25910APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO1 1.1 IN(�TRI A PERMITNO,
APPLICATION/PERMIT PI.UMNING-MF.CIIANICAI. 25910
1{UII,DING DIVISION III111,UINO PRO.IRf:'1'IDNN'1'IPICATII3N. JJ
BUILDING ADDRESS: {�% SANITARY NO. APPLICATION SUBMITTAL DATE
/\/9M'I'M n II
OWNERS I?: .� PLO - ?/a/
� CONT CfOR'SNAME: CCle J
IVS ;�N_ICT 'ROLM
�ARCIIITECT/RNGINEER: LIC NO: ADD SS: ��� ❑
CONTACT: PHONE:
BUILDING PERMIT INFO
n J�5�'� 37�_-75"/,
QTY. ELECTRIC PERMIT' FEE
� liCll
PERMIT ISSUANCE LD ELECT PLUMB M
LICENSED CONTRACTOR'S DECLARATION APPLIANCES -RESIDENTIAL El .JOB DFSCRI
owx Iherebyaffren that l am lic<nsedwJerprovisionsnf Chaprer9(commrncing with f
PLC[uO Sermon 7001 Division 3ofthe Businosand ProfeW.mE e,and my license is in PANELS I
oto full fbro"t"" �f, /fid
I<" Licenx Clas Co, Q6 UP TO 2MI AMPS � e up
(J
mQy Date Contmctm 301-1000 AMPS (/'uV
Z FO�Z A CIIITECT`SDECLA OVER 1000AMP5 SQ.FT.FIOORAREA HSQ. IT.
O Z —C 1 understand my plans shall be used as public mcmds
r n � SIGNS ELECTRICAL /'�
K '4 Licensed Professional 06`�-
0,C) OWNER DECLARATION SPECIAL CIRCUIT/MISC,
yaqOaF I hereby uflimh that I son -
m exempt from the Contractors License Law for she II II g_
W3�m whichfolloveingremmr (Section co3L5, Business and improve.
de oli Co de: Any city nr county TEMP. METER OR POLE INST. R,
POWER
1—
which requires a permit m construct, alms, improve, demolish, or repair any structure C
prior to is issuance, also requires the applicant far such pemail m file a signed statement POWF,R DfsVICES `
that he is licensed pursuant m the provisions of the Contractors License Law (Chapter
a0.x o�' 9(commencing with Sermon 7100) of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VA.CATION
W_m or tint he is exmnpuherefnan and the basis for the alleged exemption. Any violation of OUTLETS - SWITCHES.FIXTURES 50—
not
Section 70315 by any applicant for a pemhit subjects the applicant to a civil penalty of
not mom than Ove hundred dollars ($500). NEW RESIDENTIAL RLECIR _SQ. IT.
o ❑ I,nsownero❑hepmpeny,ormyemployeeswith wagesas thcirsalecomparetraon, STORIES TYPECONSTRUCION
will do thework, and the sonnet is not itnendedomffered forsale(Sec. Mom, Business
and Professions Code: The Contractor's License Law does net apply to an owner of /
property whobuildsorimproves domemand whodoes such work himulforshrough his OCC.G UP RES. UNITS
own employees, provided Nuauchimpmvernermaren0t in cr dedorofferedforsnle. 1[
howeer, will have
burden
or proving that
liwithin id one year of cprove on,far phe urpose f TOTAL /��
.aider will hour the burden oT proving tint he did nm build m improve for purpose of
sled.
❑ I,azownerofinepropeny, un exdusivelyconvacting wish licenud cammemmo QTY. PLUMBING PERMIT PIiE FL ULONE APN
construct the project (See 7()14, Business and Professions Code:) The Common's PERMIT ISSUANCE.
License Law does not apply [(,an owner of property who builds or improves thereon, and
who contracts for such projects with a contacmr(s) liecowd purauwuo the Commemee
License Law. ALTER . DRAIN & VENT- WAFER IRA) FEE SUMMARY
❑ I am enempt under Sec. B & P C for shin reason BACKFLOW PROTECT. DEVICE O . I E FEE
Owner Dose SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS- FLOOR. ROOF, AREA, COND. RECEIPTN
SCHOOL TAX Y N
❑ Ihereby affirm that l have a certificate ofcomunt to self -insure, or a certificate ofFIXTURESRECRIPI'p
XTURfS -PER TRAP
Warkers'Compensetion lnsmmnceoraceri Red<opy thereof (Sec. 3800, Lab C.) which PARK FEE YN
covers all employ rola GAS- HA. SYSTEM. I INC. 4 OUTLETS RECEIPTp
Pnl vyM 767 BUILDING DIVISION FEES
Company GAS - EA. SYSTEM -OVER 4(EA) PLANCHECK FEE
❑ Ccrrfiedcapyi creb famished.
❑ Cenified copy is filed with the city inspection division. GREASPONDUSTRL WASTE WERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHTRAP SOILS FEE
COMPENSATION INSURANCE
(Thisscnionmecd nos he completed ifthe permit is resume hundred dollars (S 100) SEWER - SANITARY - STORM EA. 200FT. ENERGY PGE
m less.)
Icertifythuliithe perf nonce ofit workforwh'mhthixpe chis'sued. hal WATF.RIIIETERW/VENT(ELECI'R
oat employ any personIn samer ns ao sa become subje t PAID
Compnsa
etionlnwSof orifi D WATER SYSTEWMEA'TING Dam Receipt#
O Z Applicant (� (I}�.ch
0 NOT ICG' TO APPLIC fterm ing this Certilicme of Exemption, you should NEW RESIDENTIAL PLMB. SQ. FT T TAL:
f/3 become subject a the Worker's Compensation provisions of the Labe Code, you must
FFFa"'; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING ILE
W z CONSTRUCTION LENDING AGENCY SEISMIC PER
^� I hereby affirm that here is a construction lending agency for the performance of
U O the work for which this lemon is issued (Sec. 3097, Civ. C.) TOTAL: HLF,CTRIC FEE
U.Lenders Name
O F Lenders Address QTY. MECHANICALPERMIT FEE
PLUMBING FEE
U 1 certily mut 1 have read this application and sone that the above information is
correct. In tocom 1 MECHANICAL FRE
gran comply all city wJ<nunty oNinances end stain laws to PERMIT ISSUANCE
F-' building construction, and hereby scheme representatives ofthis city m enter upon the CONSTRUCTION TAX
U Z above-empro ed pro rtyfarinspectien purposes. ALTER OR ADD TO NIECE I.
(We) agree m, afi,.,t
emnify andke armless the City of Cupertino against
Iiuhilides,Judgmo t cJoxpcnseaw ch ay in any way accrue against sol City AIR HANDLING UN IT(TO 10,000 CFM)
ronuquenceo ggNNis it
AIR HANDLING UNIT (OVER 1(1,000 CFM)
Signamreo A ant/ ontrnaor ef
Dat EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MA IiRIALSGISCLOSURE HEATING UNIT (TO 100.000 BTU) Dem Recei Ip
Will the applicant or future building mourner store or handle haurdous material HEATING UNIT (OVER 100,00E BTU) 0
as defined by the Cupertino Municipal Code, Chapter 9.12, and she Health and Safety
Cndo; Section 25532(e)Y
0Yee 1:1 No VENTILATION PAN (SINGLE Il
BOILER - COMP DHP OR 100,000 BTU) ISSUANCE DATE
hazWill thespend
connotations
ns its building by the tuseequip Air Quality Manaes gement - P p
•
District'
air cmm�minanrs ns defined by the Bay Arca Air Quality Management BOILER -COMP (OVER 100,000 Ell U)
1— M
Distrin?
Cl Yes ❑ No NEW RESIDENTIAL MECH. SQ. FT. APR
{] n �^
1 have read the hannNnus materials m,mmmems under Chapter 6.95 of she A R til FI k�
California 1leahh & Safety Code, Sections 25505, 25533 and 25534. I understand fiat CI I Y Vr
Tthe building does not currently have a tenant, that it is my responsibility m early the 0111
occupant of the requirements which must be mer prior to issuance of a Certificate of
Occupancy. -
Owner or authorized] agent Date TOTAL: ISSUED BY:..
OFFICE