25137 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BLDLD1NTrELpZTRTCA. PERMIT NO.
APPLICATION/PERMIT PhUMIIING-MF.CIIANICAL 25137
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
BUILDING ADORFSYj& SANITARY hip. APPLLicA'DUN SUBMO[TAL DATE
23 ly\We UNITN Q LOTH
pW RSNA li: 110 CONTRACTOR'S NA f LIC NO:
N/C COMTROI.q
D
z�ARC ITF-CT/ENGINEER: LIC O: ADDR 5: ❑
CONTACT: PHONE. BUIL-DING PP.ItMIT INFO
Pprii-0Rq)7-647(QTY. ELECTRIC PERMIT FEE
J 'l �y• gLpG ELECT PLUMB MF,CH
7 V U PERMIT ISSUANCE r I7�EIL_ 11 El El
LICENS' ONTRA TOR'S DECLARATION APPLIANCES-RESIDEN71 L 3pB DGSCRLPTION
IOmZ I hereby affirm that l am licensed underpmvisionsof Chapmr9(commencingwilh ION �0
Pi100 Section]000)af Division 3ofsh.Business and Professions Code,and my license is in PANELS `
y�Fy- full force and effect.
4Z� Licenxc Class Lic.N PS
tvfo< Date Contractor E AMPS SQ.FT.FLOOR REA $ISQ.FT.
1—Z, ARCHITECTS DECLARATION
Z O vs— l understand my plans shill he used as public records.
OZ—Q
y W IGNS EIPC4RI (3 V0 f�
51 Al
<.,_n Liccn.wd Professional
LdcdQ OWNER-BUILDER DECLARATION SPE CI U SC
K
aatOaU I hereby affirm that 1 11,exempt from Ne Conwcmrs Li i f the ALED ' A'
u134.fir fallowing reason(Section]03 L5,Business wed Profesiom Code n o ouny RPoLE INST. N
l_-'�02 wM1ich requires n permit no bmawm,alter,improve,demolish, v t y larni DEVICES
�p�Y� priortn iu inuancc,also requires the applicant fursuch permi fil1e signed smemenn
W,<,)
6 O0p that he is licensed pursuant m the provisions of the Convect 's rat, n
cense Lew(Chap¢r SWIMMWG POOL ELECTRIC
Ota, 9(commencingwith Section]000)of Division Sof Ne Businessand Profesiom Code) VA.DATIpN It
QO
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of DAT Q
FZQ Section 7031.5 by any applicum fora Permit subjects the applicant roncivil penalty of OUTLETS-SWITCH -FlXTURES
i20 not armadsn five hundred unit.S50% NEW RESIDENTIAL EESLECTR _SQ.FT. STIIIS TYPE CONSTRUCT ION
?.a
❑ othe%oaoD ha,streny,ormyemtendisdor ffired orsdc(Scla c0m.Bus n,
will do the work,and the he Contisnm mendede offend fm sale(Sec.to a4,c sea' as
and Professions Cede:The Contractors License Low docs not apply m an ow er of
pmpenywhabuilJsorimpmves thereon,and whodoes such wad hoexcie ann ghhis OCC GROUP RES.UNITS
own employees.provided Nm suchimpravememsae not imm�dWoroffcrdfor 0If.
however.the buildingor improvement issoldwithinoneyemafcompletion.the wneTOTAL:
builder will have the burden of proving that he did net build or improve for purpose Of
QTY, PLUMBING PERMIT FEE FLOODZONE APN
zIe.)I,asowner oDhe progeny.amexclusivcly contracting wilt licensed cono-dors to
construct the project(Sec.7014,Business and Profession.Code:)The Comramors
License Lawdoes misapply to on ownerofproperry whobuildsorimpraves bacon,and PERMIT ISSUANCE
whoconnecnsfor such projects with acommetor(s)licensed pursuant to the Conwaor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. .B&P C for this reason OU'I'SIDH FIiES
BACK PLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam DRAINS-Fl,OOR,ROOF,AREA,COND. RECIi1P1'N
• cu WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ers reby Compensation
rn that lhave
rance or aceuteedi copy
Lab C.)which
Of PIXI'URFS-I'T;R TRAP RECEIITp
Workcrs'Compcnsasion lnsumncanrettrifdcopy thereof(Sec.3800,Lab CJwhich PARK FEE YN
vers all empin tt i under this cannot. ECEIPT'p
Y GAS-EA.SYSTEM-I INC.INC40IITLET3 BUILDING DIVISION FEES
Policy x
Company GAS-EA.SYSTEM-OVER 4 HEA) PIANCHF.CK PIAT 6
❑ Ccnified copy is M1erewith bshed.
❑ Certified copy is fid with be city inspection division GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section Decd oat be completed ifhe permit is for molandrd dollars T$100) SEWER-SANITARY-STORM EA.YWIFT. ENERGY FEE
or lest)
I cenify that in the performance of Ne work for which this permit is issued,l shall WATER HEATER WNE,1T/ELECTR
not employ any person in any manner so as in become subject to the Workers PAID
Compensation Hawsof Celifomis. Date WATER SYSTF,MURGTING Date Re tips
O Z Applicant a�
z O NOTICETOAPPLICANT:IL after nuking this Ccrifcne of Exemption.you should NEW RESIDENTIAL Pi- SQ.FT. TOTAL: .\Z`
become subject o she Worker's Compensation provisions of the Labor Code,you mus
Forthwith comply with such pmvisionsor this permit shall be deemed revoked. BUILDING FEE
a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE - 6 z
I thereby affirm leauheo iso construction lendingagency for the rf.to,of
z y TOTAL: ELECTRIC FF.E
U O the work for which this permit is issued(Sec.3097.Civ.C.7
Lender's Name PLUMBING PGI:
IZ
loaders Address QTY, MECHANICAL PERMIT FEE
U I certify Net 1 have read this applicmion anal sum 11181 the above information is MECHANICAL FT-E
acorrect.I agree to comply with all city and county ordinances and into laws relating to PERMIT ISSUANCE
building construction,and hereby authorize mpresematses of this city to enter upon the CONSTRUCTION TAX
U Z abovcmcalamad propery far inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to save,indemnify add kap harmless the City of Cupertino against
Iiabilitics,judgmenu,cosmand expenses whichmny in any way acerungairad said City AIR HANDLING UNIT TO 10,000 CFM)
in,omcyuenee of the gmming of this permit.
AIR HANDLING UNIT(OVER IU,W()CFM)
Signature of Applicam/Comrxmr Data EXHAUST HOOD VIMUCID 7 C
PAID
HAZARDOUS MATMILALS DISCLOSURE HEATING UNIT(TO IW,OW BTU) Da¢ Receinif
Will the applicant Or future building accupanl store of handle hazaedoua material HEATING UNIT(OVER I W.IXNI H'TID TOTAL:
as defined by she Coleman Municipal Cods,Chapter 9.12,and the Health and Safety
Code.Section 2553](m? VENTILATION FAN(SINGLE RESIDE 16 2-
0
❑Yet ISSUANCE DATE
Will dcapplicintorfumm building Occupant useeyulpmenmrdeviceswhichemin BOILER-COMP(311P OR IOQ(NNI BTU)
hwardous it comamimanu m define y she Bay Amo Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yeso NEW RESIDENTIAL MECH. SQ.f4. P A pr♦
ead
1 have rthe hazardous materials requirements under Chapter 6.95 of the 6!
California Health&Safety Cede,Sections 25505,25533 and 25534.1 undersand Ih.1 MAY
if the building does not currently have o hoard,than it is my mspm.ibiliry 17mp
no notify the t I �nQy�r9
rcupam Of Wet orb ich mus be m prior 10 issaa of a C rife c of
addaranwncy. 1 CII
Oerar oath rued.gem •U c TOTAL: ISSUED BY: IIYU