25814 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO n ILUI ELh61R1 AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTID IANICAL 25814
BUILDING PROJECT IUNN'1'IFICAI'ION
BUILDING A]DDRESSSS: I1 - SANITARY NO. APIPILICA'11ONSSUyBMMII'TI'ALDATE
l o` /A(,r ^-e v z)`7 UNIT# LOT J ylrvl l
OWNERS NAME: A �`J PRONIi: _ n CON ACI'Oq'S NAME lA� Ll NO: 4 { V
P 3 V L l G,/ 7%-4 nl 7rnn71P7` f/G_ N/C CONTROh p
HCHTTEC'1'/IiNGINEER: LIC NO: ADDRF. 57U�� FMCt(NFiI.D D2 - ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT 1'L B MECH
PHRMITISSUANCE -
LICENSEUCONTRAerproaDECLARAThON APPLIANCES-RESIDENTIAL gpyGplF�+PION
OCZ thereby affirm theni E licensed uACTORvlaDECL DECLARATION
with
11100 Section 00)01 of Division 3 of the Business and i'mfesamns Calc,and my license is in PANELS
y.U
fall force and effect.
Qz License Class Lim.# UPT0200AMPS
F 6 y Date Crntm". 201-I INTO AMPS
ZOy� ARCHITECTS DECLARATION OVER 1010 AMPS SQ.FI'.FLOOR AREA S/SQ.def.
I understand my plans shall he used as public records. (►
FyFul SIGNS ELECTRICAL.
4 Licensed Professional V
6 that
IOWNER-BUILDERexempt DECLARATION SPECIAL CIRCUIT/MEC. s�
OyF 1 hereby affirm then um exempt from the Contractors License Law for the t lJ Illi
3Won lmlmdr,re...r.(Section 9031.5.Business and Prnfessions Calc:Any city or county TEMP.METER OR POLE INST. 1
�.�-.�g wM1ich 2yuircsepermitmconstru<L aller,impmv0.demolish,or repair any structure POWER DEVICES
E Y,2 primm its issuance,also requiresthe applicant fasuch Permit n file a signed statement
1,0 that he is licensed pursuant to the provisions of the Contravenes License Law(Chapter
4 0�' 9(commencing with Section 7(ad)of Division 3 rfihe Business and Professions GWe) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefmmand the basis for rhrulleged exentplion.Any violation of OU'T'LETS-SWI'fC111:9-PIXTURE9 O�—_
GSection 00315 by any applicator for a permitsubjects the applicant to a civil Penalty of
nm mane than rofve he mr ny,ormyempl jQ NEWRFSIDENTIALELEC1R _SQ,FE STORIES 'ITPECONSINUCION
❑ I,urwncrofthepropeny,rrmyemployeeswith weguutheirsolecamp<nsmion,
a cal
willdr the work,and the swnum is not intended orrffered bristle(Sm.7 4 ,Business
and Professions Cale:The Comrunors License Law does not apply to an owner of
property whohuildsorinu roves thereon,and whodoes such work himselfrrthrough bis
own employees,provided that such improvementsme not intended oroffemd for side.If. OCC,GROUP RES UNITS
however,the building orimprovement is sold within one yezrideompletion,Roessner.
builder will have the burden of that he did not build or ire for f TOTAL:
proving prove purymeo
ale.).
❑ I,as owner ofthe propcny,vmexclusively contracting with licensed convaannm QTy: PLUMBING PERMIT FEE FLOOD ZONE AI'N
rt,%mat the project(Seo.9044,Business and Professions CndeO The Continent's
License Law docs not apply to an owner offrolamy who builds in improves thereon,and PERMIT ISSUANCE
who comrucn forsuch projects with acorm ctods)licensed pursuant to the Contractor's
License law. ALTER-DRAIN&VENT-WATER(EA) FEF.'SUMMARY
❑ 1 aro esempaunder Sce. .B&P C for this reuon ITT]SIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY YN_
Owner Dare REcEiPT#
DRAINS-FLOOR,ROOF, GOND.
WORKMANCOMPFNSATIONDECLARATION SCHOOLTAX Y N
❑ IM1crehy album thatlhaveacenificete of conxnnoself-imurc.nracenifiwmnf R[CIiIPf#
IPXTURES-PER CRAP
Workers Crnnkyreeion&,ttis orecertified copy themof(Sm.Jglq.lab CJwhich PARK FEE Y N
corers all employs a under this permit. RECEIPTp
GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy# IiU]LDING DIVISION FEES
Company GAS-HA.SYSTEM-FIVER 4(EA) PLANCHECK THE
❑ Candied copy is hereby famished.
❑ Cenificd copy is filed with rhe city inspecrinn division OREASIy1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP _ SOILS FEF.
COMPENSATION INSURANCE
(The a section need not he cnmpleuA it the permit is for one hundred dollem($1f(d SEWER-SANITARY-STORM HA.200FL ENERGY FEE
or less.)
I cerifytherm the performance of Ne work for which this Permit is issued,l shall WA117R HEATER W/VENT/E1ECTR
nm employ any person m any...in so qF to beComg sapjevt to the Wake. PAID
Compensmi' so�ffJ� Date Z / Yip WATER SVSTEM/1'RLATING Data Rcceiplp
Q z Applicant- ^`+ rt���--2-�
z NOTICE TOAPPLICAN makingthisCenificaleofExemption,youehnuld NEW RESIDENTIALI'LMB. SQ. T. AL:
FVJ become subject m the Wnrkcr'a Compensation,prnvismas of the Lnhor Code,you must
? forthwith comply with such provisions or this permit shall be,deemed revoked. B I
CONSTRUCTION LENDING AGENCY SEISMIC FEE `
z ]hereby affirm that hem iso consVuelts.lendingagency for the perfxonamcm of
U Q the work for which this pemnir is .cal(Sm.3091,Civ.C.) TA ELECTRIC FEE
Leader's Name
C) Lender's Address QTY. MECHANICAL PERMIT " " FEE PLUMBING ITE
V I certify that 1 have reed this application and state that the above information is
correct.Iagrce to comply with all city and county ordinances and stare laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingeorstructice,and hereby amhodm representatives ofthis city meaner upon the CONS'TRUCT'ION TAX
V aMve-meminnal property for inspection purposes. ALTER OR ADDI'0 MECH.
(We).,me to save,indemnify and keep hmor ess The City of Cupertino against
liebilities,judgmenrs,arses and expenses which may in any way accrue all said City AIR HANDLING UNIT(TO 10.000 CPM)
in wnsu ucnce n(ne g a his permit.
AIR HANDLING UNIT(OVER IB(itq CFM)
Signammof Applica nnu r Dale EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO 101.000 BTU) Dae Receipt#
Will the applicant or future building occupant store or handle hunrdrus material HEATING UNIT(OVER U00,00)BTU) TOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sarion 25512(a)? ,,fftt VENT RATION FAN(SINGLE RES]D) t
❑Yea W No
Will rhan
e�npplicrorfutum builJingaccupam uuequipmcm BOILER-COMPQHPOR 100,000BTU) ISSUANCE DATE
nrdeviceswhichemit � p
A
hanrdous air mmaminants a defined by the Bay Ams Air Quality Management ROLLER-COMP(OVER 1)0,(1(10 BTU) � D
District?
%oil . ❑Yes Nn NEW RESIDENTIAL.MECH. SQ.FT. S�� m
I have read the hnverdrus materials reyuirromes under Chapter 6.95 of the U
CWifomi.licalth&Safcry Cala Sections 255(15,25533 and 255]4. l undersmnd nm
ifrhe building does not currently have a tenant,that it is my responsibility to notify the City Ur
a.peat of rhe requirements which moat be met prior ce of a Cenifictm of '+ Mk/!'tl
xtisa 492PTOTAL: ISSUTDBVrOwnernuthmized end Dam Y
OFFICE