25126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R ILLI G-ELECTRICA L PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 25126
BUILDINGADDRESSS 1/� CI 1, SANITARY NO. APPLICATION SUBMIT'T'AL DATE
69 O Jy A` ON,is LOTH `iLl�
OWNERS NAME: PHONE: ONTRACTp .S NAME:: LIC NO: J
M N/C rte/ CONTROL 4
'��RCIIITF.CI'/IiNGINI?I?R: LIC NO: DRISSS - ❑ � Y I�
CONTACT: PHONE:
�f,Y'ry1 L y� QTY, BLECTRIC PERMIT PEC BUILDING PERMIT INFO
(/f�+• ` - Vr V PL•RMI'I'ISSUANCE BLDG E EQI' -UM MFCII
LICFNSF.DCON'T RACfOR'S DECLARATION APPLIANCES-RESIDENTIAL. .013 D;SCR PI'ION
tA—
p �Z Iherehyaffirm that lam I c'madunderpm,kicamcdChaplere,bommeming with
�UO_O Semien]0(do of Division 3 ofthe Business and Professions CWe,and my license i. in PANELS
force and
<GU4,p IJdcnae Classeffccs. Iic.M ����� � UP TO 200 AMP. /�){��\��
y¢y Cut ' Contrucmr I^ 201-IOW rs -
F-y Z_ ARCHITECPSDECLARATION OVERT P SQ.FI'.FLUOR AREA S/SQ.FT.
Oz1 understand my plans shall be used as public resounds.
PYFJ SIG ',E. 1 AI.
qyy�dpr,, Licensed Pn s
Syve.Q s for exe LD ER DECLARATION I
CIAI.CIR I'1'/MFSC.
°J 3 F I hereby affima that 1 efn exempt frons Ibe Conwmor's Liceme low bertha
following oblon.(Section 7031.5.Bte inessaM Professions Code:AnycityorcmruMP.METER OR
ONa which requires a permit In construct,alter,improve,demolish,at repair any structureWER D C
}� prinnoiu issuance,also requires Ne applicant farsuch permit mfile asignW sfaemem
_0Oz Thal he is licensed pursuam to the provisions of the Cuntrnnnls License Law(Chnp¢r
i eLL 4(crnnmencing with Section of DivisionJof the Business and ProfessionsCWi) IMMI 01 F.1. IC VAhUAT1QN
or that he is ea<inpnherefmm and the basis for life alleged exempt'..Any violati.nnf
�Z¢ Scaion]O3L5 by any applicant for a permit subjecHthe applicant ma civilpenaltyufTLETS- TCIIES-FIXTURES
not more than five handled dollars(5500). NEW RESIDENTIAL LLECIR _SQ.FT. STORIES J
kkll6Cp� ❑ f,mowneroftheproperty,ormyemploymswithwagaustheirwlecompensmion, 'TYPE CONSTRUCTION
T
will do the wark,and eheanuoom is nm intended.rofferW for sole See.]B44,Business
and Professions Code:The Convectors License Law dins not apply to an owner of
f property whobuildsorimprovestherton,and whodoessuch work Nmselforthrough his OCC.GROUP RES.UNITS
own employees,providttl thin such improvements art not intended or of&rte'for sale.If,
however.the building or improvement is sold w'nhin me year of completion,the owner-
builder will have the burden of proving thin he did not build or improve far purpose of
sale.).
❑ I,us owner of theproperty,nm exclusivelyttmtrazting withlicensed mntrectmsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
ansvuct Lha project(Sea.9(b44,Business and professions Coda:)Thu Contractor's IPERMIT ISSUANCE,
License Low doe not apply to not who builds or Lmprew.therenn,end
whocentructs forsuch pmjects with a contractogs)licensed pursuant to the Contractors pLTF.R-DRAIN&VENT-WATER(FA)
License Law. FEB SUMMARY
❑ 1 am exempt under See. ,B&PC for oda mmrmUT_IDE FLL.
HACKFLOW PRO)'F,Cr.DEVICE SANITARY YN
Owner Date RECEIPT X
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION SCHOOL TAX Y N
❑ Fherebyansatliilnsu eceraMa fj cmaw eoof(Snwre,o.uab C.)atuaf It HCBIPTM
mker%Compcnsatian Insurance oruttraifiW copy thereof(Sw.3g00.Leb CJ which TURKS-PF:R'IRAF PARK IsF:E Y N
covers all employee's under Has permit. EA I?M IAC.b O 5 RECEIPT'R
i PnlicyN BUILDING DIVISIO
Company r�il V 4p7A)LPLANC14ECK FEE
❑ Certified copy is hereby fumishW.
❑ Certified copy is filed with the city inspection division. EASIJIIID 6X: - 1; R GRADING Mr.
CERTIFICATE OF I?XEMPI'ION FROM WORKERS' p WE51?TRA 50119 FEE COMPENSATION INSURANCE(Das section sad not b,completedifthe action is for one hunthW dollars 151210) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE?or less.I cenlly sht in the to,fomanceof Ne work forwludi this permit is issued.lshall WATERHHATRRW/VENT/fiECTR
nal employ any persons any manner so as to become subject to the Workers' pplp 04 CompereationLawsofCalifomia. Date WATER SYSTEIAORFATING Uma4'1 z ApplicantNOTICE'10 APPLICANT:IL aftermaking this Cemficam of Exemption,you should NEW RBSIDENTIALPLMB. SQ.FT.
Vj become subject to the Worker's Compensation provisions of the Labor Code,you muss
Ffa" ? forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING THE �a
W Qz CONSTRUCT ION LENDING AGENCY SEISMIC FEE
5 I hereby affirm that is a construction lending agency for the peRormwce of
U O the work for which this permit is noted(Sec.3097,Civ.C,) T ( ELECTRIC Hili �-
Hatr lenders Name
L'� Leaders Address ,QTY. MECHANICAL PERMIT PBB PLUMBING FEE
U F certify that 1 have read this application and stem that fine above information is
cmrcef.l agree to comply with all city pact county o manes and matelaws rclmingm PERMIT ISSUANCE MECIIANICALFEE
buddingconstructiao,and hereby anthorim representatives of Nis city to enter upon the
CONSgRUCTIONTAX
U z nhnve-mentioned propend farinnify ad purposes. e ALTER OR ADD'fO MF,CI I.
(We)agree nt save,indemnify end keep mayin theaya co Cupenino against
liabilities,judgmems,costs and expenses which mayins�y way az<meegeinm said City AIR HANDLING UNIT LTG I0,000 CFM)
n'consequence of the granting of this permit.
� / AIR HANDLING UNIT(OVER 10,000 CFM)
Simulate of Apithe1miCianninmr / /Date EXHAUST HOOD(WNUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0(10 RTU) Duro Receipt a
Will the applicant or fumm building occupant store or handle hueerdous material IIFATING UNIT(OVER 100.000 BTU) 'TOTAL:
us defined by the Cupertino Municipal Code.Chapter 9.12,and the Halt end Safety
CWe,Section 25532(a)] VENTILATION FAN SINGLE RISIDI
❑Yes ❑No
BOILER-COMP LINE OR FLU,"BTU) 'WACf BTF,
Will Nit emicanmrfumrc building by the mac equipmentualityc Management it 'WA
�t
ill?
air mmanfinants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100AX)BTU)
IxoicR � JUL •
J ❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. Ut�.91993
1 have read the haandous materials requirements under Chapter 6.95 of the Oily
/�
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand tact - U�� I ul- GUF'trI111VV
occupanf the t of the resnot umoneo ntly hmx must
the et t itprior
r to remove,bila Confiy to otify the V, _V
occupant of she rtyuimnents which must be mm prior to issuance of a Cerfificate of
oecnpanay.
Owner or anthodzedagOT
em- Date TISSUHDBY: