25275 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMIT No.
BUILDING DIVISION APPLICATION�PERMIT PLUMBING-MECHANICAL25275
BUILDING PROJECT IDENTIFICATION
BUR_UjIG ADDRESS I SANITARY NO. APPLICATION SUBMITTAL DATE
SS UNIT# LOT# -
OWNERSN ME: PHONE: CONTRACT(jR'Sti LIC NO:
1 N/C CONIMLis
4RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: d is V�� Q.I.Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
— BLDG ELECT PLUMB MUCH
ore eft
PERMIT ISSUANCE � El 01
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL /OB DESCRIPTION
p ye 9 I hereby(fi m'affirm that Iwid.s.an licensedBmiti der provisions Professions
off0ions Coder and romancing with
h1U SectioncaridefDivision3of the Business end Profusions Code,and mylicenee is in ppNpy$ T
Fy+V Li force and effete
or License Clus Limp UP T0200 AMPS
y Date eve 201-1000 AMPS
Z FO y a ARCHITECTS DECLARATION OVER 1000 AMPS - SQ.FT.FLOOR AREA $/SQ.PI'.
I understand my plans shall be used n public records. f
SIGNS ELECTRICAL �/�
q'��1 Licensed Professional \J
ES OWNER-BUILDER from
SPECIAL CIRCUIT/MISC.
y°ql O ar I hereby affirm that I ren exempt from the W'3 ConnectorLicense Law for the W vFi following reason.(Section 9031.5.Business and Professions Co'de:Any city or county TEMP.METER OR POLE INST.
L.ter which requires a permit to concoct,alter,improve;demolish,or repair any strucnue
Y priortaits internee,also requires the applicant forsuch pemtinofile a signed statement POWER DEVICES
OO
that he is licensed pervesnno the provisions of the Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC' VAL TION
W_m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for.permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
^� O not more than five hundred dollars($50)). NEW RPSIDENTfAL ELECS .FT.
a w ❑ I,asownerofthepmNny,ormyempleyeeswiNwagesutheirsolecompensadon, ITt Q STORIES TYPECONSTRUCTION
y .., will do the work,andthestmeture is not intendedoroffered forsale(Sec.9044,Business
and Professions Code:The Contmctors License Lew does not apply w an owner of
property who buildsm improvesthereon,and whodoes such workbimselfortluough Ns OCC.GROUP RES.UNITS
ern employees,provided that such i mprovements are not intended or offered forage,If,
however.to building or improvementis sold within one yearofcompletiors,Neowner- TOTAL:
builder will have the burden of proving that he did not build or improve for Impose of
sale,).
❑ I,mowneraftheproperty,awenlusivelycmumingwiNlicensedcontraewmw QTY. PLUMBD7t E FLOOD ZONE APN
untrue the project(Sec.7044,Business and Professions Code:)The Contractors
License Lawdoesnolapplymanownerofpropenywhobuildsorimpmvesthereo,anti PERMIT ISSUANCE
whocnmmets forsuch projects with a coneraums)licensed pureuentm the Contractors ALTER-DRAT &VENT-WATER(E
License Law. FEE SUMMARY
E3 1 an exempt under Sec. ,B&P C for this rescan BACK FLOW OTECf. 1 DOI SIDE FEES
N.TAR Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a certificate ofconsent to self-insure,or a cemifiuseaf FlXTURES-PER TRAP RECEIPTS
Workers'Compensation Insurance or a certified copy thereof(Sm.3800,Lab C.)which PARK FEE Y
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#_
Policy is BUILDING DIVISION EES
Company GAS-EA.SYSTEM-OVER 4(EA) - PLANCHECK FEE
❑ Cmified copy is hereby famished.
❑ Certified copy is filed with the city inspecdon division. GREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbecompliaml ifthe name is furore hundreddolbn($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m lon.)
I certify that in the perform.nce of Ne work for which this permit is issued,I shall WATER HEATER W/VENT/ELE
not employ any person in any manner so in to become subject to Ne Workers' PAID
z Compensntan Lawsof California. Date WATER SYSTFMITREATING Da eceiptis
Applicant
C2 NOTICE TO APPLICANT:If,after making this Conifcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
tp become subject in the Workers Compensation previsions of the Labor Code,you must BUILDING �^
Ki forthwith comply wish such provisions or this pored[shall be doomed revoked.
--<5—
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of
the work for which this Permit is issued(See.3097,Civ.C.) TOTAL: ELECTRI
OLvrder's Neme
0 U Lender's Address - QTY. MECHANICAL PERMIT FEE PLUMBlfSGFEE
W rt w 1 certify that I have read this application and send that the above information is MECHANICAL
t.l agree comply with all city aM county ordinances and state laws relating w PERMIT ISSUANCE
toac
Cel buddingeonsuuction,and thereby mission representatives ofthis city wenterupon the CONSTRUCTIO TAX
f-) above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
li.bilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
ce of the granting of this pormit. -
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicano'Contmcmr Data EXHAUST BOOT W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE - HEATING UNIT(TO 10000(1 BTU) Dan Receipt#
Will the applicant or future building occupant store or handle hazardous materialT
as defined by the Cupertino Municipal Ca , apter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
deChon
Code,Section 25532m)? VENTILATION FAN(SINGLE SID)
Cl Yin
❑No RE
0UAA�MATE-
Will she applicantor Poturebuildingoecupentteseequipmentord¢vices wM1ichemit
BOILER-COME(3HP OR 100,00)RTU) 1 ,
.hazardous air contaminants in defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) JUS O 1993
Dilmel9 tel❑Yee 11 No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hazardous maAol.75e3n3sapd
itunder Chapter 6.95 of the yl I Y Vr k tdr❑M I IIVU
Califomis I lealth&Safety Coda Se25534.I understand Net
if the building don not crrtently M1evat it is my responsibility wnnify Neme atoftheaqui ems which t prior in Issuance of a Cmificam of
Oc a sol,109
r reu[honze agem Date• TOTAL: ISSUED BY:
1.
18'
10'
25'7"
® 25'
11' 10"
8'
25'
2' 31'6"
3'10"
C9i ¢p
N ` �r � PCO1ASed 13'
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CAD
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o
20'T 12' 11"
ill 01
Total Lot Square Footage: 10657 Key •
Existing Structure has 13.4% Lot Coverage
Proposed Addition (168 sq.ft)
With Existing Carports and Patio Covers 18.5% ® •
Existing Overhang (543 sq.ft.)
With Proposed Addition to Car Port 20.1%
❑ Existing Structure (1427 sq. ft.)
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TURN
Pt 4 C-F: