25466 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPERTINOBBD.DI G-PUTDUCAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING:-MECHANICAL 25466 5 �I �C
BUILDING PROJECTIDEMI'IFHCAI'[ON J LC V
BUILDINGADDIiESS: ��..aC. /}•••� SANITARY NO. AAPPPP�JLICATIONNSSUB/MIITTALDATF.
I VW C4FE �L!,4PNIT# LOT is `/{49_11
OWNIr.RSNAMR: PHONE: Q/ CONTRACTOR'S NAME: LIC NO: I �/ Y
NIC CONTROL#
RCfJI'f,Cl'/IiNGINLER: ADDRESS:
�kft �LC NO: ❑
CONTACT: PHONE
QTY* ELECTRIC PERMIT FFiG BUILDING PERMIT INFO
Y/srYalgli97 Id BLDG ELECT PLUMB MECH
JZ i-AL T PERMIT ISSUANCE
LICENSED CONT ACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihe,ebyamnm Nw fan licemsedtnder provisimno1'CTnpmr9(cammeneing with
,100 Section V000)of Division 3 of the Business and Professions Cole,and my license is in PANELS O
<1—W{'' fall once and effect. �/
Z0 Lillro as- 1.at , �y�� • s� UP T02fN1AMPg
co<L Date Comrve fl" 201-1010 AMPS
zC7 ARCIII'IECT:S DECLARATION OVER MIKE AMPS SQ.M.FLOOR AREA $/SQ.F.
0z_G I undersand my plans shall M used ns public records.
W SIGNS ELECTRICAL
2yj Licensed Professional
�y�6 OWNER-HUILDER DECLARATION SPECIAL CIRCUIT/MISC.
4x4x O0. 1 hereby affirm that I am exempt from the Contractor's License Law for the
W 30 on tullowing reasun(Secdnn 90:iL5,Pusineax nnA Prnfeaslons Calle:Any city.,count, '1'EMP.M ETER OR POLEINSL
u'0I which requires a parol to t mdmet,alter,improve,demolish,c r repair any fracture}�F prinrm itaiaauance,ho reyuimathe appliesm far such permitm file naiFodivienenr POWER DEVICES
ddoG0 that bo is licensed pununt n the prevision,of the Contmaor'e License Law(Chapter SWIMMING PORI.GLIiC'1'RIC
�' 9(commencingwith Secli.nlOWlnf Division Softhe Husiness end Pr.fcssiona Code) FIXTURES
SWITCHES- VALUA'l#
_,, or that he is exempt and the basis for the alleged exemption.Any violation of `V
�zGSection 70315M1y any applicant fora pennilmlapcta the applicant to a civil penally of OUT'LET'S-
s$0
achrome than 11vc hundred dollars($5100).
W F-o ❑ 1,asownerofthepropny,ormyemployecswiihwagesotheirsolecompmation, NEWRESIDENTIALELECTR _SQ,FT. STORIES TYPECONSTRUCTION
y;_° will do the work,and the structure isnainendedor offered forasle(Sec.1044,Business
and Professions Code:'Ilie Contractor's License Law does not apply In as owner of
propertywhobulldsorimprovesthereon,and whorl«such work himaelforthnmgh his I s 1 t
ownemployces,provided thatsuch improvemenmam not imeaded.r.fered f.r"ale.If. / s t p •> CC. ROUP RES.UNITS
on
h.wevcr,the building.,improvement issold withineyearofmsmpldion,the owner. r I� I
builder will have the burden approving that he did not builds improve for purpose ofJ,
sale.). QTY. PERMIT PI,UMBINO _ v tli. likgk)U ZONE MIN
❑ I,as owner nflhc pmpeny,am exclusively contracting with license)contractors to
consumer the pmidel(Sal.70144,Business and Professions Cade:)The Contractor's H I
License Law does not apply manownerofproperty, mPERMIT ISSUANCE whobuildsorimpvestonevan,and -�
win contracts forlorn aninceds wilhucothardr(s)licensed panam,In the Conametor's
License law. AL'IT:R-GRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT'.DEVICE. OUTSIDE FEE
SANITARY YN
Owner Dow - RECEIPT,
DRAINS-FLOOR.BOOP,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ ' ywfirm that
nlhave acif:oc of concent.eel ,nr ) FIXTURES-PERI'RAP
� RECiIPI#
Worke.C.smpensaion lspmnceo,acenfcJ copy thereof Sed.38W,Lob C. which
PARK FEE YN
covers nil employed"umderthis permit. GAS-HA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Cerified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASIONDUSI'RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Phis train.meednm be completed ifthe permit is for one hundred drillers($100) SEWER-SANITARY-S1Y)RM EA.200171'. ENERGY FET?
or less.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER HEATER W/VENT/F.LECfR
not employ any person in any manner so as t
zi , �.. b�� Workers'
PAID
Compensai Dam WATER SYSTEM/RFATING
Date Racipt#som
Q w
I%W.�f%/i�
Z 0 NOl'ICETOAI'PLICNter:R•Ilf ,..kingthi,Cenificmeof a ,ti on,you should NEW RESIDENTIAL PLMR. ' SQ.Ff.
TOTAL,:
F' fq
become subject y the Worker's Compensation previsions of the Labor evok you must
� forthwith comply with such previsions or this permit shall be deemed revoked. BUILDING FEE r+
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is a construction lending agency for the performance of
U0 the wok for which tblapermit is ixaudd(Sec.3097,Civ.C.) TOTAL: ELECIRICFLE
Lenders Name
L1-, PLUMBING FEE
F
Leader's1vemdresa QTY. MECHANICAL PERMIT PGE
G 1 certify that 1 comply
read This city
and county
and state that the stave information is
torten.lagree to comply with all city and county ordinances and stale laws refining to PERMIT ISSUANCE MECHANICAL FEE
I-' 0,) building construction,and hereby submiu representatives alibis city to enter upon the CONSTRUCI'IONTA%
U z above-mentioned property for inspection purposes. ALTP.RORADDTOMECIL
(We)agree to save,indemnify and keep Intruders the City of Capenimn against
Iiabilities,judgments,costs andexpenses which may in any wayaccroengainst said City AIR HANDLING UNIT CTO 10,000 CFM)
in wase the gmntlng of thio permit
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Aant ' 'axtvr QtDame EXHAUST HOLD(W/1)UCn
PAID '
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOg000 BTU) Uwe Receipt#
Will the applicant or future building occupant store or handle hazardous material IICATINO UNIT(OVER IUO,(g011'I'U) I'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Cade,Section 25532(n)Y VENTILATION PAN(SINGLE RISID) r
❑Yes ❑No
' ISSUANCE DATE
Willthenpplicarnorfuwmhuildingmcupamuse uipmenmrdeviceswhichemit BOILER-COMP(3HP OR 100,000 BTU)
�hiam ous air contaminants as defined by the Buy Area Air Quality Management BOILER.COMP(OVER 100,000 BTU) PAID
Dislricty
❑Yes ❑No NF.W RESIDENTIAL MECH. SQ.FP.
I hose rend the It m,r dous mwurinls od,ircments under Chaptu 695 of the UG 18-1993
Coffman Health&Safety Cade,Sections 25505,25533 and 25534.1 underaland that ^'F
ifthe building does not currently have a tenant,Nns
at it ismy respoibility m notify the (# 'rf-�L f�
causal of Nc reyulrenents which moat In met prior Io lawunde of a Certificate of f�VI1T-LIl�l
Occupancy.
Owner month orizdd agent Data 'TOTAL ISSUED BY: