25560 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO " H.DI '-ELECTRICAL PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 25560 5 5 6 0
BUILDING PROJECT IDEST IFICA'HON c
BUILDING ADDRESS SANI'T'ARY NO. /AAvJi%ICA'fION SIIHMTITAL DAT I:
UNIT# LOT It , N—I
OWN RS NAME: PHO E: 2' CONTRACTOR'S NAME: LIC NO: 1111
11L l� . LIF 27P 2 NIC cov EOL«
"�ARCHI'f1iCT'/P-NGINEER: LIC NO: ADDRESS
SW > rte (oRZ r, 0110 Sill AAIIDA)lo uD 94305 EJ
4'CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
IL1L )A :11,5-4q4-701V J PERMIT ISSUANCE BLDG ELECT PLUMB MECH
LICF.N5131J CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL EllEn
0042 I hereM1yam that l am licemedumder,onsciocom
neufaitiner9( menting with )OB DESCRIPTION
POO p Section7")of Division 3 of the Business and Professions Code,anti my license is in PANELS ��
CUE frllforceald If t.
V,Z ty Liana ass Lic.N� 'i F37_. UPT02MAMPS
rn=y Duu Contracmr zy' L� 201-1000 AMPS
z0�7z ARCHITECT'SDECLARATION OVER I(IOIIAMPS SQ Fin ARMs f� , $/SQ.FT.
02-a0 IundcrsmnJ my plans slnrll be uxJ es Puhlic recoNs. I�,... Isl II p>r�
rr45.w4 SIGNILLECTRICAL \ L'�., 0 V
Y K<,� Lrecnxd Profcsvonal P
� T E— R
i c'u1V OWNER-BUILD Ek DECLARATION SPECIAL CIRCUD'/MISC. 1 IPS.
iCO aF.. I hereby affirm that I an exempt from the Comment' License Isw for Mc
W3LLOti fallowing rcasoa(Senion]031.5,Business and Prnfessio Cusle:Anyciymomnty, TEMP,METER OR POLE INST.
pJ a which rcquirea a permit to wnntrnet,eller.improve,d olish,nr repair any court ure
'LLLL�11a� poor to it,issuance,also requires duripplicant fon permit m fileasigned ataumrnt POWER DEVICES
y)Kp0 (lathe is licensed pursuant m the provisionsul Contractors License Law(Chapter
d4o� 9(commencing with Section 7")of Divisi ofthe Business and Professions Code) SWIMMING POOL ELECTRIC /• VAI UATIO
blill
e"ok
( _y orthathcisexempiturefromandthebas' or the alleged exemption,Any violation of OUTLETS ,1 wail
[-.IT Senion](13151, anyapplicuntfnra unit subjects the applicator a civil penalty of ` (,Jud
y�y 0 ll re than fvchundreAJnllors 500).
p ❑ LisownerNlhe t m em to eeswifh wages as oheirsolecom NEW RESIDENTIAL ELELTR _SQ.FT.
e' P«mer Y� Y P Y g 1,Business
STORK 1'YPI:CONSTRUCTION
y 3r_ will dotheande roue not is License Lo etd for ntapplale y to an Boniness
end Professions Code:Th ommctors License Law docs not apply m an owner of
propertywhObuddsor ves themon,andwhodoeaauch work himselforderough his
employees"" it thatauchimpmvememeurt noointendedornfkrcdfmrsele.IL OCC.GROUP RES.UNITS
however,thebuild.. or improvement is sold within one yearo!completion,the owner- 'ID
builder will have w burden of proving that he did not build or improve for purpose of
sale.).
❑ I,can croOhepropeny,amexdusivelycomrocting withlicrnsd convanon oo QTY. PLIJMRING PF,RMIT FEE FLOOD ZONE
APN
constmct a project(Sec.]Bi4,Business and professions Code:)The Commcmr's
Liter ,awdres not apply to anownerofpropeny who builds or improves thereon,and PERMIT ISSUANCE
who Tirana fur such projects with acomvacmr(s)licensed pursuant to the Contractor's pL'IER- WATER(BA)
Lic use Law. DRAIN&VENT- PGF,SUMMARY
❑ 1 um cxcmpt under Sea ,B&P C for this reason BACK FLOW PROTECT.DEVICE 011,IDE FEES
Owner DateSANITARY Y N WORKMAN COMPENSATION DECLARATIRECEIPT#
-1 ON DRAINS-PLOOR.ROOF,ARFA,COND.
SCUOOL'1'AX Y N
❑ Ihcmby affimrthat lhuve eccnificate ofcmnxmto self-iwur<,orecetificete of RF,CEIPT#
FIXTURES-PLR TRAP
Workers'Compcmation lneurana orecenifieJ<npy thereof(Sec.3gfXl,Lab C.)which PARK FIO? yN
Policyalrove.ul�gq plLyep,.sy Oc{hy+pertlll_. _r GAS-FA.SYS'FEM-IINC.4OUTLBTS RECHIPTk
W DCIa 251 (d3JxF BUILDING DIVISION HI tS
aCompany #4ATU>A It h 1L- GAS-PA.SYSTEM-OVER 4 03A) PLANCHBCK FEE
C1 Certified!copy is hereby famished. mo
Cenifid copy is filed with the city inspection division. GRBASEnNDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE 017 EXEMPTION FROM WORKERS' GREASE'TRAP SOILS F131?
COMPENSATION INSURANCE
(This section rad nm bewcompeleo 'f the permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FL•E
or less.)
I Terhythat int he perfn fine work for which this permit is issued,l shall WATER ItiATER W/VENDAILECIR
not employ any person) y manner so us m beemme subject m the Workers PAID
Compensation Litivip Lulifomia. pine WATER SYSTEM/TREATING Data Receipt#
Z
NOTICBTOAPPLICANT:If,after making This Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.FT. TOTAL:
t•+ � become subject to the Workers Compensation provisions of the Labor Code.you must
•�' 7 forthwith comply with such provisions or this Permit shall be deemed invoked, BUILDING FEE /a
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby aflirnt War them is it construction lending agency for the Performance of 1 11
V O the work fill which this permit In issued(Seo.3097,Co.C.) ELECTRIC FEE
IL r: Lender's Name
lauser's Addre•. QTY. MECHANICA12PERMFT FEE PLUMBING FEE �r
L) I certify that 1 have Rad �s application and stare that the above information is MF.CI IANICAI.FEE
r�"' 4 correct lugrce mcimply all city and county ordinances and some levee rclming to PERMIT ISSUANCE
y building amsvudiorl hereby amhorixe representatives ofthis city to enter upon the CONSTRUCTION TAX
V 7 uhuve-memioneJ pr ray for inspection purposes. ALTER OR ADD TO MECI I.
G7 (Wc)agree to save,indemnify and keep harmless The City of Cupeninu against
liabilities,judgmeohs,costs and expenses which may in any wayacerueagainst said City AIR HANDLING UNIT(1-010,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IR"CFM)
Signature,of Applicant/Contrncur Dau EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IgLIXat ITT U) Date Reecipt#
Will the applicant or future building neap on nom or handle haysNous materiel
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)]
❑yes 'tJo VENTILATION FAN(SINGLE RESID) CF
rt
qN✓DATE
Will theapplicano orfumrc M1uildingoccupam mm
eequipmeordeviceswBOILER-COMP QHP OR 100,000 BTU)
hichemit
Inas air communism'ns defined by the Boy Area An Quality Managemem BOILER-COMP(OVER 100,000 BTU)Distric
O�s�
❑Yes 15(o NEW RESIDENTIAL MECIL SQ.FT. e Y 17 1993
I have rend the hicardd�`eas muudals oe CAy
- ) yuiremema under Chaplet fl95 of the
'California l lealth&Safety Code,Sections 25505,25533 and 25534.1 understand at
Ur (�Of-C2'2222$
if @e to
does not cu mly have eunant.that it is my responsibility to notify the LJ
opcupant of tht is hich nit be met prior to issuance of a Ctrtifiwte of
capitally. �
Owner or at,
nriacJ agent _I Duk T01'A1. ISSUED BY:
OFFICE