25613 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO �C I PERMITNO.
-BUILDING DIVISION APPLICATION/PERMIT
PLUMBING-MECHANICAL 25612
BUILDING PROJECT IDENTIFICATION
BUIL DINGO DURESS: SANITARY NO. APPPLICATIONSUBMITALDAT
(N/L� LOT♦ {64c�3
.-NE ME: PHONE: CONT ORIS AME: L O:
�� NIU CON TROL#
RCIII /ENGINEER:I I LIC NO: AAD St_1
CONTACT: PHONE: QTYLL.W�TJ�`ELECTRIC PERMIT FE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR gmsiDconfar TION APPLIANCES-RESIDENTIAL
I hereb ffimtthatlam licened under p ( gwiN TOB DESCRIPTION
Poo
ya provieiomsionsC¢f9comylimn
Wsf00 nOOW7 of Di '' Jotthe Business dRoPossions Code,and my liana is in PANELS ����
WtW— toll Inree send effa ^ �r.q
Fyy) License Class Lic.# V SCJ UPT0200AMPS
F=uo Dam Cmmmcmr 201.IBM AMPS
20yz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ,FT.
0z—O 1 understand my plans shall be used m public reeords.
W SIGNS ELECTRICAL
��Y,5�, Licensed Professional
pm< OWNER-BUILDER DECLARATION SPECIAL CIRCUITyMISC.
X. I hereby affirm that I am exempt from the Contractor's License Law for the
w 3 a hmn
following rms .(Section 7031.5,Bastions and Profession de
Co :Any city memory TEMP.METER OR POLE HIM
F 4 05 which"Writ a permit to maintain.alter.improve,demolish.m ir an
repay swctate
Sa�Y7 prior In its issuance,also requires the applicant for such permit o File a signed sctement POWER DEVICES
W C p O that he is licensed pursuant to else provisions of the Contractors License law(CTapter
,i,aa8� 9(commencing with Section Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
m_.m or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
FZQ
Section 7031.5 by any apPlicantfair.permit subjats the applicant m OUTLETS-SWITCHES-FlXTURESpplicaa civil peachy of NEW RESIDENTIAL ELECFR _SQ.FT. OG
not more than five hundred dollars($500).
CFESp o ❑ Lmowner Ofthe propeny,ormyemployees with wagesnstheirsole compensation, STORII!S TYPE CONSTRUCI'IOD
4302 will do the work,and thestme9oreinnot intended mothered forsede(Sm.70sil.Busiosss
and Professions Calc:The Contractor's License law does not apply to an owner of
property who builds or improves thereon.and whodassuchwork himselforduough his
menemployeas,providedthat such impiuvemenmvanot intendedorofferedtorsade.If, 50C-GROUP RES.UNITS
however,tha building or improvement is sold within one year Of completion,the owner 'TOTAL:
builder will have the burden of proving that he did not build Or improve for purpose of
sale.).
❑ 1,an mwneronhe property,am exclusively contracting with licensed contractorsto QTY. PLUMBING PERMIT FEE FI.00DZONE APN
construct the project(Sec.7lpm,Business and Profession Coded The Conclusions
Licnowe"wdoesmatippTyt.an.wnefofpropcnywho builds no impmvesdonerm,and PERMITISSUANCE I/
Lhhonrn�µtsfor such projects with ammractims)licensed pursuentm the Contractors ALTER-DRAIN@VENT.WATER HA)1 'r t
FEE LIMMARY
❑ I em exempt under Sa. B @ P C for this reason BACK FLOW PROTECT.DEVICE ! ) e r� OUTSIDER
Owner Dam SAN Ally— Y N
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT N
WORKMAN COMPENSATION mcom DECLARATION S I N
covers
Co affirm ntihntlbaveacoracc iofcamemtnrsf(Sm.38 o,a bC.)wa cf FlXTURES-PER TRAP �IL ECEIPTp
Wmkeri Compensation lmuranceo accnified copy thertof(See.38110,Lab C)which N
rs all employee's under this permit. GAS-EA.SYSTEM-I INC.40UTLETS ECETPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA)
❑ Conduct]copy is hereby famished. PLANCHECK FEE
❑ CampW copy is filed with the city impaction division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.20017,
or les'.) ENERGY FIHi
I certify that in the piefommnaofine work fow 'ch ild nnit iaissued,l shall WATER HEATER W/VENTIELECTR
not oy person m any soon to a so Ne Workers' PAID
ricna lit . D�t� WATER SYSTBM/1'REATING Date ReeiptX
0 Applicant
zee NOTICE T, AM TCAlsTIf,acf making this Cenifiwte of Exemption.you should NEW RESIDENTIAL PLMB, SQ,FT. TIAL:
became subject to the Workers Compensation provision of the labor Code,you mmt
forthwith comply with such provisions or this permit sludi he chemical revoked.
_ BUILDING FEE
yQ CONSTRUCTION LENDING AGENCY SEISMIC FEF.
Z Ihemby affirm mm there is a construction lending agency for the performance of
U O 'he work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
lander',,Name
VLender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have road this application and state that the above information is
co
(• C1. rrect.l agree to comply with all city and county ordinances and atom laws relating to PERMITISSUANCE MECHANICAL FEE
_ h building construction,and hereby audienu representatives ofthis city menerapnn the
L) z chosememimard property for inxpection marmot, ALTER OR ADD TO MECH. W�TAL
(We)agree to save,indemnify and keep hmmlae the City of Cupertino against,]Jgments.cosrs andcxpenseswI ichmayinanywaymn, tont said CityAIR I IANDLING UNIT(TO 10,01)CFM)
in con. anccofthcgranti ofNis mattAIR HANDLING UNIT(OVER 10,000 CFM)
el Slgm o ppliamVCotrcmr Doe EXHAUST HOOD(WIDUCI')IIAZARtureb Ming co pandstSCLOSURIi HEATING UNIT(TO IW.00fIBTU)Will the applicanttiforumbuildingoccupantsort or handle Healths mammal
C defined by the Cupcnino Municipal Coa Chapter Y.li,and the Health and Safety IIGTING UNIT(OVER 100,(I(q BTU)Code Section 255J2(a)'t❑Yes ❑No VENTILATION FAN(SINGLE RESID)
W ill the applleanmffmure building occupant use equipment ordevices whi<hemitHOILF.R-COMP(3HPOR I00,MlJBTU) ISSUANCE DATE
limits hazardous air contaminants as defined by the Bay Arta Air Quality Management nintBOILER 100.1X)0 BTU)
nyo p r1 ZqD3
❑ 11H.Yes No NEW RESIDENTIAL MECSQ.FT. OCT1�
1 have rend the hazardous materials mryirements under Chapter 6.95 of theCid1,
ifthe uil Health @ Safety Cody,Sections 25505,25533 titisand responsibility
1 understand that ��� _� ��
ifthebuildingdamnot currently have atenant,that it my mace ofd. to notify the
sccupan of the reyuirements which most be ton prior w isnunnce of a Cenificme of
txyapamyy. ..
'
Owner or omhryCII
al agent Date
TOTAL: ISSUED BY:
OFFIC