25766 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CJ Y OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
SING DIVISION APPLICATION/PERMIT PING PROJIBING MECHANICAL - A C 7 C G�
BUILDING PROJECT IDENTIFICATION L J / v C7
BUILDING ADDRESS: 1 c,�FbFW \WSANITARY NO. ���l1LDATE
OW�Ii(R�SON�_w`/3� qrM^ P CONgTJtACfOR'SNOyFA �Tg LIC NO: NIC CONTROL#
RCHI I EUVENGINEER: YY//�� L7 LIC NO: AD'DDRRiESSIS`\,,w+1F✓s J/V ❑
CONTACT:. PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT TEP.
@CDG E PL M i
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Jnnnppp D' RIPION W
�Z I hereby affirm Net l am licensed usWttprovisionsol'Chapter9(wmmencing with
Rog
w�
00 Section 7000)of Division 3 of the Business and Professions Code.and my license is in PANELS -`
Vfull rores and effect.
QZ License Cless Lic.0 UPT0200AMPS s�..
.<s Date Common, 201.IWOAMPS l�
Zco,— ARCHITECTS DECLARATION OVER IOOO AMPS A � SQA
OZ-0OZ-0 I understand my plans shell be used as public records. 9
F4t,4 SIGNS ELECTRICAL. _
Q C,,D Licensed Professional t nJ�
pWw< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. L' u—
P13WU I hereby affirm that 1 sm exempt from the Connecoes License Law for the
¢ following rcamn.(Semon constr.Business mpr Professions Cade:Any city nr roomy TEMP.METER OR POLE INST.
ON.] which requires m permit re construct,altar.improve,demolish.Fi repair ed twemrc
Si YiT� poor to issuance,also requires the applicant forsuch Permit to flea signed statement POWF:0.DEVICES
ssy�rj p0 that he is licensed pursuant to the provisions of the Commences License Law(Chapter SWIMMING POOL ELECTRIC
ado 9(commencing with Section IND)of Division 3 of the Business and Professions Code) VALUAggbt—.
�:2y other he is exempt herefrom and the home for alleged exemption.Any violation of UTLETS-SWITCHES-FI%TURES
y Q Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of VVV
g_� tq
t re dam five hundrtddollan(E500). NEW R]KADENTIALELECIR -SQ.Pf.
NEcn s owncrofthe prssic;,mmyemployecswithwo8esastheirsolecompenation, STORMS TYPE CONSTRUCTION
a3= mldo tbework,and the swnune is not intended proffered forsale(Sm.7044,Business
d Professions Code:The Convectors Live Law does not apply to an owner of
propetywhobui[dsorimproveethereon,undwhodoessuch workNmselfmthmugh his OCC.GROUP RES.UNITS
n employes,prov ided That such improvements are not i mended or offered far sale.If,
however,thc building or improvement is wld wi thi n one yea of mmple6m,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
stale.[.
❑ I,ssownerofthepropeny,ameaclusivelycenttectingwithlicrosedconh tomto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pmjmt(Sec.7044,Business and Professions Code:)The Contmetore PERMIT ISSUANCE.
License law does not apply m u ownerof property who builds m improves thereon,and
whoconuets forsuch projects with aeantoctors)umadedpursuut mthe Constrictors
License law. ALTER-GRAIN&VLNT-WATER(EA) FEE SUMMARY
❑ 1 oro exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE
SANITARY. YN
Owner Da¢ DRAINS-Fl.00R.ROOFAREACOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION . ,
SCHOOLTAX YN
❑ Thereby effms Netl have acuifute of coneenno self-insurc,on urtifi<e¢of MIXTURES.PER TRAP RECEIPT#
WorkersCompemahm Immuuromiscertifiedcopy thereof(Sm.3800,Lech C.)which PARK FEE Y N
ciwerstill employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy is BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city impcetion division. GREASF,4NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Tlhisaecuonneed not be completed Runs permit is foyers,hundred dollars(510D SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or los.)
I certify that in the performanceofthe work far which this permit is issued,l shall WATER HEATER W/VENTIELECTR
not employ any No.in any roomer w as to become subject to the WmInri PAID
z Compensating L.mwsof Colifomia. Date WATER SYSTEMIMEATING Date Remipt#
Applicant
z�z�-I 0 NOTICE TO APPLICANT.If,aRm making this Ccmficete of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
t' rA became subject to the Workers Compensation previsions of the[.tabor Code,you must BUILDING FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
Ct
CONSTRUCTION LENDING AGENCY SEISMICFEE
t z I hereby affirm That there is a construction lending agency for the performance of
O the ELECTRIC bEE work for which this permit is issued(Sec.3097,Civ.C.) 1
Lender's Name O P, Lenders Acidness - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
(,-) I musty That I have rued this application and state that the above information is MECHANICAL FEE 2 ��
acorrect.i agree to comply withal[city and county ordinances andnme laws relating to PERMIT ISSUANCE �w
buildingconstruction,and herebythoriure ressntmivesofthis cit in the
C..) Z above-mentioned property for inspection purposes. y Wn ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree to save,indemnify it keep families the City of Concern.against
liabilities,judgments,costs andexpemeawhich may in any way accrueMainst said City AIR HANDLING UNIT(TO I0T000 CFM)
ideas a of Ne granting of i
AIR HANDLING UNIT(OVER 10,000 CFM)
atureofApplicant/Co m Date EXHAUST HOOD(W/OUCI) PAID
HAZ I OUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant ancers or MMIe Immediate materiel HEATING UNIT LOVER 100,000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sorts.25532nd? VENTILATION FAN(SINGLE RESID)
❑Yes 11 No
Will
ISSUANCE DA
the applicant ofulumbuildingmcuput useeyuipmentordeviceswhichemit
BOILER-COMP CHIP OR I100,0410 BTU)
heraNws air or.. sums as defined by the Bay Arca Air Quality Management BOILER-COW(OVER IN,"BTU)
District?
❑Yes ❑No NEWRESIDENTIAL MECH. SQ.FT. r p�
A '
I have read the Safety
Code,
materials requirements udder Chapter 6.95 of the
if the
iHulth&Safety Coyhave a seems,
it is and 2552t4.1ugderstand Ohm O�
occupanofbuilding dues no caents w ich m st IN,Nat h is my neuance of ay nificay the V 1993
occupant of the requirements which mart be mu prix m issuance of a Cenifcate of
Occupancy.
yr (l
owner art authorized ager Doe � ISSUED BY J
OFFICE
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