25855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25855
BUILDING PROIF.C1'IDENTIFICATION
BUILDIN2GG/fA[D�DRESS77: (1\\'��1w' / //,�5�',/ SANITARY NO. APPLICATION SUBMITTAL DATE
l !S) - z �cf,l � ' gIN�N�1 LOT ,_02yr
-q 16t
Nf iyNF._�`I� �� PHONE: CONTRACI'OR:S NAME: LICNO:,
�Qxh G MC CONTROL#
4 CHITECIYENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
B ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACT`OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRII'f10
pyz Ihereby 7000) ffirmof
Nm l3 ofth sed Business ndvlslaen.fO,Core,and
mmrndng wvh
w00 fail Section7000)of DivisionJ.f the Business and Profueior Code,and my license is in ppNpy,S 'fel
tilt full(...0 and effect.
42 License Class Lic.p IIP T0200 AMPS
on6y Date Corrector MI-1000 Amps
F s z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA 5/SQ.FT.
z0 Z�a I understand my plans shall be used as public records. OVER 1000 AMPS
F m t®,,1 SIGNS ELECTRICAL
<y�J Licensed Professional
�-a Rea< OWNER-BUILDER DECLARATION SPECIAL CIRCUTOMISC.
KOiF 1 hereby affirm that 1 an exempt from the Contractors License Law for the
6130 m¢ following mason.(Section 7031.5.Business and Profusions Code:Any city casualtyTEMP.METiR OR POLE NBT.
which requires a permit to construct,alter,improve,demolish,or repair any structure
}�
price o its issuance,also requires the applicant fosuch permit to rile a signed statement POWER DEVICES
6ttJ�'A O
the he is licensed pursuant to the previsions of the ContractMs LicttuC Law(Chapter
L t1o1' 9(commencing with es
Section 0000)of Division 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC VALUyjW
W,w or that he is exempt therefrom and she basis for Ne alleged exemption.Any violation of ^ — d1.I
��
8. ¢ Section 0031.5 by any applicant fm a Permit subjects the applicant m a civil penalty of OUTLETS-SWITCHES IX
-FTURES l'spMx/V
^� O not more than five hundred dollars(5500).
_p ❑ . NEW RESIDENTIALELECTR _SQ.FT.
STORMS TYPE CONSTRUCTION
a3= will dothe woh,and the struaumis not intendedoroffend forule(Sec.7014.Business
and Profess ion Code:The Contractor's License Law does not apply to an owner of
ownemploym,Mvirimprovu NemMnve wbodmam.hendedoroffe fN Wa.M1f.
hoempLytaa,proviJW thm such improvemcmaare not imm�dedoroffared(oracle.If. OCC GROUP RFS.UNITS
wever,the building or improvement is sold within one year ofcnmpletion,the owner- TOTAL:
builder will have the burden of proving that he did nm build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE Fl.000 zorvE APN
❑ [.usn
us sof the propenmdv
y,aexusively contracting with licrncon
eed vacrrsto
construct the project(Sec.70]4,Business and Profession Code:)The Conoactah
License Lawdoes not only mon.wnerofproperty who builds or improves Nereomand PERMIT ISSUANCE
who contracts for such projects with a contrectone licensed pursuant to the Contractors ALTER-TRA 17�5)F T A 1 )
License Law. V „ r FEE SUMMARY
❑ I am exempt under Sta. ,B&P C far Nis reason BACK FLOW CI^. E C ID
I SANITARY Y N
Owner - Dau RECEIPT is
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,R D. SCHOOL TAX Y_N
❑ Ihereby affirm that l have a certificate efconsem toself-insure,aracerlilicneid FlXTU SES-PER Aqt�m RECEIPT#
Workers'Compensation Insurance or a modified!copy Nerwf(Sec.3800,Lab C.)which y/rTE PA KFEE Y N
coven all employee's unde,this pemnit. - GAS-FA.SYSTEM-I INC.4 OUTLETS � RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with Ne city inspection division. GREASIDINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This secti.nnecdnm becomplene if Ne permit is Ensure handled dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I minify that in the performance of the work fm which Ws permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so u to become subject to the Woken' PAID
Compcnunion Laws.f Califumie. Date WATER SYSTEM/IBEATING Dau Receipt#
O r7-s Applicants
Z 0 NOTICETO APPLICANT:ILafter making Nis Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
became suhjcm to the Workee.Compensation provisions of the Labor Cade,you must
7 forthwith comply with such provisions or this perch shall be deemed revoked. BUILDINGFEE rw
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby afftrr that thele is a consuuNoa lending agency for this N fomance of
U O she work for which this permit is issued(SIL.3097,Civ.CJ TOTAL: ELECTRIC FEE
r.a Lender's Nem PLUMBING FEE
0 U Lender's Address QTY. MECHANICAL PERMIT FEE
1 certify Nat 1 have mad this application mad state Out the above intonation is
commit les rca to mom 1 g MECHANICALFEE
g py withylciryrimiepnosencismofand site la moupin to PERMIT ISSUANCE
UN iflime-rantiwctioeaod herebyauNoimmpmacnutivu.fthiscitymentuupon the CONSTRUCTTNTAX
V Z above-memione mgrapenty save,,an inspection purposes. ALTER OR ADD TO MF.CH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabili' , nu,k uandexpenses ich mayinsn y rtsaid Ciry AIR HANDLING ON"(TO HLMKI CFM)
inc sequence in tint.fthis it.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signmu f pH...Kenn.. Dau EXHAUST HOOD(W/DUCG PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Rompt#
Will the the Cuumerrfuture Municbuilding Code,Cnt hapter
or hanand the
ehrseMh es and Sae HEATING UNIT(OVER 100,000 BTU) T
u defined by the Cupertino Municipal Code,CM1apur 9.12,and Nc Health and Safety
Code.Section 25532(07 VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
WiBthee licaosmfutumbuildincecu BOILER-COMP(JHP OR 100,000 BTU) y1�SSUANCFs DATE
pp g he muse equipment ordevic Management
it k^ I D
.dohs air contaminants u defined by the Bey Area Air Quality Martagetnent BOILER-COMP(OVER I00,(#p BTU)
DiauiatP �1AA►2�
0Y. 0 No NEW RESIDENTIAL MECH.—SQ.FT. 1994
y I have read the harsrdous materials requimmems onda Chepur 6.95 of the l
- Califmnia Health&SoferyCoda Stations 25505.2553]and 25534. I undersand Nat Ply
I 1
if the building does not currently have a tenant,that it is my msrymsibiliry to notify the Ur `urthJp
a ,apum of the mporearears which must he met prior to issuance of a Certificate of
Occupancy.
Owner o amM1orizN agent Dau TOTAL: ISSUED BY:
OFFIC � -- - - - -