25614 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOR ng,7,-FLE RI AI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. a� /I
4
BUILDING PROJECT IDEN'pHICA'1'ION G nC J 1
BYIILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
UNITY Lor# 16- 3
\ 01' NAM PH .ONT C O ,I'nn NIC CON TROL#
CHI'fF. 4iNGINEER: LIC NO: gDD@rls$rs�� V(tJ�j.� ❑
CONTACT: p}ZONE: ��' DUILDINO PERMITINFO
QTY ELECTRIC PERMIT FEE
rcuf-� Is_�,s,�-,.1,� J S BLDG LECT PLUMB MECII
'�JC��y PERMIT ISSUANCE El 1:1
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDEN'I'lAL - TOR DESCRIPTION
aZ I hereby strove that l em licensed anderprovisiwtss ofCM1uptar9(commencingwith -
0W0 Section 7000).17 Division 3of the Bovinesvan��(Is"n}lf/Y�,L,�C and my license is in PANELS
�U� Toll forty unA t. "f`'� UI'T02W AMPS
)Q„Zm License Class N�
m=y Date Con'I I U 201-❑NNl AMPS SQ.IT.FLOOR AREA S/SQ,IT,
ZOyz ARCIIII'EC'I"SUE AT N OVER IOW AMPS
Ozp I understand my plans shall be used ns public records.
r y t¢l SIGNS ELECTRICAL
9,��'..4.II Licensed Professional
.wxQ OWNER-BUILDER DECLARATION SPECIAL CIRCUpUMISC.
OaU I hereby affirm that I ant exempt from the Contractors License Low for the
u13 try following reason.(Section 00315,Rosi ness turd Professions Code:Any city or county TEMP.METER OR POLE INST.
which require,a permit to canxlruc,alteaimprove,demalkh,or repair any'madam
wwQ7 prior m its issuance,alw requires the applicantseemed for such pto file a signed statement POWER DEVICES -
,iiOOy� the he is licensed pursuant uthe provisiorts of the Cnntreaer's Liana Lew(Chapter
L0x.0, 9(commencng with Sectio AlW)of Divisionvson 3 tf the Bus les IprofessionsCode) SWIMMING POOL ELECTRIC VALUATION
W_m onto 7031.5 by
refntmund the bas at subjects thedexempt n Any of fan of OUTLET S-SWITCHES-FIXTURF
�ZQ net on than so madiehcom forapermit subjects the appbcannoacivil penahy of
W= not methanBofthepreddol,ormyem). NEWRfSIDlF IALELFCTR S .Ff.
m ❑ I,asnwneroftheproperty,ormyemployceswith wagesastheirsalecompensoner. Q STORIES 'ITI'E CONS'1'RUCI'[ON
ty wi 11 Jo the work,and the structure is not imended or of feral for sale(See,70,14,Business
and Professions Code:The Con rr chmis License[.rise does not apply to an owner of
properly who buids or improves thereon,and who does such work himselfor through his OCC.GROUP RES.UNITS
the
ebuping or ithmsuchimprovementsarene yea
completion,
owner-
builder Ir,
however,thebuildingor enofemem is soldwithinoneyear of completion theposeof
will have the burden of proving Ole he did nm build m improve for purpose of
side.).
❑ I,as ownerofthepropeny,rim exclusively connactingwithlicenud commmorsm QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
construct the project(Sec.7014,Business and Professions Code:)The Contractor's
License Lawdoisnatapply loan ownerofpropeny whobuildsorimproves themon,and PERMIT ISSUANCE
whoccentracts forsuch projects with a contrachodi)licensed punuanuo the Contractor's
License Law. ALTER DRAIN&VENT-WATER(PA) PEE SUMMARY
❑ 1 am exempt under Sec. ,H&PC for this mason Ol SIDE FEES
RACK MAW PROTTiCf.n[VICE.
SANITARY Y N
Owns Date A I 1 RT:CIiIPI'p
n DRAINS-PLOOR.ROOF,ARE? O D
WORKMAN COMPENSATION DECLARATION i HOO I YN
Ihercby affirm thmlhavenanificam of mnumm�elf-insure,nr acenificate of FIXTURES-PER TRAP RECEIPT#
Worken'Cnmpensvuonlnsurana orewrlifed mpy tM1emo[(Sec.JSW,Lub C.)whl<h i' AR :B YN
J
covers RF.CFIP M
Policy N I empymsFirods1t1Y9®nit,
OAS-F?A.9YSTEM-1 INC.40 .T y BUILDING DIVISION PEPS
Company—�-1 IIL�MC.AI�'•l�lo GAS-IiA.SYg9'IiMOVf: 4(I?A) DAT .A 1 E
❑�G'enined npyishem y unnat
Certified copy ix fled with thecity innrenimt divisina GRfiASEIINDI,STR1.WA F.RCF.ITOR GRA LNG♦EI.
CERTIFICATE OF FAEMPUON FROM WORKERS' GRFASE'IRAP SOILS FEE
COMPENSATION INSURANCE.
(Ihissecom,need at he completed firm .it is feature hundreddellers(EIW) SF.WER-SANITARY-STORM F.A.2(ki ENERGYPEE
arless.)
I verify that In the wifomance,of the work for which this per it is issued.Is hall WATER HEATER W/VIN3'/ELECTR
not employ any person in any m as to become subject to the Workers PAID
Compensation Lawsof Califomia. Date so WATER SYSTEM/1'REATING Dam Receipt is
App
Z 101OTI vm NEW RESIDENTIAL PLMB. S .FT.
dry7�s-I Z 'IAOlies.TO APPLICANT:Jr.after making this Cenlfcme of Exemption,you should Q '10'I'AL;
became subjectunthe Workers Compensation provisions of the Luber Cade,you must
[�^ ; forthwith comply with such previsions or this pernit shall be deemed revoked, BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
V Z I hereby vfRrtn that there is a construction lending agency for the performance of TOTAL: ELECTRIC HE
work for which Ih is permit is issued(Sec.3097,Civ.C.)
Imder's Name §�El
01- Lender's Address QTY. MSCI IA NICA L PERM IT FEE PLUMBING FEE
U 1 certify that I have read this application and state that the above information is MSCI IANICAL FEE
�•' W correct.I agree to comply with all city and county ordinances and slate laws relating to PERM IT ISSUANCE
haildm comnucti.a.malhereby uuthu' eemaives ofthiscitymenteruponthe CONSTRUCTIONTAX
U Z above-.....maned property for in, in pmfars ALTERORADDTOMECE.
(We)ogre m s e,inJem and kap ha less the City of Cupertino against
liubil'i ,judge av wound swhichrn y inany wayietvaii,cm,wrid City AIRIIANDLINGUNIT(TO 10,0110CF1,)
in rye`s.
it a it ;pemtil. AIR HANDLING UNIT(OVER 10k000CFM)
not reof Applican/Contraatnr Dam EXI IAUST I IOOD(W/DUCU 'PAID
IIAZARDOUS MAI FRIA"DISCLOSURE IIEA7INGUNLT(TOIW,000BTU) Dam Receipt#
-
Willtheapplicud future buildingncv.punlrlocar handle thaaardnas material
0Yes S No HhATING UNIT(OVER 10s).000 BI'll) L:
as dermad by the Cupertino M viral Code.Chapter 9.12,and the Health and Safety
Code,Section VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
WIII Oeeppllcanmrfuwre bulldingoccupantusoeyuipment orlevlcaswhlcM1 emh BOILER-COMP IMF OR 100,000 BTU) ��ssYY pp
h rardoos air ttmlarica to as Reed by the Bay Area Air Quality Management BQE.ER-COMP(OVFR IW,IKp RITIj P M
Disois,T
't ❑Yes n /�c NEW RI IDM[ TIAL MECIL SQ.FI'. ®� _ 1993
1 have read the mianddiotins mnmrials reyeiremems under Chapter 695 of the T 9,93
Califomia Health&Solely Coda Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the - .1 1 VUrC 11
occupant of the requirements which must Ito met prior to issuance of a Certificate of irn
Occupancy.
Owner ur wlbmiuA
,at Date TOTAL: ISSUED BY:
OFFICE '