25760 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL .- . L RIA PERMIT NO.
tlUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25760
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMI
TTALDATE
/✓ 11
l / R./r UNIT# LOT#
OWN RS[JpP: PfIpCONTRC� _ NIC 1CONTROL#Tn�, yaO ( �+
W1
•ARCHITECDENGINhhW LIC NO: ADDRESS: ❑
1, Sv/
CONTACT: PHONE: QTY, EL CTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El E] 1Z
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, LOB DESCRIPTION
QMZ Ihereby affirm Nat l oat licensed underprovisions of Chapter9(commencing with
1400 Section 7000)af d PANELS
3.fOa Business and Professions Code,and my license is in
C Wc[' fall force aneffect,
<Z, License Claws Lia# UPT02MAMNf lj
Dy
Dole GOalfarar 201-1000AMPS \ (_-
ZO'Z ARCHITECTS DECLARATION OVER IOn0AMP5 SQ.FT.FLOOR AREA $/SQ.FT.
OZ66—�� lundcrsmnd my plans thrill mused.public..Ms.
SIGNS ELECTRICAL
< 7,4 Licensed Pmfmsi...I
='Ai< OWNER-BUILDER DECLARATION SPECIAL CIRCUCEMISC.
XOyF 1 hereby n.affismSe Net 1 am exempt from the Camionst o License Law for the r r-
tAiOm follmwhich ing¢ason. ermii as tocona.S,Businessandve.demolish,
Come:Any city orccture TEMP.METER OR POLE INST.
F' m J which requires a permit to coretmn,Jwr,improve,demolish,or repair any twaurt
7. priorto its issuance,also requires the applicant frsaush permit to file a signed statement POWER DEVICES
W C INJ
CO that he is licensed pursuant tat the provisions of the Conrector's L.icenae Law(Chapter
axdxp�m 9(cammrncing with Section 7WO)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC /ell� LUA ON
W_ or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUf1.ETS- FlXTDR
tZa Section 7033.5 by any applicant for a permit subjects the applicant a civil penalty of
not mart than five hundred dollar($500).
W . ElI,asowncrofthepmpery,mmyemployeeswithwagesutheirsoleaompcns.tion, NEW RESIDENTIAL.SWITCH[S-ELECIR .FT. STORIES TYPECONSTRUCTION
a 3 oft will do th Professions
Codd: he Cort imme,tendlora a,data not apply t an owsiness
end Profeuions Code:The Conwcmh Liansc Law docs not apply to an owner of
propertywhobuildsorimprovestherton,ondwhodaetxush walk hitmelfarthmughhis
ownemployres,providcdthat such imptovermntsam not imeadedoroffered hostile.If. OCC.GROUP RES.UNITS
however,the building.improvement is sold within one yearofcampletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ l,Rsownerafthe Pmpeny,ameaclusivelycammctingwithlicemedconaactmio QTY. PLUMBING PERMIT FEE F100DZONE "N
construct the project(Sec.7014,Business and Professions Cade:)The Contmewes PERMIT ISSUANCE _Q
License Lowdoesnot apply manownerafpmperty whobulldsorimproves thereon,and
whuconuactsforsuch projects with acanraror(s)limnsedpuruanuome Conuactoes I
ALTER ( ) FEE SUMMARY
License Law. DRAIN EA
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dela GRAINS-FLOORROOF, RECEIPT#
. .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby affirm that l have a certificate ofconsem to aelf-imure,macenificrue of FIXTURES-PER TRAP RECEIPT
Wmker%Compenution lationaeorneerifiedc.,floareof(Sec.Jg00,1<b CJwhich PARK FEE Y N
covers all employee's under his permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'#
Policy p BUILDING DIVISION FEES
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4 TA) PLANCHECK FEE
❑ Certified copy is filed with the city impaction division. GREASPANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASP.TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Him permit is formalundrrd dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or loss.)
I card fy that in the perfommnce of the weak far which this permit is i,man,Ishall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
O z Compensation Laws of Califomia, Date WATER SYSTEMITREATING (� Date Receipt#
Applicant
QNOTICE TO APPLICANT:If.after making this Card ficme of Exemption,you should NEW RESIDENTIAL PWB. SQ.Cr, TOTAL:
F W) become subject to the Worker's Compensation provisions of the Lubar Cade,you must
7 forthwith comply with such provisions or this pernalshall be deemed revoked, BUILDING FEE
ped_, Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that hem is a construction lending agency for the performance of TOTAL: �j-(� ELECTRIC FEE
U O the work for which this permit is issued(Sec.30D,Civ,C.)
pr Lender's Name
U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �j.
1 certify that 1 have rend this application and state that the above information is MECHANICAL FEE a correct.I agree to comply with all city and county ordinances and slate laws rtlatingm PERMITISSUANCE
to building construction,and hereby omhoriu represenatives of this city to enter upon the CONSTRUCTION TAX
U z above-mention
ed property for inspection purymes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep h.rmless the City of Cupertino against
liebili' ,judgmeme,coals apcnses which may in any wayaccmeagei trend City AIR HANDLING UNIT(TO Hl."CFM)
inc ce of the a of this permit.
it.
AIR HANDLING UNIT(OVER 10,000 CFM)
i
ignamm of Applic t(Convactor Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUSMATERIALSDISCLOSURE HEATING UNIT(TO 100,000 BTU) Dat R.ipt#
Will theapplicantorfuwrt building accuponutm:.handle hmajohmoarmerial
ss HEATING UNIT(OVER 100,000 BTU) TOTAL:
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seedan 25532(:)?
❑Yes 0 N VENTILATION PAN(SINGLE RFSID)
BOILER-COMP(31{P OR 100,000 BTU) ISSUANCE DATE
Willtair coutormarfature building by henmu Ars.Aent malum Management,
ant, Pip Al D
• heurdous air contnminana ss defined by the Bey Arca Air Quality Management BOILER-COMP(OVER JBIL 0BTU7 tJ' fW
District?
❑Yex ❑No NEW RESIDCNTIAL MECH.—SQ.FT. WOO 12 IM
I have read the haurdous materials r�uirements under Chapter 6.95 of the �YI�VI VV
California Health&Safety Code,Sectio.25505,25533 and 25534. I understand Net
if the building does not currently have a tcnmt.that it is my responsibility to notify the CII* ser uurrmuvv
accupant of the requirements which must be met prim In issuance of a Certificate of
Occupancy. �(s
Owrommisuthomudagent Date TOTAL: ISSUED BY:
OFFICE