25438 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BIHEDIR�1..L1 R A PERMIT NO.
APPLICATION/PERMIT ING P OJECI ICHA NICAL
FICA n C /I 3 8
BUILDING DIVISION IfU1L111NG PHOJEC,I'IUEN'1'16-ICA'I'IUN L J!•f
BUILDING ADDRESS: F ^ OI'� \ % SANITARY NO. APPLICATION SUBMITTAL DATE
�8 hj N l UNIT - L).. /_�` LDI b
[R AME: PHONE: CONTRACTOR'S NAME: LIC NO:
ICV/ N/C CONTROLa
0A CIIITECp1iNGINEER: LIC NO: ADD ESS:
COM'AC"U PHONE: BUILDING PERMIT INFO
QI'Y. ELECTRIC PERMIT FEE
G PLUMB
PERMIT ISSUANCE
LICENSED Ia DcenCONTRACTORS andovDECIARATION APPLIANCES-R17SIDENTIAL` -
�y 2 I hereM1y alt rat Ihm l am licensed unJnprovisions ofChapter9(commencingwitM1 J09 DESCRIPTION
PO_O Section 7101))of Division 3 of the Business and Professions Code,and my license is in PANELS
WWFF.. fol l force and effect.
ec VkJ UP T0200 AMPS �\ I
HZW License Class Lic.p
m Q e Date oriume 201-I IXq AMPS
]rn CSV.FT.Fl.00R AREA S/gVFT.
7ONZ ARCHITECTS DECLARATION OVER 1000 AMP.
O/,_O 1 undersmnJ my plans shall be used as public rmmds.
OZ—M SIG 'HCFC HIC
Q04Y2,
Ycaj Licensed Profcvsional '
ec6 OWNER-BUILDER DECLARATION .0 LC 1 LQ —
KOiU I hereby affirm that I am exempt from the Contractor's License Law for the
t+13ay following reason.(Section]0315.Business and Professions Code:Any city nr county TE P. . F.R OI
[ �;O Q which requires a permit o concoct alter,improve.demolish,or repair any swcture
$mnu :F prior to its issuance,also requires the applicant!orsuch Permit file a signed statement WFA OEVI
that he is lie ensed pursmrm to the provisions orthe Commnts's License Law(Chapter i%oK 9(commencing with Section 0011(11 of Division 3 Other Business and Professions Crate) SWI MING PO LE .CfRIC VALUATION
W ern onhat beiseaempn decrt(mmant the basisfonhe dlegeJ exemption.Any violation of UTLEfS-SWR ES-FI%Tl1RES
Z G Section]031.5 by any applicant for a permit sabjeceathe applicant m a civil pen
f— ally of \I�:JJJ
5y"yO not more than five hundred dollars(S500). NEW RESIDFJJ AL ELECfR _SQ.FT.
W M ❑ [,asow. pa
erofthepforty,ormyemploecswithwagesaslheirsolecomµnsution, STORIES TYPE CONS'IAUCTION
y3'2 will do he work.and the structure is not intenJedoroffered forsale(Sce.]044,Business
and Professions Code:The Contractors License Law,does not apply o an he,of
property who builds or improves therm.,and who does such work himself or through his
employees,provided drat such impmv<mennsart not inlendeJoroffercdfon.le.IL OCG GROUP RES.UNI R
however.the building or impmvemcm is sold within one year of completion,the owner-
builJcr will have the burden of proving that he did not build or improve far purpose of
x0le')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las mjmt(Sropeny.am usinsivelyconteacting Code:)
he Contractors construct the project apply
Tw,Business end Professions Code:)"Dee Contractors
Liconsal.aca,rumw uppjects awncrafprapeny whneved,mimp""he thereon,and PERMIT ISSUANCE
wbocnneraw.forsuch pmjcctswinh lmommrogs)liccnsdpursuanunthe Contractors AL'I ER-DRAIN&VENT-WATER(Its) FEE SUMMARY
License Law.
❑ I am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE. OUTSI UE FEE
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA.GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihembyiffirm nam[have a certificate oftonscntto self-insure,ora ttrificate of FIXTURES-PER TRAPRECEIPTa
Workers Compensation insurance or a certified copy thromf(Sec.3800.Lab C.)which PARK FEE Y N
RECEIP #
covers all employee's under this permit. GAS-EA.SYSI lzm-I INC.4 OUTLETS BUILDING DIVISION EES
Policy a
Co y GAS-EA.SYSTEM-OVERT EA PLAN II rC F2E1
nifnl copy is hereby famished. Itatia I
Certified copy is fled with the city inspection division. GR FASE/INDUSTRL ASTI, E C .RA N
CERTIFICATE OF EXEMPDON FROM WORKERS' GREASETRAP I S l '
COMPENSATION INSURANCE
(This section need ambecompleted iftbepennit islbranehundreddollurs(810P) SEWER-SANITARY-STORM P.A.300FT. ENP YFEE
m less.) nn nn
I driify that in the per6rmance ofnhe work for which this permit is issued.I shall WATER HEATER WN0,4
NT/ELELYITTE
not employ any Person in any n anoints r as to become subject to the Workers
Compensation Lawsol Culifomia. DaleWATER SYSTEM/TRFATING Date Ramona
z ApplicaNOTICE
NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
O NOTICE TO APPLICANT:IL attam
r aking this Certificate of Exemption,you should
tibecome subject to the Workers Compensation provisions of the Labor Cade,you must BUILDING FEE Q
� > forthwith comply with such provisions or this permit shall be deemed revoked.
F CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherchy affironnht.there is a construction lending agency for the performance of
L) O the work for which this permits issued(Set.3097.Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name PLUMBING FEE
Leaders Address Q'fY. MECHANICAL PERMIT FEE
V 1 certify that I have real this application and and that the above information is MECHANICAL,PEE r
Y' 127 colter.I agree no comply with all city and county ordinances and sore laws relating m PERMIT ISSUANCE
builiingeonswction.and hereby amhance representatives ofthiscity Renter upon the CONSTRUCTION TAX
Vz above-mentioned property for inspection purposes. Is I ALTER OR ADD TO MF.CH.
(We).,red Iosave,Indd ly sent Or I,Rfarmlesx t uy of Caperton,, mom
Iiabililict.j Jgm rnG p c (h mnyin ay ammeagaimisuid Ciy AIR HAND1_INGUNIT('fOl0,WI1CFM)
AIR HANDLING UNIT(OVER BLOOD CFM)
f,pahua6cf ApplicanUContracmr Date EXHAUST I IOQD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO tW,"BTU) Date Remain,#
Will the applicant or fmure huildingoecupumsora or handle harardous material HEATING UNI-['(OVER I00,m)BID) TOTAL:
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Ucalth and Safety
Code,Section 25532(x)' VENTILATION FAN(SINGLE RISID) _
❑Yes ❑NO
BOILER-COMP SHP OR 10),0010 BTU) 615Syy I�CB'DATE
Will Iheirpplicnntorfature buildingacuporusa equipmemordeviceswhichemit L/
,• hazardous air contaminants as defned by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dimricfl UG 17199
❑Yes ❑NO NEW RESIDENTIAL.MECH. SQ.FT. 3
1 have read he ha=ardons materials fegturements under Chapter 6,95 of me CI I Y Uf
(;U-
California Health&Safety Code.Sections 25505,25533 and 25534. 1 undi manJ thanttl FIV
lithe building does not contrary have a tenant dem it is my responsibility to notify the
occupant of the requirements which must be met poor to issuance of a Certificate of
Occupancy.
Owner mmulamrodegml Dam I" ISSUHD BY'.
OFFICE