25125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO. 25125
APPLICATION/PERMIT PING PRNG CIFID IANICAL
BUILDING DIVISION BUILDING PNOdECT'IUF1N'1'IfICAT'ION
BUILDING ADDRESS: y7 SANITARY NO. APPLICATION SUBMITTAL DATE
16q7l 14 UL y UNIT �— LOTX 5--.2�—`Y 3
OWNERS NAME: PHONE: CONTR 'OR'SNAMF,: LIC NO:
n QG WC C°N'IAGLH
1RCHI^IENGINF,ER: CNOL: Z ADDRESS: �JZ 9
CONTACT: l PHONE: BUILDING PERMITINFOQTY. ELECTRIC PERMIT FEE
LD EL PLUM MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
O=Z Iherebyaffirmlha,lam licensWudderpmvisionsof Chapter9(commmcingwlN TOB DESCRIPTION
W 00 Section TKdO)of Division 3 of the Business and Professions Cade,ami my license is in PANELS
P
FZ�m full force and idlest. s�/•—
License Class Li,0 UP TO 200 AMPS
In 7 y Date Contractor 201-1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
ZCyz ARCHITECTS DECLARATION OVER I"AMPS /� 'I
OZ—G I understand my plans shall M:used az public records. ��S y��a
r,�I-W..1 SIGNS ELECTRICAL C/ t
¢'g C Q Licensed Professional
KK OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO y V 1 hereby affirm that 1 ma exempt from the Contractor's License Law for the
m 3 a ti following rosin.(Section 9031.5,Business and Professions Code:Any city or roomy TEMP,METER OR POLE MST.
F E•0a which requires n ocor it to construct,alter,improve,demolish,or repair any sweture
K�QS
prior its issuance,ako requires the applicant fmsuch permit le file a signed statement POWER DEVICES
rt
C That he is licensed Fromm nt m the provisions of the Conrad or s License Law(Chapter
9(cnmmencingwith Section l(p0)af Division the Business and RoPossiom Cade)
y 0.00m SWIMMING POOL ELECIIUC VALUATION
eW
nr shut be is excnpl lhcrefmm and Ne bazis for the alleged exemption.Any violation of I� �'/` O I D 9
OUTLETS-SWITCHES FIXTURES J a
FZQ necli me Ih.Sv a undrddollforapanni,subjects the applicanuoacivilpenally of
not more Nan five hundred dnllan(5500). NEW RFSIDEN IAL ELECIR _SQ.FT.
M-0
M-0 ❑ I,nYawmm�flheprop Tty,nrmyemplayeeswithwagesas Neirsolecompensalion3°—° will do the work.and the structure is mut imendeamoffened for We(Sm.1044,Business
and Professions Cale:The Cmarscmrs License Law does not apply m an as,of
property who bui Ids or improves Ncrcon,and who does Such work himself or through his
employess.provided that such improvemenlsare not imendedoroffend torsade.IL OCC GROUP RES.UNI IS
however.the building or improvement is sold within one year ofcompletion.be owner- T
buil will havethe burden of proving Nat he did not build or improve for purpose of
')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
s I. Ownefofthe pmpeny,amexclusivelymnm clingwiNlicens con=tomto
ons, T the project(Sm.1014,Business and Professions Codc:)The Contractor's PERMIT ISSUANCE .l
License Law docs not apply lnnnowner ofpropcoy who builds or improves lhcreon,ane
who contracts fmsuch projects with.contrec,on,)licensed pursuant mthe Contractors ALTER-DRAIN&VENT-WATER(G) FEESUMMARY
License Low.
❑ 1 am exempt under Sec. ,R&P C for,his reason OUTSIDE FEES
BACK PLOW PROTECT.DEVICE
SANITARY Y N
Owner Data DRAINS-1 FLOOR,ROOF,AREA,COND. RECEIPT
TIWORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
C (hereby of litre thm lhuveacenilica,e ofconsist to self-insure.or acenlftcateof FIXTURES-PER TRAP I RECIiIPTX
Wmken.'Compcnsationlmurancemaccnirtdmp Nereof(Sa.N.Lao which PARK FEE Y N
.oven all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RDC BUILDING DIVISION SION IliF.S
Policy X
Company GAS-EA.SYSTEM-OVER 4 HA) PLANCHECK IEE ZZ,
f ❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. pp rys,pp GREASEAND S 1 WAS INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WO
SI U V R L 5 TRA SOILS FEE
COMPENSATION INSURANCE ,,II UUUU
(This section need not he completed if Ne permit is fmone dolyrSl$100) S& R-SANITARY-STO MEA.2WI9'. ENERGY FEE
Or leu, �� t,,,,
(certify thatin Ncp in anyuneeofthework farwhichis tisvaued,lshall W IIF ENT LECfR �L l
U.employ any person li any manner as m Mcnme subja,m the Workers PAID
Compensation Inws of California, Date no � -�� ��' � TIN Ore eccipl X
Q C) Appbcanl
Z NOT ICE TO APPLICANT:If,after making this Cerificat of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL: v,a„!�e•Q�
I-" become subject to be Workers Compenution previsions Of Ne Labor Code.YOU must
> forthwith comply with such provisions m Nis permit shall be,clamed mvokcd. BUILDING PEE 3 Q 0
1 [� CONSTRUCTION LENDING AGENCY SEISMIC FEE -
UI 1 hereby afftnn that them is a construction lending agency for Ne perfor mans of ELCCM IC FEE
O ,he work for whichthis pumit Is issued(Sec.3099,Civ.C.)
Lender's Name PLUMBING FEE
U'• F Lenders Address QTY. MECHANICAL PERMIT' FEE
L11 anify that l have read,his application and stat,that Ne above information is ter. MECHANICAL .1
r1" Lia cones. l agree to comply with all city and county ordinances and state laws relating to TPERM IT ISSUANCE
I-" building conswction,and hereby auNariu¢powmintives of this city to enter upon the CONSTRUCT ION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify and keep harmless,he City of Cupertino against
Iiabili,ies,ju osuandeS,.eswhichmayinanyweyaccmcag'nsInUc City AIR HANDLING UND(TO 10,D(s)CFM)
in con use of the ranting of this
AIR HANDLING UNIT(OVER IB"CFM)
S' nil, Appli "Y"mmclor Dat EXHAUST I300D(W/DUCq PAID
HAZARDOUS MATFR1ALS DISCLOSURE. HEATING UNIT(TO 100.000 BTU) Dae Receipt X
B,tba implicant nr forum building mcupanl stem or handle hawdous material HEATING UNIT(OVER 100.000 BTU)
TO
as defined by,he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532pt I VP,NTILA'I'ION FAN(SINGLE RISIDI
❑Ycs ]�No A.
(/ BOILER COMP(JIIPOR 100.000 BT11) ISSUANCE TE
Will the upPllwnl tuturchuileingmcupum usacquipmenlor Juvlcea which ami,
huallous air contaminane as defined by the Bay Area Air Qush Manegcment BOILER-COMP(OVER 100,000 BTU) JUL 1 1993
V rI}
❑Yes Nn ryCW RESIDENTIAL.MECB. SQ.FT.
I have read the havzrdous materials requirements under Chapter 6.95 of the CI 1Y OF Gur art I(IVU
Colidomin Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
BIN,build,- es not currently have a tenant that it is my res si m lily to nosily the
occupants o he u'u u who. us,be mel Prim tsse a of a Cenificut of
Occupan �`
Own or aulh iaed agcar Date ISSU12D BY: