25924 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ROIL " A. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- . "MECHANICAL
n�C 9�2
/
BUIINGADDRESS: BUILDING PRO.IECr IDEN'rIFICATION SANITARY 0. APPLICATIONSUBMITIALDATH/O3a0AI'ckUwd- 1b,% UNIT# LOTM
CO LIC NO:
Ul
N/C CONTROL M
�ARCI ItMCLIENGINHER: LICNO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PF"E BUILDING PERMIT INTO
ELECT PLVB,,, MECH
PERMIT ISSUANCE as;K13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
0042 I hereby affirm that]am licensed underprovismnsof Chapinr9(commencing with 1 JOB DESCRII'rION
500 full love and)ofect. onlof the Business and Professions Code,and my license is in PANELS
¢ttss�� full move and affect.
m` `1,►YRs�^a'
f..,Z Lianas Class LIC.# UI"I'020OAMPS
to<y Data Contractor 301-IO00AMPS
Z0 ARCHITECT'S DECLARATION OVER IWO AMPS tr SQ.FT.FLUOR AREA E/SQ,FT.
O Z 4 m 1 understand my Plans shall Sensed m public rwoNs. /9
Q SIGNS ELECTRICAL
Prol'essimill
or < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC. t \/_1\1^ I IIIIII\Vo
F- 1 hereby affirm that I am exempt from the Commit License Law for the J '
W 3 t+.m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
t o,¢ which requites.permit to caneune0 elmq improve,demolish,or repair any strvemm DAT
is m< to irs issuance,alsore thea licant for such emir to file a si nen statement POWER DEVICES
�IEOpprior quires pP p g
C thin he is licensed purred to the provisions of the Counselor's License Law(Chapmr SWIMMING POOL ELECTRIC
1Lo0. 9(conunencing with Section 7000)of Division 3 tithe Business and Professions Cade) TJ(j l
or dim he is exenpnherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCI{ES-PIXTURIiR 1 /01� Cwt
rr_z� Seaton]031.5 M1y any applicant for u permit subjects the applicaal m.civil penalty of
orx< ore than Five hundred dollars(SSW). NEW RFSIDENT1ALELF.CTR _SQ.Ff.
I,as owner ofthe propedy,onr,employees with wages as their sole compensation, STORIES TYPE:CONSTRUCTION
a will tole work, it the smhaure usual intended m mffcted for ale lSec.]044,Business
and P fessions CWe:The Contractor's License Law does nm apply to an owner of
propert who bu,ldsorimpreves thereon,and whodms such work himselforthrough his OCC GROUP RES.UNITS
wnemp oyeex,provided Nat such improvemen¢arenot intended trofferetl ftraole.If.
however,the bufld,ngor improvement is sold within on yearorcompletitn,the owner
builder will have the trader of proving that he did nm build or improve for purpose of TOTAL:
sole.).
❑ I,asownerofthepmpay,amenclusivelycontrctingwimlicenxedetntractorsm QTY. PLUMBING PERMIT FEE It.t3oD ZONE APN
consuua the project(SIL.7041.Business and Professions Code)'The Contractor's "
License Lawdace antapPtylo anowneropm
fpeny who builds orimpmves thereonend PERMIT ISSUANCB
whocmnraas for such projems with acontracmr(s)licensed pursuant to the Contractor ALTER-DItA1N&VENT'-WATER LA
License law. (' ) SUMMARY
❑ I am exempt under Sa. ,B&P C for this reason BACK FLOW PROTTCT.DEVICE. SANITARY Y DN
Owner Data RUCK P`P#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Thereby off nn thatlh:rvee cenilicam nretnsam meelGinsure,macedificmeolRECEIPT'#
Workers'Compensation Insurance or a certified copy lhereof(Sm.3800,Lab C.)which FlX'IVRES-I'ERTRAP PARK PEI? Y_N
err all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Palley# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 BAT PLANCHECK FEE
❑ Cenifiedcopyishand famished.
❑ Candied copy is filed with the city inspection division. GREASE/INDUSTT RI.WASTE INT HRCEP1'OUR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOY'S FEE
COMPENSATION INSURANCE
(This section need nm Ise completed lithe permit is for one hundred dollars D1W) SEWER-SANITARY-STORM EA,20Orr. ENERGY FEE
ke".)
I certify that in the Performance ofthe work for which this permit is issued,I shell WATER HEATER W/VENT/ELECTR
not employ any person in any manner m as to become subject to the Workers' PAID
O 7—' AppGcam ton Lows of Collfomia. Date WA'rERSYSTEMOREATINO Dam Re«iptk
z NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should IDENTIAL PL SQ.FT. 'TOTAL:
F-i V) become subject to the Worker's Compensation provisions ofihe Labor Code,you must
�i > forthwith comply with such proviamnsm this permit shall bo deemed reaction. BUILDING FEE �R
W [] CONSTRUCTION LENDING AGENCY live SEISMIC ITE
z I hereby affirm that then is a construction lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) T .. / ELECTRIC FEE
Lender's Name� PLUMBING TEL•F^ Lcri Address QTY. ,MECHANICAL PERMIT ' FEE
L)' I torridly that I have read this application and state that the above information is
Or
�" Or comct.l agree to comply with all city and county ordinances and state laws relming to PERMIT ISSUANCE. MECHANICAL FEE
building construction,and hereby amortize representatives ofthis saym enter upon the CONSTRUCTION TAX
V 7 ohmic-mem, d roperty for inspection purposes. ALI ER OR ADD TO MSCI I.
O (We) g t s .indem y and keep hamdess the City of Cupertino against
liabilities, hdg a is costs and x toes which may in any wayeacruea 'rest anal AIRHANDLINGUNrr(TO IO,OOOCFM)
mmq. c the alln aft is permit. .{`'If/
' AIR HANDLING UNIT(OVER 10.00 M)
SiL hm,mf m Conthe Date EXHAUSTIIOOD(W/DUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will thitpplicapt or future building acceptor store or handle haamdous material HEATING UNIT(OVER IW,OW BTU) TAI
as darned by the Cupertino Municipal Code,Chapter 9.12,and the Heath end Safety
Code,Section 25532001
❑Yes 1:1 No VENTILATION FAN(SINGLE RCMD)
Will thea
ISSUANCE DAJE
]team orfmurebuilJin Luxe eviceswhich emit BOILER-COMP(3HP OR IW,MNI BTU)
pp g«capon equipmenmrJ
•hazardous air contaminants 45 defined by the Bay Area Air Quality Management
BOILER-COMP(OVER 100,000 BT'lIl
Dinnic0
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.PI'. PAID
I have read the hazardous materials requirements under Chapter 6.95 of the
California l tartan&Safety Code,Sections 8505,25533 and 25534.1 understand that FEB 1519
tithe building dos not currently have a tenant,that it is my responsibility to notify Ne
aconpam at'tha neurmm rrcnu which must be met prior an issuaneo or u CcNfiwm or
Occupancy' CITY
Ownertr amhariscd.,cut Date TOTAL: ISSUED BY: I U
OFFICE