25276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
pi Jf—i .- CRU RICA L PERMIT NO,
APPLICATION/PERMIT PLUMBING CT IDEN MMIC n C 2 7 6
NUIhItIN(i DIVISION flI111.IJiNG PR(JJECT IIIBN'CIF'ICA'I'if)N G J G U
BUILDING ADDRESS: SANITARY NO. •APPLICA'DON SUBMITTAL DATE
Ii0D1 S. /// LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: �J LIC NO' t
K L -►�iDmR5 L NIC COMROL p
ARCHI'IECIENGINEFR: LI ADDRFS
v !G H C 0 f 074 Zo9,4Aw fm Gopr i q)ei
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PPE BUILDING PERMIT INFO
EAU TNbJ'NA5 BLDG r Mr:'
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES F. JOB DESIPTION
py�Z Ihertby afErm Nedlam licensed underprovisions nfChapmr9(commencing with
[ 00 Section 7000)of Division 3 ofthe Business and Provisions Coda,and my license is in PANELS
y�F fullfoeC1u,a f��p ✓
<yy Vit License Class�Y2!Lie.p -4/2�4 PTO BA S
Till
E,6y Date Carron, r fel_ y -YFbi/'Dfff 2 -I P
7-1-5'3
Z FOyZ ARCHITECTS DECLARATION O :R 1000 PS _ SQ.FT.FLOOR ARIA � S/gQ.F1'.
p Z,.,C I undenund my plans shall be useJ ae public records. p.�
F�_iz SIGNS F.CITtICAL
'y�d ._.41 Licensed Pmfcssmord _ x'
A.y U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. 1 J
xOi I hereby nffinn dhat I am exempt from the Contractors License Law for the _
W3Oy rnllnwing,anion.lgectinn]B3 L5,0usinws ane finfe;xiuns Code:AnYcitynr team- TEMP.MITER OR FOL-,;NST. g
whichim iresupemtit to construct,aim.improve.demolish,or repair any nwcdurc
ENyIY� prionoi¢issuance,also rtquiresthe applicandforsuch permiuo fdeasigned statement /{TE
COzp dim he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
POWER DEVICES
'KOLL 9(commrncing with Sation](g0)of Division3nf the Business end Professions Code) SWIMMING POOL F.LP.CTRIC �\ VALUATI N OO
WZ. Seor ctatheisexempt byady refromand the onspermit atir cllegedexemption. civilplationof ALFTS-SWITCHES-FIXTURES \ D /tl�f
F Z y Section 7031.5 hy any applicant for a pcnnid subjects Ih<epplicant m a civil penalty of 11 V
DQ urn mote than Eve hundred dollen(ESIXq.
o ❑ I,asnwneroftheproperty,ormyemployceswithwagesasiheirsolecompensation, NEW RESIDENTIAL ELECTR _SO,FT. S'ORTES TYPECONSTRUCfION
a3— will do the work,and the strecture is not imendodoroffered for vale(Sm.9044,Business
and Professions Code:the Contractors License Law does not apply to an owner of
property who builds or improves ihemon,and whodoessuchwork toomeror,hrough his
ownemployeewpmvided that suchimprovementaare not intendedoroffared foreale.If, OCC.GROUP RES.UNITS
however.the building or improvement is sold within one yearo(completion,theowner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asnwnomfdhepr.Peny,nm exduslvelyamtremingwidhlieensedemanmmrsm QTY, PLUMBING PERMIT FEE PIAODZONE APN
construct the projcet(Sec.7814,Business and Professions Code:)The Contractor's
License Lawdoes notapply to an ownerofproentywh0 buldamimproves thereon,and PERMIT ISSUANCE
whocammsis for such projects with a commands)licensed pursuantto the Contractors ALTER PEE SUMMARY
Litems law. (EA)
❑ I am exempt under Sec. ,fl&P C for this rcasnn BACK FLAW PROTECT.DEVICE OUTSIDE. F;ES
SANITARY Y N
Owner Date RECEIPT0
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION DRAINS TAX Y N
❑ Ihercby af0nn@m lhaveaceni0cate ofconummulLinsurc,urn<eni0cme of FIXTURES-PER IRAP RECEIPT#
Workes'Compensation Insurance ora cenifed copy the.f(Sec.3800,Lab C.)which PARKFEE Y N
nwen all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'N
Policy Y BUILDING DIVISION Fl? r�
Company
❑ CenGAS-EA.SYSTEM-OVER 4(EA) PLANCHF,CK FEE. 3 e-!r�
diedcopy is famished.wem
[2 Cmifed copy is filed with the city inspersion division GREASUANDUSTRL WASTE INTERCEPTOR GRADING FEF
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOI
COMPENSATION INSURANCE
(Thissectinn rewound be completed if Ne permit is foreae hundred dollars D100) SEWER-SANITARY-S'I'ORM V.A.200FT. ENI?RGY THE
ortes.) S •UCS
Iccnlfy ohm iu theperfamanceof the work for which thi,serad isissued,I shop WATER If3ATER WNENTfELECTR
mpvoy any person in any m once so 2s1 to me.5 peat m the Workers' pppy
Co pensatio�ws oC�ifo p /ted "/j WATER SYSTGM/IREATING Date Receipt
C) A licam f
OUCH TO APPLICA If,aOer making this Cenlficute of Exemption,you should NEW RESIDENTIAL PLMR. SQ,PT. TO AL DO
become;abject to the Worker's Compensation provisions of the Labor Cade,you must 3
forthwith comply witin such provisions.,,his permit shell be deemed rcvokcl. r
LDING FI?E '1 06
aCONSTRUCTION LENDING AGENCY MIC FEE _C W
Ihercby af0mtthet them is aconswcdon lending agency fm thepMo,mence of CTRIC FEE
V the wnrkfar whicM1 this permit is issued(Sea 309],Civ.CJ ��
Iandeh Name MBING fEI?
O Lenders Address QTY. MECHANICALPERMITI certifytat I hovermdthis application ad cram that the above informmion isIIANICAL FIiEcorrect.I agree in comply with all city and county ordinanms and state laws minting do PERMIT ISSUANCE s�building construction,and hereby authorizempresentadives ofthis city to enter upon theSTRUCTION TAX
C1 7-. above-mentioned property for inspection purposes. 1 eR OR ADD TO MHCU.
(We)agree mauve indemnify and kee h em the City of Cupertino against
linbilities,judgmems,cost and expert sesc yin any weyaccmeagainst said City AIR HANDLING UNIT(TO 10,000 CIM)
in conscyue the gmntineir" pe
AIR HANDLING UNIT(OVER 10,0011 CFM)
7 3 -
.1. l of ApplicenUCnntrc r Dam EXHAUSTHOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT LTO IOO,WO BTU) Date Receipt it
l the applicant or future building eccupant store or handle hav,dom material
rs by the Cups,inn Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I WAW BTU) TOTAL:
ti Yea 2(o)'!
El0N VENTILATION FAN(SINGLE RMID)
Will thea licuum orfundebuildin rata BOILER-COMP LED OR IWAs)BTU) ISSUANCE DATE
pp g panBayA pmrn Quality
Management
hazardous ail cmnaminnms as defined by the Bay Area Air Quality Management BOILF,R-COMP(OVER 100,000 BTU)
District? PAID Cl Yea ❑No NEW RF.SIUENTIAL MECH. SQ.FT. I— j�
I have read the hvnrdous materials requirements under Chapter 6.95 of the JUL I
California Heath&Safay Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a leaam,tam it is my oesponsimi ty to notify the
occupant of the requiremcnn which most be met prior to issuance of a Certificate of Cp Iy
`
Occupancy. H I
Owner oOF L:,authorized agent Date ISSUED BY: