25099 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO bi-E111.1 TRICAL PERMIT NO.
APPLICATION/PERMIT w.umnlNc-MepunNlCAL 25099_
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: r. r� SANI'1'A RY NO. APPLICATION SUHMI'PI'AL DNI i
20-1500 erm.1ftt-115 vl�tszll< UNITE LOT# —GA,_
OWNERS NAME: PHONE: CONfRACfOR'S NAME: LIC NO: t,/���
�I N/C CONTROL Or
ARCIBIFE '1'/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE
QTLY- -{,f ELECTRIC-PERMIT FEE BUILDING PERMIT INFO
SVr� y�� l� BLD ELE PLUMB ME
W AY ekA ��U�S�3 �^�SaJ PERMRISSUANCE ❑
stt
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWz Ihereby affirm that l um licemedunderprovisionsofChapur9(commencing with JOB D 'CRIPI'ION
1400 fall
of DivisionJof Ne Business end Rofessionx Code,end myliunu is in ppNELS --y�--��
y full foae and effect {//
<<y License Close � Lic.p Q�I17$ UP T0200 AMPS
I�n6y Dr. Cmlm,lm *Jr.It2aldw tom:_ 201.1000 AMPS
S FOy� ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
0 Z C 1 undersland my plans shu11 be,used es public records.
�yF; SIGNS ELECTRLicensedt L� ® `1
LicenJ Professional
E Naimnal I 'V
0.a WU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t
%Oy 1 humby af0rm that 1 oa,exempt lions the Commmer'a License Law for theC7tTtAPU —
W a rn following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
�f30� which rtquim,n permit to construct,after,improve,demolish,m rcpnlr any macmrt
W.' 7 prior to its issuance,alta requites the applicant for such permluo file.signed abutment POWER DEVICES
W 0 that he is licensed puruanuo the provisions of the Comment's Licenx Law lChepter
a a�' 9premmencing with Section 7007.fDlvisim3.fthe Business and Professions Cone) SWIMMING POOL ELECTRIC
VALUAIW
or he is exempt thenfrom mrd the basis for Ere alleged exemption.Any violation of
Section 7031.56 applicant for OUTLETS-SWITCHES-FIXTURES 3�5OB
by permit subjects applicant pevlty of
not mom than five hundred dollar($500). NEW RESIDENTIAL ELECTR _ Q.F
ST.
ce
W m ❑ 1,asownerofthepmpny,ormyemploy .withwaguastheirsolecompenvdon, STORIES TYPE CONSTRUCTION
a3— will do the work,and the mucmrc is not intended or offered for ule(Sea.7044.Business
and Professions Cnde:The Contractors License Law does and apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his
employees,provided that suchimprovemenmumnotimendedoroffend(mole.If, OCC.GROUP RLS.0 ITS
however,the briddingor improvement is sold within one year ofcomplah n,theewner. T
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
❑ I.usownerofthe properly,am exclusively convecting with licensed convectors to QT' PLUMBING PERMIT FEE ------MOOD_ZONE APN
onstrucr the project(Sec.7144,Business and Profession,Code:)no Contractor's
License Low docs not applyto an ownerofpropeny who builds or improves thereon,and PERMIT ISSUANCE
whocommcmfor such projects with acontractor(s)licensed pummonto the Convector's ALTER EA
License law. ( ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY O fY N
WORKMAN COMPENSATIONDECLARAT
owner DATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
21�
�r !l IherchY affmm thetlhave accrtifcam of consan[u selGinsurc.oracenificnrc SCHOOLTAX YN
of
Workers Compcnsetionlnsusenceoracenified ropy Nercof(Sa.3800,1ab C)which FIXTURES-PF.R TRAP RECfdPT#
FEPARK E YN
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifiedemyisherebyfumimed.
910enifird copy is filed with the city inspection division. GREASE(INDUSTRI.WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thiasectionneed not be completedBNe permit is(mune hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY HE
.1.e.)
l certify that in the isafmmnnceof Ne work for which Nis permit is issued,(shall WATER HEATER W/VENT/ELECTR
nm employ any person in any madmr m as to become subject n Ne Worker' PAID
Compenutionlawsof Califomie. Date WATER SYSTHM/IREATING Dore Reccipt#
z Applicant
y� NOTICE TO APPLICANT:If,after making ibis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. T TAE:
FVJ become subject to the Worker's Compensation provisions of the Lahr Cade,you must
a ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING HE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.D- z 1 hereby affinn thin them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name n PLUMBING PEfi
w0 pLenaer,Address QT1'y ,' MHCIIANICALPERMIT FEE
V I certify that 1 have read this application and mute that the vbove iNortnation is `
Gconst.lagmcucamply with all city and county oNinenccs and sate laws mladngm PERMIT ISSUANCE MliCfiANICAt.IFF: r
building construction.and hereby auNorise tepresenntiveso(this city to erns upon the CONSTRUCTION TA%
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wc)ogre. ,indemnify and keep harmless the City ol'Cupenirm against
liabilities,judg nu6costsnnd expense which may in any way acemeagainst mid City AIR HANDLING UNIT(TO 10,000 CFM)
I.couseyue of Negro 'ng of Nis permit.
5
AIR HANDLING UNIT(OVER 10,00)CFM)
Si swan A r t/Cnnvucurr p¢ EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT G`0100,000 BID) Dote Receipt If
Will the applicant or future building osrupaot store or handle heeerdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safny HEATING UNIT(OVER 100,000 BTU) TAL:
jittt"I'm 1,
Cede,Seen,,.25532(.)( VENTILATION PAN(SINGLE RP.SID)
❑Yes El No
Will Nev licantorfmumhuildin rose BOILER-COMP(3HP OR IW,IXIO Ii'1'U)
ISSUANCE.DATE
baboundpp l by
equipment orality Management
)i,mct sea air contaminants ns defined by the Bay Area Air Quality Menvgement BOILER-COMP(OVER 100,000 BID)
�)isv a7
❑Yes ❑No NEW RHSIDGNTIAI.MECH. SQ.PT. P A F D'
I have read the It Safety
Coo,materials requirements antler Chapter ervi of the
California llcalN&Safety Code.Sections 25503,25533 and 25534. Iundersumd that ��� O�
if the building does not responsibility currently have a tenant,that it is my resnsibility to notify the TV
occupam of the requirements which most be met prior to issuance of a Certificate of
Occupancy. _
Owner,or nu0rnriren ugcm Dam I 1 'IInij
ISSUED BY: -