25633APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
CITY OF CUPERTINO RHRAHI`'G-FLE, rRRUAL
PLUMBING CT IDENTIFICATION
BUILDING DIVISION APPLICATION/PERMIT
NI111.IIING PR(LIFC'f IDN;N'1'IIrICATIfIN
PERMITNO.
25633_
BUILDING ADDRESS:
NO,
AI'1'LIGTION SUBMOTAL DATE
d&rySANITARY
OO UNIT LOT
l6 -1 > 3
OWNIiRS A 1?' PHONE:
CON RAC"I QIj'6NAML: I.IC NO:
N/C
❑
CONTROL p_\
ARCIIIIE '/F INL•FR: LIC NO:
scoan g: a yy
Edeb Cl
CO,NUACI': PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INhO
EC
PLDG ELECT PLUMB MH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby am th underpmvisiamofChapter9(concing with
ffirat 1 ma licensed mme
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
PANES '
Section 7000) of Division 3 ofthe Business and Professions Cade, and my license is in
full force and effect.
1� 1 ,
LiLic.N
Licence Class
UPT0200AMPS
W ` I
Data Comreetnr
201-I0001 AMPS
ARCHITECT'S DECLARATION
1 undersand my alws shell be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA S/SQ. IT.
-
/ ® S
SIGNS ELECTRICAL
I.icenwd Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I son exempt from the Comemares License law for the
.1A
SPECIAL CIRCUIT/MISC.
7
I�
UTE R
TEMP. METER OR POLE INST. l
following reason. (Section 7031.5, Businees mad professions Code: Any city tar caanry
MP
a � J U—
which requires a permit m construct, alter, improve, demolish, or repair any structure
prior to its isausnce, also requires the applicant lorsuch pamiOo file a signed statement
POWER DEVICES
that he is licensed Leaned to the provisions of the Contractors Liceve Law (Chapter
9(commemem, with S«tion 70ol Division 3 of the Business and Professions Code)
IVAULIATIFN_ -
SWIMMING POOL ELECTRIC Ilp
onhalheisexempttherefromandthebasis(ar NeallegW exemption. Any viohtionnf
Section 7031.5 by uray mplicam for a pe.it subjects the applicant to a civil Peolry of
Of1TLETS-SWITCHES-FIXTURES
not more than foe hundred dollars ($50B
❑ 1,uownerofthepmo y,ormyemployaawithwagessstheirwlecomp matron,
NEW RESIDENTIAL ELECIR _SQ. PT.
STORIES
TYP CONSTRUCTION
will do the work, and tole stwctum is not intended cerebrated for sale (Sce. 7044, Business
and Pmfessiom Cade: The Contmaors License Lew does not apply to an owner of
property who builds m improves thereon, and who data such work himself or through hie
owncmployees,provided teal suchimprovemmatsamnot imendedmofferedfrande. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the mildingor improvement is sold withinone yearofcompinion. the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEEFl.00D
sale.).
❑ haxowner of the Property.em exclusively contacting with licensed cnnhecmnlm
ZONE
APN
mown the Project (Sec. 7DM, Business and Professions Code:) The Contractors
Licen x Law d«s not apply u) w owner of property w ho bu i I ds m improves.hertmn, and
PERMIT ISSUANCE
who contracts forsuch projects with aconRuctor(s) licensed pursuanttnthe Contraemra
Liccn.w Law.
ALTER-DRAIN&VENT'-WATP.R (KA)
s-
FEE SUMMARY
❑ 1 mm exempt trader Sec. , B & P C fm this noon
BACK FLOW PROTECT. DEVICE
OUTSIDE E
SANITARY DD N
RI..CEI PT#
Owner Dam
DRAINS- FLOOR. ROOF, AREA, COND.
WORKMAN COMPP.NSAT'ION ORCIARATION
SCHOOLTAX Y N
❑ I hereby affirm that l have acenifirnkofconsem to self-insure.cra ceraricaleofFlX'1'URFS-1'ER'TRAP
Workers CompenmtionlnsumncemauniriWwpythetmf(Sm.38W,Leb C.)whicb
RFCEIPT#
PARK FEE Y N
awenall employee's trnderrhis permit. -
Policy M
RECEIPT#
GAS - EA.SYSTEMd INC. 40IpfLE75
BUILDING DIVISION RES
Company
OAS -EA. SYS'PEM-OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy ishemby famished.
GRRASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Ccnified ropy is filed wits the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS PEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. I00FT.
ENERGY ME
(This section need not beeompleted ifthe permit is human hundred dollars($I0B
or less.)
WATER HEATER W/VENT/ELECTR
I certify that in the perfoanwa of Ne work for which this permit is issued,I shall
not employ any person in any manner so as to annme subject to the Workers'
PAID
Citmpensationlawsof Califomia. Date
WATER SYSTRNFTRPATING
Dam Receipt#
Applicant
NOTICE TO APPLICANT. If. after making this Cerlificam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, IT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply wNe such provisions or this permit shall he deemed revoked.
BUILDING FEB
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction leading agency for the Performance of
the work for which this Lamin is issued( Sec, 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Leader's Nem.
lenders Address
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that 1 have read this application and sate that the above information is
correct, l agree as comply with all city and county ordinances and state Iowa adoring to
PERMIT ISSUANCE
MECHANICAL F7iE
building construction, and hereby authorize representatives of thiscity w enter upon the
above-mentioned properly, for inspection purposes.
ALTER OR ADD TO MECIL
CONSTRUCTION TAX
(We) agree to save, indemnify and keep homeless the City of Cupertino against
liabilities, judgmenes, costs and expenses which may in any way ..'an numal City
AIR HANDLING UNIT (I'010,000 CFM)
in consequence of a granting of th'a pe 1.
DAIR
HANDLING UNI '1'(OVER IQ(IfIn CFM)
gnmurta App lc U ntactor Dam
EXHAUSTHOOD(W/DUCq
PAID
HEATING UNIT(TO 100,000 BTU)
HAZARDOUS MAT17RIALS DISCLOSURE
Data Receipt#
Will the applicant or future building acceptant store or handle Innuendoes material
u definad by the Cupertino Municipal Code, Chapter 9.12, and the Iledth and Safety
HEATING UNIT (OVER 100,000 BTU)
Cade, Section 25532(a)T
El Yev El Na
VENTILATION FAN (SING LE RESID)
Y
BOILER - COMP (31 IP OR 1011,601) BTU)
ISSUANCE DATE
Will the applicanmrfmurthuilding«cupanwseeyuipmenmrdeviceswhichemil
BOILER - COMP(OVER 100,000 BTU)
haardous air contromanb as defined by the Bay Area Air Quality Management
District!
❑Yes ❑ No
411
�EIr��
NEW RIiS1UliNTIAL MIiCFl. SQ. Ff.
I have read the Inco dma matedab requirements under Chapter 6.95 of the
cur Code, Sections 1 understand that
Healthdoes
25534.bility
!aJ/
y
if the uil not have ant, that itis y responsind pond
tealitis myresponsibilityenotify the
ifthebuildingdocsnmcurrentlyhaveost
�/s
al'the rcyuiremena which nun he met prior to issuance of a CeniOcme of
Oc be
L
upon
Occupancy.
U,e
ISSUED BY.
Owner or mthoriad agent Data
TOTAL:
OFFICE