25394 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO '�"�' 'S'I'R A PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25394
BUILDINGPROJECTIDENTMEATID—
BUILDINGADDRESS: ,(/.Iy� SANITARY NO. APPLICATION SSU'BBMHTTAJL DATE
I(o 5 � S Q / et/ , UNIT# LOT# 12--2-7-9
2� F--9
OWNERS NAME: ON F.: CONTRACTOR'S NAME: LIC NO: 111 11..
I m Q C}6_ p. / �V e N/C CONTROL#
• ARCHITECT/ENGINEER: 'LIC NO: t ADDRESS.-
1455-
❑
k5S U)rzr�
CONTACT: PHONE: y• � � I BUILDING PERMIT INFO
ELECTRIC
QPV; s P.LHCTRIGPHRMIT x . u - FEE
x. : ' .. . ..'° BLDG ELECT PL' MLCH
PERMIT ISSUANCE � ID El
LICENSEDCONTRACTOR'S
ands mammCLARATION APPLIANCES RESIDENTIAL JOB DESCRIPTION
pay Thereby affrmision Jothat Is.lilie Bmpraduprd Professions
Coer 9(commencing I,in -
a00❑ &clll rorce000)ofD'vlslon3 o//f the Business nvd//Pro@salons Code,and my llcanse is In PANELSr � /'
FZW License Clas. V i 4. Lia# V� UP T02W AMPS / !/J/u
y 5 h Date_��—a.��?� Conaacmr 201-1000 AMPS
SQ FT.FLOORAREA $/SQ.PC
ARCHITECTS DECLARATION OVER IOW AMPS
O Z—F.G 1 understand my plans shall be used ie public records. ^
r4C'1 Licensed Professional eq SIGNSELECTRICAL ® E lid 8 s
ull�{e
�Q
OWNER-BUILDERDECLARATIONSPECIAL CIRCUIT/MISC.
0.0ytJ I hereby affirm that 1 am exempt fromm the the Contractor's License Law for the p p F-1
�LLOm F. which nguiresa emit to construct,
Business and Professions Carta:Any city structure TEMP.METER OR POLE INET. ,. t �� I II frQ
which requires a pemtit m consmuct,alter,improve,demolish,or repair any stmmure `�.L YY \l
prior isissuence,assure the applicant for such permit file ass ed smtement POWER DEVICES
r quires pp pemti gn _
that he is licensed pursuam codes,provisions of the Contractors License Law(Chapter
9(commencing with Section 7000)ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
W_rn or that he iseaempt therefrom and the basis for the alleged exemption.Any violation of
a Section 7031.5 If any applicant for a Permit subjects the applicant a civil penalty of OUTLETS-SWITCHES-FIXTURES �,/
nm more than Bve hundreddalleas($500).Fpm NEW RESIDP.NTIAI.ELECTS 9Q.Pf.❑ i,asowneroftheprnpedy,ormyemployeeswithwMeswtheirsolecompensatioo, STORIES TYPE CONSTRUCTION
will do the work,and the shumum is not intended or offered for sale(Sec.7( ,Business
and Pmfessions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work ldmselfor Nmugh his OCC.GROUP RES.UNITS
own employees,provided that such Improvemmre
esanot intendedoroffered I..Ile.If,
however,the building or improvement is sold within one year ofcompleion,theowner
-
builder will have the burden ofproving that he did not build or improve for purpose of TOTAL:
We'), QTy - " `PLUMBING PERMIT:. 'EPEE r FLOOD ZONE APN
❑ I as awnernnne pmpedr am exawamely tano-aet ng wvn beenaea comractoram '„ r
onstmet die project(Sec.7044,Business and Professions Code)no Contractor's PERMIT ISSUANCE
License Law doesnot apply loan owncrofproperty whobuildsorimprore
vestheon,and
who contracts forsuch projects with a contentions)licensed puauanrtothe Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) jFEESUMMARY`L
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDH FEES
SANITARY Y N
Owner Dale RECEIPT#
t DRAINS-FLOOR,ROOF, GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
1 hereby affirm that I have a certificate a consent I.of(Sesum,La certificate of RECF;IPP M
Workers'Compensation Insurance oracettified copy thereof(Sec.3S00,Lab C.)which FIXTURES-PLR TRAP PARK FEF. YN
ell all amp`R,omll5h�pemnt, GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING E(El T#FEES
Policy !/T /
�s
❑ ified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
49�Ceftbfirsd cagy is filed with duality inspection di,orear. GREASEINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKER, GRF.ASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thixseotion need not be completed ifthe permit is for one hundreddollsba SH(p SEWER-SANITARY-STORM P.A.2001cf. ENERGY FEE
a,last.)
I codify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lmeird Califomia. Data WATER SYSTEM/TREATING Date Receipts
Q z Applicant
�ZZ+ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL,
become subject to the Worker's Compensation provisions ofthe Labor Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked- BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a coasvuation lending agency for the performance of �\
O the work for which Nd(S
is permit is issueec.3097,Civ.C.) TOTAL: arJ ELECTRIC FEE
Lenders Name Q a { -_ r��
Lenders Address - TY. MECHANICAL PERMIT FEE PLUMBING PLUMBING FP.P.
O W 1 certify that I have read This application and state that the above information is - -
�" correct. l agree to comply with all city and county ordinances and state laws relating do PERMIT ISSUANCE MECHANICAL FEB
hbuilding construction,and hereby authorise representatives ofthis city to enter opera the CONSTRUCTION TAX
V y above-mentioned property for inspection purposes. ALTERORADDTOMLCH.
�i (We)agree to save.indemnify and keep harmless the City of Cupertino against
iabilitiw.judgmenb,costs and expenses which may in any way acerueagainst said City AIR HANDLING UNIT(TO 10,000 CPM)
in consequence of the gaming of this permit.
AIR HANDLING UNIT(OVER I(LOW CPM) �L
Signature of Appllcent/Comraemr Date EXHAUST GOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or foots building occupunt smre or handle haeardme internal HEATING UNIT(OVER 100000 BTU) TOTAL:
as defined by the Cupenino unicipal Code,Chapter 9.12,and the Heal,h a ,
nd Safety r
Cede,Section 25532h, VENTILATION FAN(SINGLE RESID)
11 yes No
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will the applicanmrfowrcbuildingcecupand useequipmenmrdevices whichemit Al }���rrpp
hazardous air contaminants defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) F A 'lye
Dlsdo .
❑Yes �No NEW RESIDENTIAL MECH. SQ,F4.
I have mad the hazardous materials requiremenrs under Chapter 6.95 of the DEC R 7 1993
Califnmla Health&Safety Code,Sections 25505,25533 and 25534. I understand that
ifrhe building data not curendly h anam,that it is my responsiblilty to notify the
a a f re airmen,w h sk, ro t promo Issuance of a Ce fire of
Ceyp � �Cilll VU wEGf5111YV
IA
Choler or authorized a m 'Date TOTAL: ISSUED BY:
OFFICE—-