25202 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF,CUPERTINO BUILD i-
ELL TRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 25202.
IIUILDINO PROJECT IDENTIFICATION
BUILDING ADDRESS: ,- l/1Y /.d q 1 �') SANITARY NO. APPLICAITIIIONNSS.UBMITTALDATE
/Il/dy 7WW _U VVI UNIT# LOT. 46a?n
O FR AM.: '�// / HONE: CO R'S r1E: LIC NO: N/C CONIBOLN
R IIECryF.VGINEEIL LIC NO: ADDR.. r/ ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DIISCRIPTION
1402 Thereby affiraffusionhin I 3 ofth licensedunderitIimfiesofChuptes9(comm.ming with
ln00 Sectian]OW)of Division Jofce Business and ProfessiamD de,e(c m eaveis in PANELS l^'a�f,
full fo dof�TL.�Clic � .4-' DP T02W AMPS
y« are Contrac[or 201-IIXp AMPS
7Oy_ ARCHITECTS DECLARATION OVER TWO AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
oz—q I understand my plans shall be used republic records.
K Y t� SIGNS ELECTRICAL
K Licensed Pmfessi...I
,W< OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
�OiU 1 hereby affirm that 1 an exempt from the Contractor's License Law for the
LLLLON following reason.(Section 7031.5,Business and Profession Cade:My city or county TEMP.METER OR POLE INST.
,�5 which requires a permit to construct,alcor.improve,demolish,or repair any soucture
ta}g priorro its issuance,also requires the upplicam mrsuch permit file u signed stmemem POWER DEVICES
e'<O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
0c'a 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC �ATION
y)�y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
t�Q
Section 7031,5 by any applicant for a permit subjects NQUTLE'1'S-SWITCHES-FIXTURES ��
e applicant to u civil penalty of
f�14 net more than five hundred dollars($50(h.
❑ I,esowocrofnhepmpM,ormyemploymswiNwagesas Neirsolecompemation, NEWRFSIDENMALELECIR _SQ.FT. STORIES TYPECONSTRUCION
a3� will dufesions ands Th ContisnotisLt..,Law
apply L1a4,Business
end Professions Code:The Contractor's ndwho Lew don or apply m an owner of
propenywho
yces,pdvided that
Nertomvndwhodaessumicade Mmulfm through his OCC.GROUP RES,UNITS
own employees,provldedmar improvement
of iewofdmoffacd for sale. r-
however,ill have he b r ien affirming
is solthat
he within one year o improve for the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I.as owner culls,property,amexclisively contracting wit licensed contractors to QTY. PLUMBIN _RM IM E OOD ZONE ANN
omvue,the project(Sec.70sFL Business and Professions Cade:)The Comractara PERMIT ISSUANCE
Li cense Law docs not apply man owner of property who bui Ids or improves tercon,and
who contracts forsucli projects with acomracmgs)licensed pursuant cote Conitucmr's
License Law. ALTER-DRAM&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt ander Sec. ,B&P C fm this meson BACK FLOW PROJECT.DE
--4 9
Y Y N
Owner Date RECEIPT.
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ I hereby affirm that l have a cenificate ofeansenun self-wure,or a cenifiewsw FIXTURES-PER TRAP RF,CEIPTp
Workers'Compensation Insurance orucedifiel copy Nereof(Sec.38W,Lab CJ which PARK FEE Y N
coven all employed.,under this permit. GAS-M.SYSTEM-1 INC.4 OUTLETS RECEIPT'N
Policy. BUILDING DIVISION FEES
rCety GAS-EA.SYSTEM.OVER 4(M) PLANCHECK FEE
Certified copy is hereby fumishea.
nified copy is Bled with the city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollmu(SIM) SEWER-SANITARY-STORM M.2011717. ENERGY FEE
or less.)
I certify that in the performance of the walk for which this permit is issued,l shall WATER HEATER W/VFM/ELECTR
nm employ any person in any manner so as to become subject no the Workers PAID
Compensation Luwsaf California. Data WATER SYSTEMTRMI'ING Data Receipt.
Q O NOTICE tTO APPLICANT:If.after making this Cenific to of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
VJ become subject to the Worker's Compensation provisions of the Labor Code.you must
5 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING IEE Its
SEISMIC FEE
ra, Q
CONSTRUCTIONisa,moLENDING AGENCY
^� z {kfobyaffirm Nauhem is asumtructi.3lendingagency for the performwce of TOTAL: ELECTRIC FEE
V O the work far which this permit is issued(Sec.3W],Civ.CJ
0 ULender's Name
' Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V I certify that 1 have read this application and ordinances
that an above information is
building Iogree,.on,comply no lumby autbodd representatives
Dfibis state laws refining to PERMIT ISSUANCE MECHANICAL FEE
U h idarse-meng ntioned
pmJand hercwsrenow mpre:entexvex of Nis city menur upm the CONSTRUCTION TAX
V z above-memianed property fm inspection p sag ALTER OR ADD TO MECH.
ON I eg no save indemnify m ecp erMa the City of Cupenin t against
liubilities,j gm ms, send experts whicM1t a y way acetum against said City AIR HANDLING UNIT TO I ROM CFM)
ranting of tis is.
/ AIR HANDLING UNIT(OVER IO,"CFM)
Sign o Applicnm/Cm-nowtor (01 ate EXHAUST HOOD(W/DUCI') PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Dau Receipt#
Will the applicant or future building occupant more or handle hvardous material HEATING UNII'(OVER IW,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and to Health and Safety
Cade,Section 25532ha)?
❑Yes ❑No VENTILATION FAN(SINGLE REBID)
nISFUNCE DATE
Will rheepplicenmrfuwrtbuildingmcupannau equipmentordeviceswhichemir BOILER-COMP(JHP O0.1W,000 BTD) UY 1 0
hessrdous air conwminams as defined by be Bay Amo Air Quality Management BOILER-COMP(OVER IM,"BTU)
DiatrieR
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,FT. JUN 15 3993
I have read the moue n o materials requiremems under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25537 and 25534. 1 understand that C�j y tar (;Urtn I"Wif the building does mar cureaily have.broad,that it is my responsibility,.amity Ne
acceptor of the requiremems which must be men prim,.issuance of o Certificate of
Occupancy,
Owner or authorized agent Dau TOTAL: ISSUED BY: