25380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOa L .- TRI A. _ PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINf:-MECHANICAL 2 5 3 8 0
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. � /. ,I l SANITARY NO, A^PP-ICA'1'ION SUBMITTAL DATE
[J V {' r UNIT# LOT 1/�O
WN SMli: PHONE: RACOltS LIC NO:
"' CONTROL
CH /ENGINF.E : LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QW. ELECTRIC PERMIT FEE
HLDG ISLECf PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACfOR'SDECLARATION pPPLIAN -RES .'V'N IOd D' IPT$]fJ _
pyZ (hereby affimsthetlam licensed underDrovisions ofCh.pter9(conunemarem,with _ 1E'�^T��� ��A7✓
4100 Section 70t10)of Division 3 ofthe Business and Professions Colamd my license is in pANHIS u s
yy��F fall to.and effort. �'�
<r U License Closes Lic.# UP TO 2m
y« Date Contractor 20I-I1q AMPS
FyZ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.f>r.
ZO,— IundemanJm 1 shall be used as blit records. OVER IfKK1A
OZ—O yPanss a public
F.rn W SIGNS ELf:CfRIC
(Licensed Pmfession.l
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
q�(Oy0 I hereby affirm that 1 mo exempt Gam the Contractor's License law for the
n13 V.ya fultivem, e.ams(Section703L5,Busimcss.nJPmfesslom Code:Amycitymrmmy TEMP.METER OR POLEINS'I'.
Oy J which requires a permit to consomet.nlmr,improve,demolish,or repair any structure
f;!fT� prior m its issuance,also requires the a,spliwm for such Permit file a signed statement POWER DEVICES
W—tea_C C that he is licensed pursuant to the provisions ofthe Contractors License Law,(Chapter
e 9(commencing with Section'/ONyof Division 3 ofthe Business and ProfessionsCale) SWIMMING POOL ELECTRIC a�LUA
F�y or that he is exempt therefrom and the basis far thealleged exemption.Any violation of •ss
z6 Section 7031.5by.a,applicant far a pmaitsamasa,the appl isomer,a civil penalty of OUTLHI'S-SWITCHES-FIXTURES ��I A I� L.,✓ li �I
nt more than live hundred dollar(85(10).
O ❑ NEWREmBENTIALELECUt _SQ.FT. I S Ili.m ';CON TRUCTION
m hsnwnerofrheprnpeny,nrmyem,sloyee.swith wages us theirsolecompensetlmn, Iu .0
yg-, willdomewmk,andlhestmnureisnot inlnnJM orofferW forsele(Sec.70g4,Business
and Professions Cam:The Contractors License law does nor apply to an owner of
property who lumldserimproues rhereon,mid hadces suchwmk hiareadorthmugh his D RES NITS
own employees,pmvidedthat such improvements adenotiemin doroffered forsale.If,
however,the building or improvement is sold withinone yearof completion,the owner
builder will have the burden of,sowing that he did not build or improve for purpose of TOTAL:
sale.). ,. . ..
❑ Las owner ofthe propeny,nmexclusively conuacting with licensed conunnnram 9TY. ' PLUMBINGPERMIT FEE ROOD ZONE. APN
consumer he project(Sce.7044,Business end Rofcssisms Code:)The Commnm's
License Law does norapDly he an ownerofproperry who builds otimpmvesthereon,and PERMIT ISSUANCE
whembensQS for such projects with acOOVOcros)licensed puRaaOt to the Contmelof9 se law. EA
License
pL3ER-DRAIN&VENT-WAgRR( ) FEE SUMMARY
❑ l am exempt under Sec. B&P C for this reason BACK FLOW PROTECT,DEVICE SIDE FEE.
SANITARY Y N
Owner Data DRAINS-PLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a cenificateofConsent toselGinsum,or a certificate of FIXTURES-MR TRAP RECEIPT'#
Wmkadd Compensation Insurance oracenified copy thcreof(See.3800,Lm CJ which PARK FEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenified urpy is hereby famished,
❑ Candid copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING EEE
CUR'19FICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompated ifrhe Permit is forone hundred dollars(SIM) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or less.)
Icr ify dist in the Nirfnmmrcof the work for which tor,smrit is issued,l shall WAT17R[]EATER WNEVEELECPR
not employ any peon in any manner aro as to become subject to the Workers' PAID
Compenmtinnlawsof Celifomia. Date WATER SYSTEM/fRFATING Dam Receipt#
O z Applicant
z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL VLM. SQ.FT. TOTAL:
� V) become subject to the Worker's Compensation provisions of the Labor Cade,you must
a forthwith comply with such Provisions or this perNt shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC JUL,
I hemby.flimn that is.mnsbuction lending agency far the performance of
U O the work for which this permit is Issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name
0F-^ Lcndcrs Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that I have read this application and sure that the above information is
correct.Iagrcc In comply with all city and county ordinances and state laws relating to PERNU fISSUANCE MECHANICAL FEE
U y building construction,and hereby authorize representatives of this city tacmter.imn the abCONS'fRUCTION'1'AX
ove-meat ALTER OR ADD TO MSCI I.
indemnify an ass the City of Cupertino against
g. ;iii
rmaymanye City fCupeitno agCity AIR HANDLINGUNIT(TO IO,OW CPM)tin;!!MT
o is permit. p
J\ AIR HANDLING UNIT(OVT:R IO,pp CFM)
Signature of ,smft
ut Dae EXHAUS'I'f100D(W/DUCT)
PAID
11 RDOUSMATERIALSDISCI.OSURIi HEATINGUNIT(T0I00,W09TU) Data Ruelpt#
Will rhe the CuNtrum mmbupdi Core.Cantsmrcor handle Health a d Safety ))EATING UNIT IOVFR 100,0010 BTU) TT
ns defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health antl Safety
Cade,Section 25532(a)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
WilUhe u,splicamorfurure M1uilJingstecupant useequipmemnrdeviceswhich emit
DOILER-COMP(3HP OR loc'mat BTU) ISS N
ImmvAous air comnminants as defined by the Bay Amt Air Quality Management BOILER-COMP(OVER 100.000 BTU)
Drsuin? 11JUL 2 91993
❑Ycs No NEW RESIDENTIAL MECH.—SQ.Pp.
1 have rend rhe hazardous materials requirement under Chapter fi 95 of the C11� Ur. l#UI'trI I INV
California Health A,Safety Code,Sections 25505,M533 and 25534.1 understand that
if the building docs not currently have a tenant,that it is my responsibility to notify the
auprat of the mquircrecnu which most he met prior'to snacre of.Certi fiaae of
Occupancy.
Owner or aurho nd agent Date TOTAL: ISSUED BY:
OFFICE