25879APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPE'- --
PERM1TNo.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
BUILDING PROJECTIDENI'1FICA'ION 25879
BUILDINGIIDDRCSS: SANITARYNO. APPLICATIONSUBMMALDATF
Iry\IJII UNIT # �1�b�.I LOTp 2l-, L4
OWNI;RSNAM : P N CONE R;SN Mt: LIC NO:
a ' ///1 J� .�� 11 NIC CONTROL#
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ARC] II'ItiCTIENGINF iat/� I �N 1 C ADDRESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MF,CH
PERMITISSUANCE El
CONTRACfOR:SDECLARATION APPLIANCES - RESIDENTIAL
p 0LD Ihcreby aif Division 3 orthnscdinder ssand rifesions Codes, and
with �1 E$('yIP�JpII�w
00 Section 70(0 effect. Division mTthe Business and Professions Code. and mylimrau is in PANELS ``J✓r(.VwJ'/IL.IIr\
CZW Licfall foroClass fect.
I.Q., Z to License Class . # UP TO 2W AMPS
ttjrait UDataCo..,.,-
201-IOW AMPS
Fot-L ARCHITECTS DECLARATION � U IXRtgRFSS
Z `' 0 1 understand my plans shall h used as public records. OVER 1000AMPS Q \VY Ii/SQ. FT, SIGNS ELECTRICAL IOI
Q Y 7 J Lucre Professional I
=y,KQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. u J C
KC eii 1 hereby affirm that I um exempt from the Contractor's License law for the u
W 3 tr-r~¢is following mason. (Section 7031.5, Business and Professions Care: Any city nr county TEMP. METER OR POLE INST.
J which requires a permit to consumer, alter, improve, demolish, or repa'u any struaum
KW}F prior to its issuance, also requires the applicant forsuch Permit to fleasignedstatement POWER DEVICES
W z G p ohm he is licensed pursuant to the provisions of the Gmmcmr's License Lew IChup¢r
dXp 9(commencing with Section Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATIONj�/'�
or he is encmpnhercfrnm and the basis for Ne alleged exemption. Any violation of OUTLETS - SWITCHES - FIXTURES
QD�FZ�' Se<tion Ithan by mydreddanors($50rmit subjtt¢Ne apPlicammacivil penilry of
iSQO not -ohm rive hundred Dollars ($500). NEW RESIDENTIAL ELECfR S .FT.
KFo 1, a sowneroftheprnpeny.ormyemployceswithwagesmtheirsolee mpem bon, Q STORIES TYPE CONSTRUCTION
a3O0 will Jo Ne work, and the structure is not intended proffered for sale(Sec. 7044, Business
Sand Professions Cork, The Contractors Limnae Law does not apply m an owner of
property whobuilds orimproves thereon, and who does such work himselforthroughhis
own employma,powided Natsuchimpowearems arenm intended oroffmal forsale. If, 50C GROUP RES.UNITS
however, the buildingor improvement is sold within one yearofcompletion, thwwnce- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ L:.sownerofdmpmpeDy,umexclusivelyconuctingwithlicevdcmn ionto QTY' PLUMBING PERMIT FEE FLOOD _ZONE APN
ommarl the projeet(Sec. 7044, Business and professions Cvle:)'Me Contractor's
License Lawdmsnotapplytoanowacrofpropcnywhobuiidsorimpmvesthefeon,rod PERMITISSUANCE
whocnntmcts for such projects with aeootractor(s) hemmed purmantlothe Contractor's 71
Liccas Law. ALTER - DRAIN & VENT- WATER (EA) FEE SUMMARY
❑ I um exempt mds,Sm. , B & P C Por thia reason BACK FLOW PROTECT. DEVICE OUTSI F-FEES
SANITARY YN_
Owner Date DRAWS- FLOOR, ROOF. AREA, CONE. RECEIPYp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ 1herebyaffirm that l have a cenificate ofmnsentto self-insure, or a certificate of FIXTURES -PLR TRAP RIiCGIPI'p
Workers Compensation Insurance ora crnified copy thereof(S«.ISW,Lub C.l which PARK FEE Y_ry
rs all employee's unJenhis permit GAS - FA. SYSTEM.1 INC. 4 OUTLETS RECEIPT #
Col
Policy
Company
BUILDING DIVISION FEESy GAS -G. SYSTEM OVER4 EA
❑ Cenifed copy is hereby lumished. ( ) PLANCIiF,CK FEE
❑ Cenifed ruff is filed with the city inspection division. GREASEflNDUSTRL WASTE INTERCEITOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOUS FEE
COMPENSATION INSURANCE
(This woon need not be,completcd if Ne permit is for one hundred dollars ($100) SEWER - SANITARY -STORM EA. 200FT. ENERGY FEE
mrlcss.)
I unify that in But performmce of the work for which Nis pernitisissuM,Ishall WATER HEATER W/VFM/ELECIR
not employ my person in any mnmer so as m become subject to Ne WorkersPAID
z Cian'taationlawsof Cnlifomia. Date WATER SYSTEMUREATINGApplicant Date Receiptp
z0 NO HCH TO APPLICANT: If, after making Ws Cenifcate of Exemption, you should NEW RESIDENTIAL PLMB. SQ. FT. TAL:
HZI Become subject the Worker's Compensation provisions of the tabor Code, you most
a > forthwith comply with such pmvisinm or this permit shall be deem#revoked. BUILDING FEE /�
per„ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a construction lending agency for tse fund. .ec of
U O the work for which this permit ns issued (Sec. 3W7, Civ. CJ ELECTRIC FEE
w0 V1-endels Name
Lenders Address QTY. MECHANICAL PERMITfFEFEPLUMBING FEE
r I certify that 1 have read this application and state that the above irdommtim is
(•-' IL amen. lagmc mcnmply with all city end county ordinances and sta¢laws relating to PERMITISSUANCE MECHANICALME
_ � building construction, and hereby authodu representativeso(thin city to enter upon the
L) z above-mentioned property for inspection purposes. ALTGRORADDTOMECH. CONSTRUCTION TAX
(We) ague to save, indemnify wd keep hmorde a the City of Cupertino against
liabilifies.judgmeno, costs and expenses whichmay in any way accoueagainst said City AIR HANDLING UNITTO IB,BW CFM)
a asequence of theg 'ng of this
permit.
AIR HANDLING UNIT FOYER 10,000 CFM)
:ignntoreo '"Contractor Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS# T[' 1ALSDISCLIM"11 HEATING UNIT (TO I Of,000 BTU) Dme Receiptp
Will Ne applicant or, am bmildia ucimen atom of hurdle hassrdoua mancom
as defined by the Cupertino Municipal Cole. Chapter 9.12, and the l leash mJ Safety HEATING UNIT (OVER 10xL" BT U) 1:
Cade, Section 25532(a)7
❑Yes 0N VENTILATION FAN (SING LE RFSID)
Will theapplicmtor fuwrebuilding«cupantuxequipmemordevices whicherni, BOILER- COMPQHPOR 100,01)(I ISSUANCE DATE
M1amrdnos air comuminams is defined by he Bay Area Air Quality Mmagemem BOILER-COMP(OVER 100.00DBTU)
❑ Yes ❑ No NEW RFSIDENTIAL MECH. SQ. FT. P p
I have read the hartrd4
uus materials requirements under Chapter 6.95 of the A
Ca)Ifomia I leelth & Safety Crate. Section 25505, 25533 and 25534. I undersmd Nat
if the building does not currently have a tenant, that it is my responsibility to notify the
cupant of the requirements which must be met prior to issuance of a Cenifcale of
oeeaapmay. �'��� y 1.99<,
Owner or authonud agent Dam TOTAL: 1SSUEDB.