25848 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ILIturRICAI. PERMIT NO.
APPLICATION/PERMIT PING PROJECT
CT[DEN ITER 25848
BUILDING DIVISION BUIL,DLUMBING-M ECHANIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT la LOT#
1ARCHITECT(ENGINIFER:
IsERS NAME: s.ttetwPyOCONTR TOR'SNAME: T LIC NO:.e[,llfl�• � 262 CG//Ah S` Fes-/ 9✓� AI� a�7-�O6N/C CONTROL#
LIC NO: ADDRESS,
/G. ❑
✓� /�IIL
CONTACT: PHONE: BUILDING PERMIT INFO
QTY.5ME�R
ELECTRIC PERMIT "FEE
LB6PLUMB MUCH
ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION NCES-RESIDENTIAL
I hereby ffirm that l am licensed under p (commencing ESCRIPTION
q tK0 Ya provistonsofCha ter9 wmmencm IIb
n1 if SmIxcitede(if f¢Division 1]oP the Business JProfesslone Cede,nnJ mylioenee is to S
Eyd� toll tome and d•i?6 11'? Q0 b _License Cless�O Lic.# OCC !! J � 00 AMPS �/��JDDate/ #1 '�Comrn�t��U1 /[(rF+'L S D^"e Atea, �—/ E(, t '7� oBAMps70v°fi'� ARCHITECTS DECLARATION OW AMPSEA $/SQ.FT.
I unAersland my plansshall he useA as public records. LECTRICAL _KLicensed ProfessionalEVUOWNER-BUILDER DECLARATION L CIRCUIT/MISC. �
xOy F i hereby affirm that 1 am exempt from the Cmmmcmr's License Law Par mo
W tcei folles ingreason.(Section70315,Bminessand Professions Code:Anycity or county ETER OR POLE INST.
f�cei
J which requires a permit to construct,alter,improve,demolish,or repair any structure
�'Y2 prior to its issuance also requires the applicant for such pemtit to file u signed statement DEVICESwmQO that lie is licensedpursuant m the provisions of the Contractor's License Law(Chapter
49(commencing with Section]000)of Division3oftheBusinesaandProfessionsCode) ING POOL ELECTRIC pq
-,m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
�Q Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty Of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($500).
ecce ❑ 1,asowneroftheproperty,ormyemployeeswithwagesastheirsolecompensation, NEW RESIDENTIALELEC'TR _SQ.FT. STORIES TYPECONSTRUCTION
ys°,e will dothewons and then o Contisnor3m License
Law
dos not apply in an Business
and Professions wh olo Cale:Tim Co,Uncom's License Law does not apply lf an owner of
owtipro,enywyees,pmvidedproveslhereon,aementsc who aessuch
tended roffe dforsagh his
nemployees,prmvidedthwxvch improvements arenotintended oro(feredforeale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one you rmf completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale) - y i '
❑ 1,co.owneofihe property,amexclusively emtmetngwnh licensed communismQ7 Y.?' �a IPLUMEINC PERMIT„ : 'I+P.& FLOOD ZONE qpN
construct the project(Sec.7044,[Justness and Professions Code:)The Contractor's
Licensel,aw does not apply to an ownermproperty who builds mdmpoeves thereon,and PERMIT ISSUANCE
who commes for such projects vithawntowhimso licensed pumuam tothe Corrosion, ALTER ( ) - PGE SUMMARY
License Law. WATER EA
❑ 1 am exempt under Sec. ,B&P C for Nis remon BACK FLOW PROTECT.DEVICE OUTS[ ,FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RFCEIPr#
WORKMAN COMPENSATION DECLARATION SCHOOLI'AX Y N
❑ I herebyafflrm that l have a certificate ofwmsenl to self-insure,Ora certificate of PIXTDRE9-PP.R TRAP RECEIPT#
Workers'Compensudan insurance era certified c0y,PZ,y thereof(Sec.3800,Le,C.)which PARK FEE Y_N_
covers
Policy Nl cmployyed trgdp.�tha tit$ 4 'h GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
11 YY-- Q BUILDING DIVISION FEES
Company sf d /mecca ^ GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKFEE
❑ Certified copy is hereby fumisheJ.
❑ Certified copy is died with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING IT E
CERTIFICATE OF EXEMPTUON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section oeednot M1ecmmpleted lffie permit is formic,hundred dollars($IW) SEWER-SANITARY-STORM EA,201 ENERGY FEE
mrlcss.)
I cenifythut in the,erfommrme nfthO work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
0 z Cerpereatmn Lowsof Culifomia. Data WATER SYSTEMGRFATING
Applicant Dole Date Recei
O
NOTICE TO APPLICANT:If,after making this Cetificate of Exemptimn,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
V] become subject the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions Or this permit shall be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the perfortnunw of
V O the work for which this permit is issued(Sec.XyD,Civ.C.) TOTAL: - ELECTRIC FEF
Lk. t-t Lenders Name r
CC Lenders Address QTY � 1';MEIIAN[CAL PERMIT," sx";FEE; PLUMBING FEE
Lkl I oenlfy that I have tend this application and state that the above mfonnaeoO ' r 'r
correct.l agroo to comply with all city and county melnomas and state laws relating to PERMIT ISSUANCE MP.CI IANICAI.FEE
building construction,and hereby authimizerepre.antstives of this city m enterupon the
U z downannouncedproperty for no,onlon purposes, ALTF.RORADDTOMECII. CONSTRUCTION TAX
(We)agree m save,indemnify and keep hartnlwa the City of Cupertino ag.lost
liabilities,judgments,costs and expenses which may in any way acerueagoiom said City AIR HANDLING UNIT(TO 10,0100 CFM)
In consequence of the gaming of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigwmre of ApplieanUComractor Date EXHAUST HOOD(W/DUC1)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(AT I00p00 BTU) Data Receipt#
Will the applicant in future building occupant stare or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Heahh and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code Sachim,25532bu?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will the acontaminantscentor s defined
by the Bay Area
Air Quality eanagemech nt
BOILER-COMP(3HP OR 1 W,000 BTU) ISSUANCE DATE
hazardous air contaminants as define)by the Bay Arca Air Quality Management
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes 0N NEWRF.SMENTIALMECH. SQ.FE P1 A 6h
f
1 have read the hazardous materials requirements under Chapter 6.95 of the 68
California Health&Safety Code,Sections 25505,25533 and 25534.Iunderstanafiat DEC s
occuM1uilofthe es not currently alenan6thatitismyres on"' notify the Mir 199
wcup of there n ems nuance of a Certificate of
Occ nay.
sonervin auth rived agent Data CI I Y � V
Lssul:n BY
OFFICE