25707 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bm.....N r-ELE,Mint, PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING FROG Ln.I,EMECHANICAI. 25707
BUILDING I'RIIdECI'IOEN'1'IPIG'1'I(IN
BUILDING AD RESOS. � SANITARY NO. APPLICATION SUBMITTAL DATE
L1 IL LOT p
OWN(?RS NAME: /•�(/ PHONE: CONTRACTOR'S NAME: LIC NO:6
/" • of AC L/OAly400ar /°LYON It�N NT
ea. NIC COROL#
ARCHTFECI'/ENGINEM LIC NO: ADDRESS ❑
SO 4ocserbeb C7`. C40&P—
COMPACT: PHONE: EL CT
� bEGfRIC.PERMIT FEE -'''BUILDING PERMIT INFO
III ELECT PLUMB MECH
PERMIT ISSUANCE 1:1 X 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RMIDENTIAL
ZWz Ihemb uffrmthmtl nm licensed underpmvisionsofCTapmr9(commencing mite ION DESCRIPltO
u]00 Seaion]OOfq of Division3of the Business and Pmfexsions Code,end my license teed PANELS
Ccu— fail to. and ff
eec tee/ I
FZ License Ch _ - aao• Lic.g 6,80342e UP T0200 AMPS
"ton Dale Contractor 201-1000AMP5
zOoni ARCHITECPS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ff.
Oz,-•n I macniandnryplunsshell be used as pre
ublic cords. -
(=rn SIGNS ELECTRICAL
Licensed Professional
� 6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
st'OiiF 1 hereby affirm that I am exempt from the Contractors License Law for me
Is1�+4 on following reason.(Section 7031.5,Business and Pmfessiov Code:Any city or,a.nty TEMP.METER OR POLE NST. I� i� / 1
He may; which requires u permit to consmeb almq improve,demolish,or repair any structure _ 'TER Ii
2 ,YM prior it)its issuence.also requires the applicant for such permit File a signed statement POWER DEVICES t� Y
µ�J EC G p mm he is licensed pursuant to the provisions m the Contractor's License Law(Chapter Y 1'w BBB LLL
daiss 9(mmmemrimg with Section 7000)of Division 3o fine Business and professions Code) SWIMMINOPOOLELECBI V UA'1'ION
�_y mrthat he is exempttharefrem and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES
- RES
R 4 Section 7031.5 by any applicant for u permit subjects the applicant to a civil penalty of
tY � not more than five hundred dollars($50% NEWRFSIDENTIALELECIA _S STORIES TYI'13 CONS'IRUCI'ION
❑ I.mownemfthepmpeny,ormyemployeeswithwagesmtheirsolecompansstion, Q'IT'
y,3_, will do the work,and the structure is not intended or offered tarsals(Sec.IIk4,Business
and Pmfessimns Code:The Contractors License Law does not apply to an owner of
pmpeny who bui lds or improves thereon,and who does such work hi mself or through his
own seer,thevspingor Improvement at impmvements me wthinnrnesurintended cor afromplevred dissolve If,
OCC.GROUP RFS.UNITS
howevegillhav l the buren ofishat he did net
ofc prove on,for purpose f TOTAL:
builder will have the burden of proving that he did rat build or improve for purpose of
sale.). �'
s= -
❑ 1,mownerofthe propeny.em exclusively convecting with licensed conmmorsm QTtY.• - PLUfi1BINGPEI2MIT FEE Fl.000 ZONE APN
construct the project(Sec.7044.Business and Professions Codep theContractor's rPERM I'I'ISSUANCE
v
License Law d.not apply umn owoceof property who builds or improves thereon,and
who contracts for such porticoes with a conactoubd licensed pursuant m the Commences ALTER G
License Law. I' ) FEESUMMARY
❑ I am exempt under gee. B&P C fur this reason BACK FLOW PROTECT.DEVICE Oursdffryrn�
SANITARY Y N
Owner RECEIPTp
DRAINS-FLOOR,ROOF.AREA,CON D.WORKMAN COMP(?NSA'1'ION DI3CLARATATION SCHOOLTAX Y_N
❑ Thereby affirm that l have a certificate of consent selbinsum.or a certificate of FIXTURES-PER TRAP RECEIPT#
Woroari Compensation Insurance ore certified copy ehereof(Sec.3800,Lab C.)which PARK TLE Y_N
coven all employee's undenhis penned, GAS-EA.SYSTEM-1 INC. OUTLETS RECIiIPT#
vf�r Policyp BUILDING DIVISION FRES
Company OAS-EA.SYSTEM.OVER4(EA) PLANCHECK ME
❑ Certified copy is hereby famished.
❑ Ccnified copy is filed mite the city impaction division GREASPJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is formahundieddollan($100) SEWER.SANITARY-STORM EA.20MIL ENERGY ME
miens.)
I certify thin in the performance ofehe work for which this Permit is issued,l shall WATER HEATER WNENTRiLECIR
not employ any proton in Any manner so m m become subject to he Wnrkrre PAID
Compensetinnl-awsof Califirrom Date WATER SYSI HM/IREXTING Dote Receipt#
0 Z Applicant
C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENUAL PLM. SQ.FIL TOTAL:
C,,) become subject to the Worker's Cooperation provisions of the Labor Code,you must
forthwith comply with such pmviawas or this period,shall be deemed revoked. BUILDING FRE
z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby uffirm mat there is a construction lending agency for she performance of
U O the work fur which this permit is issued(Sec.307,Civ.C.) T A ELECTRIC FEE
Lendees Name PLUMBING ME J'
k' F Lendcea Address QTY MSCI lANICAI.PBRMIT- - ..PEE
U 1 candy that 1 have read this application and state that the above information is ,r 0111 'y
0i covoct. I agree to comply with ell city and county ordinances and state laws relating to w PERMIT ISSUANCE MECHANICALPEE
rA building construction.and hereby authentic reprcazmativesofmisely to enterupon the CONSTRUCTION TAX
U Z abrwomemtioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agrae 10 save,indemnify and keep broadens be City of Cupertino agurtse
liabilities,judgments,costs and expenses which they in any way monde against said City AIR I IANDLING UNIT(TO 10,000 CIM)
in consequence of the granting of oris permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
ignmureof ApplicintiCentmctcr Data EXHAUST HOOD(WA)UCf)
PAID
I 1AZARDOUS MATERIALS DISCLOSURE 1 IEATINGUNIT(TO 100,000BTU) Dam Receipt If
Will the applicant cur future building occupant store or handle hvardous mamnd
in defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OV ER 10,000 BTU) TO'AI
Code,Section 25532(u)? VENTILATION PAN(SINGLE RFSID) �•
❑Yes ❑No
BOILER-COME(3HP OR Io0,W0 BTU) OSVNC®A 'E
,e Will the applicant or future building occupant use equipment which emit @s1'
aeandous air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVCR 100.110(1 ETU)
\ nava
❑ 3 Yes 11No NEW RESIDENTIAL MECH. $Q.IT. NOV e 1993
1 have read the hazmrlues materials requirements under Chapter 6.95 of me
,alifnmia l lealth&SafetyCode,Sections 25505,25533 and 25534. I understand mea Cl l Y OF
"I he building doe,martionatlyhave atemam,that ie is my mnprmibility miumify he
V LUPGMIII�I
eceupmm or rue roqulrements which as,ba mea poor to issuntwo o1'u Certificate of
Occupancy.
Owner or amborized agent Date TOTAL: ISSUED BY:
0