlnrfmure huildingoecupant useequipmemordeviceswhich emir
BOILER-COMP(3HP OR 100,04(d)BTU)
axadous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
istrim? ##��
11 Yes 11 No NEW RESIDENTIAL MECH. SQ.FT. g^' A D
I have read the hazardous materials requirements under Chapter 6.95 of the ���
Cif hemuingdo&Safetyentlybse.Sections itis and25534. 1itytonanfy thehad n�
thebuildinglth Saetyreoehavevtest,thatitis myresponsibilitytosonifythe
Occupant of the requirements which must be mer prior in issuance of a Certificate of
Occupancy. CI I�y�)yl�yQ�
Owner or nulhorizcd egend Date TOTAL: ISSUED BY: Float/