25724 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BI Lmn;.e."UI R1 AL PERM I'FNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB OjEgrI DENTIVIC n G J A /1
• RUILDINf'.PR(I,IE(T IDF:NT'IFICA'1'ION G J r L L�
BUILDING ADDRESS: c !a SANITARY NO. APPLICATION SUBMITTALDATH
/V3 J6S;' V1G G7 _ UNIT# IAT#
WNPRSA /Oc PHONE: CONTRACT'OR'S NAME: LIC NO:
`l //7 N/C CONTROL#
RCHI GT/FNGINEER: LIC NO: ADDRESS: El>r ONTACf: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING I'IiRMIT INFG
, D6
BLDG ELIiC PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTFACTOR'SDECLARATION APPLIANCES-R35IDPNHAL
pyzIherehyeffrLIthat I licensed 9(commencing _ _ IpB UESCRIpIMIr
with /5✓�`_���I��^- /y�Vl '
200 Section 70f10)or Division 3 ofthe Basin.,and Professions Cade•and my license is in PANELS
KU� full lsdeffrvt.
6Ztu
License
e Cl..—ChLi<.p UP T02W AMPS
cei<,y Dam Contactor 201-10(10 AMPS
70FNiz ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA $
O Z I understand my plans shill be used ss public accords. OVER IOOU AMPS
F'❑t, SIGNS ELECTRICAL
6,j�„-1 LicenaW Professionnl
C 6 OWNER-BUILDER DECLARATION SPIiCIALCIRCUIT/MISC.
RtlU I hereby affirm thm I am exempt from the Contractor's License Law for the
Oy following restos(Section 703 L5,Business and Prore>siom Code:Any city ar county TEMP.METER OR POL13 TNST.
which requires a pemdno consumer,alcor,improve,demolish,or repair any drucmm
N,7 to its issuance,also re the applicant for such t to file a sine)statement POWER DEVICES
prior requires pp pemJ g
��0 p that he is licensed pursuant to the provisions of the Contrecmes License Law(Chapter
4y0�' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iW rn nr ihnt he is aempnherefrom vnJ the basis for rhe alleged excmptiun.Anyvichoion of 'f5-SWITCH[S-FIXTURES
FSZpY Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
not mare than fee hundred dollars($500).
G� ❑ I,asownerofthepropeny,ormyemployeeswithwages axtheiratlecompensatinn, NEW RESIDENTIAL EL17M _M)FT. STORIES TYPE CONSTRUCTION
y322 will Jo thews it the svucmmfaint intended mcffemd for We(Sea 7044,Business
and Professions Cotte:no Contractor's License law does not apply m an owner of
property who builds or improves thereon,and who does such work himselforthrough his
ownemployces,provided that such improvements are norimandcdora(fend torsade.If, �P s RES.UNITS
however,the bulldingor imfc
provement is sold within one yearoompletion,the owner- QA
(Bi
will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as nwnerofnmpropeny,am excrosivNycomrncting withlicenaW commctorn nr QTY. . PLUMBING PERMIT FEE FLOOD ZONE APN
outrun the project(Sec.70,14,Business and Profusions Coded The Contacmr's PERMIT ISSUANCE
Licenu Luw does nm apply m an owner of property who builds or improves therton,wet
who crmtacts frsuch projects with a contractons)licensed pumuantlo the Contractor's AT TIiR-UNAIN&VENT-
Llceuse Law, y'ATHR(PLA) FEL SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason BACK FLOW PROTEC'L DEV IC T++ 11
iM 11 TSIDEE ..
R I YN
SANITA
Owner Data DRAINS-FLOOR,ROOP,AREA, OND. _ RECEIPT#
WORKM AN COMPENSATION DECLARATION t C SCIIOOLTAX_ Y N
T hereby arfirm thatlhvveattnificem of<onxnfto self-insmm,ar.cenTGcateof w > J U 1 I RECEIPT'#
arkers'Cnmpenmtion imuancenraifeJ cencopy Nerenf(Sec.3g00,Luh C.)which FIXTURES-PER TRAP P I YN
Povers all entpbyee's under this Formal, GAS-EA.SYSTEM-I INC OIfTI REGI?ITT#
licy# SATE BUILD GDIVISION FEES
Company GAS-EA.SYSTEM-OVER {TMT — - —"PLANCHECK FCEJ'
❑ Certified copy is hereby furnished.
❑ Car l copy is fled with the city inspection division. GREASHIINDUSTRL WASTE INTERCEPTOR GRADING FEF,
CHR'HPICATEOF IIMPTTONFROMWORKERS' GRF.ASETRAP SOILS PEE
COMPENSATION INSURANCE
(TIfl,,ectionnesdam lwemoldrted ifthepeard,isforonehundrcd doBars(SIf10) SEWER-SANITARY-STORM EA.20017, ENERGY FEE
in less.)
I certify that in the Performance of Ne work for which this permit is issued,l shall WATER BEATER W/VRNT/ELF.CIR
nut employ any person in any mune,to,as ,,hensmc subject to the Workers' PAID
Compenantionlawsof Califamia. Data WATER$YSTEM/1'REATING Data Receipt#
Q z Applicant
z C NO'DCHTO APPLICAN'1':If,after making this Cenifiwmof Exemption,ynu should NI?W RESIDENTIAL PLMIL SQ,M. TOTAL:
H (n become subject to the Workers Compensation provisions ofthe labor Code,you must
a ; forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FER
w
z CONSTRUCTION LENDING AGENCY SEISMIC PER
✓✓R I hereby affirm that hem is a,mstruction lending agency for the performance of
V O the work far which this permit is iswed(Sec.3097,Civ.C.) TOTAL: 1:11EC TRIC ITE
Lenders Name
O U Lenders Address Q•IT.. MECI IANICAL PERMIT FEE PLUMBING M,
I ttnify that 1 have read this application and state that the above infommtion is
contact.lacomply hall city and county ordinances and state laws rotating to PERMIT ISSUANCE MECHANICAL FTE
buildarg on. .mdh by authorize representatives os city 0 enter upon the CONSTRUCTION TAX
V z alsoye mentioned opany or inspection purposes. ALTER OR ADD TO ME CH.
(We)vsav indemnify and keep homtless the City of Cupertino against
rebilities,ju en stsondexpcnus whichmey in any way cue eg fast saidCity AIR HANDLING UNIT(TO 10,01(s)CFM)
in contest c timgof this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Si aanCContractor Date EXHAUSTHOODfWNUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINOUNIT(TO IfIRMOBTU) Data Raxaipt#
Will the applicant or future building occupant store or handle haza dous material
ex defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety II EATING UNIT(OVER 100,000 BTU) T
Code,Section 25512(a)?
0Yea CI No VENTILATION PAN(SINGLE RESID)
Will the applicant or fummbuildingcecupant meequipmentordevittswhi<h<mit
BOILER-COMP(3HP OR IN."BTU) ISSUANCE DATE
randoms air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
trier? �$
❑Yes ❑No NEWRESIDENTIAL MECH.—SQ.17 • 4 10
I have mad he havudous materials requirements under Chapter 6.95 of the AIO� {J
Cahromm Health&Safety Code,Sections 25505,25533 and 25534, lunderstandthar ,r m 4
acceptant
the
malutcures whicveusthi, Omnis my rsumme of
Ccrnficat !—
Ocupant of the rtquirememx which must he m,prior to issuance of a Ccnificarc of Cn Is r N7
Occupancy.
Owner or aulair Jaged, Dam TOTAL: ISSUED BY: rr fVU
OFFICE