25162 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUI IN -ELLCI RI A. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -
IIUILUING PROJECT IDENI'IN'ICAI'1(JN 25162
BUIL21NG ADDjl //�y/� n SANITARY NO. APPLICATIONSUBMITTALDATE
(�I 1 D � r I"tLJ" 1J INT�N Ac7 A�5 LOTp
owpnRRS NAME`�{']OI'0.-h PHolyej�s coV ICKg N'f IiY1e S(o�.7k
�XJ 1b5 WC CONTROL#
• % I'fECT/IiN11 yGINO :i` S El
LIC NO: AUp@�Sf�-
CONTACT: PHONE:
1/�1/�1/� q�1�1 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
1 ' c� cis I\ — ( / /V PERMIT ISSUANCE BLDG ELECT P UM MECH
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL. JOBDFS V IPTION
py.Z I hereby affirm Nen
at lam licsed under prnvisionsofChapter9(commerat with r
VOC Section T(MIO)of Division 3 ofthe Business and Professions Code,and my license is in PANELS (///
yUE full force end effect, N UPTO200AMPS
QQ zz sy License Class Lic.
ti a L Date Cause 201-IOAMPS
F toz IOW AMPS
ARCI IITECTS DECLARATIONSQ.FT. AREA S/SQ.FT.
ZOO`:— OVER 1000 AMPS
I undersand my plan shall be used as public records. ^
ry�[�i SIGNS ELECTRICAL T\
Y ....11 Licensed Professional N l
OWNER-BUILDER DECLAMATION ON SPECIALCIRCU117MISC.
PJ O y U 1 hereby .(Se that I am exempt from the CDntrmmra License Law,bodies '
t�aONG following rcason(Scesion TOJIS.Business and Profession Cade:Any ciry Drcoumy TEMP.METER OR POLE INST.
y❑ its
sisusapeonnscores the,alcor,imforsudemolish,ora a Blanyndemad
'!jyC pot hos lissumce,alsuat to teprovisionsofome Co pennons License
La ammmcm POWER DEVICES
ayy3QO ,hot he is licensed pumumnm the provisions of the Contractors Licence Law(Chapter
Ke� 9(commencing with Section 70010)of Division 3 ofthe Business and Professions Code) SWIMMING POOL BLBCfRIC ALU ION
W_m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTURES
FZ_QSection 7031.5 by any vpPlicam for a permit subjects the applimn.a civil penhy of
not K�m mommnfivehundred m).
❑ I,azuwnerofthcpropeM.ormyamploymswithwageas theirwlecmpsntion, NEWREMDENTIALELECIR _SQ.FT. STORIES TYPFCONSTRUCTION
ca. ad Prthcwork,and me he Contractor's
License
La door o,4ppec.]bt4,Business
and property
wh mr Cade:The Co ds cmr'e I.Imnse Law does not apply w m owner iof
s
own em whoes,pdsmimponsuth impr ver whodms suchwork hiroveoroff forthrough his
employees,provided thmsuchimprovesmmsart notimm�ded proffered battle.If, OCC.GROUP RES.UNITS
however,me building or improvement is sold within one yeaofcomplefon,theowner- TOTAL:
builder will have the burden of proving than he did not build or improve for purpose of
sale.).
❑ Las nwnerof thepropeny,am excursively contr¢ting win licensed conssnctonm QTY. 'PLUMBING PERMIT PEE FLOOD ZONEAPN
canuvct the project(Sec.7044,Business and Profusions Cale:)The Cmhactor's 'd
Licenminwdm ootapplymmownerofpropenywhebuildswimMvesfficmm.end PERMIT ISSUANCE
who contmnsfor such projects withaconnnctor(s)licensed pursuant to the Connector's ALTER (FA)
License Low. FEE SUMMARY
❑ I eo exempt underSec. .B&P C for this season BACK FLOW PROTECT.DEVICE L I,
SANITARY Y N
Owner D. RECEIPT'#
• covers DRAINS-FLOOR,ROOP,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ Thereby off roe thetlhove accni0cam ofcrosmn0 rtl(-inure.ora mrtificam of FUOIURPS-PER TRAP RECEIPTp
Workers'Campenetnlnsurenceotfled copy theresf(Sec.3800,Leb CJ which PARK FEE Y N
all employees er m
's undoa pench.niLRECEIPT'M
C.AS-PA.SYSTEM-I INCA OUTLETS
Policy N BUILDING DIVISION TEES
Compmy GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filth with the cityinpce0sn division. GREASEODUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FXFNP11ON FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This umionmeedna,lN,completed ifihe paoit is for one hundred dollar(SIM) SEWER-SANITARY-STORM EA.200FT. •d ENERGY FEE
or less.)
I certify that in the performance of the work for which this Penni,is issued,l shall WATER HEATER WIVENT/ELEM
at employ my person in any matter so as to become subject to the WorkerPAID
Compensation Lawsof Celifomia. Dam WATER SYSTEM/TREATING Dam Receipt#
z Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
In become subject o she Workers Compenauon provisions ofthe Labor Cade,you must
7 forthwith comply with such provisions or this famous shell be domed revoked. BUILDING FEE
li GkI "
�] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm meuhere is i sued(Sce.3 lending agency far the performance of
U � TOTAL: b,40 ELECTRIC ME
she work for which root permit is issued(Sec.300],Civ.CJ 3 B
~F Ladc,.N. PLUMBING PEE
Lender's Amlma QTY. MECHANICAL PERMIT FEE Q.�
U I certify that 1 have rend this application and some that the above information is MECHANICAL FEE
R] correct.lagreemmmply win ell city and mmryDrdivncee and stem laws mlasingm PERMIT ISSUANCE
h U) Wildingcorovuction,and hereby aothodeereprtsenmsivea ofthis city mother upon she
U Z CONSTRUCTION TAX
ebov(Wr)agr a property foe inspection keep herr ALTER OR ADD TO MUCH,
(We,),#ogrce t I save,indemnify sed keep harmless me a City of Cupertino id City
liabilirte6b�k/ry b c rundiis ng of andi many way accrue against said City AIR HANDLING UNIT(TO
OVER10,CFM)
i 1n ca m,gmming oft t. (//'/l/�!
LvI P, / /Z/ AIR HANDLING UNIT(OVER IO,OW CFM)
ZI
Signumm of Applicanl/Conuacoa Y Data EXHAUST HOOD(WJDUCT) PAID
II RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0010 BTU) Dam Receipt# n
Will theapplicant or far.building osculates arm or hurdle mourc us mamrial TOTAL: :]d`
as defined by the Cupertino Municipal Cale,Chapter 9.12.and the Health and Safety
Code,
UNIT(OVER 100,1100 BTU)
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
EI Yea CINo
ISSUANCE DATE
Will theapplicanmrfware buildingoccupent useequipmenmrdeviceswhich emit BOILER-C0MP(3HPOR 100,000 BTU) ,P M rp I D
hassrdous air comandar s as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER IM."0 BTU)
District?
❑Yea ❑No NEW RESIDENTIALMF.CH. SQ.FT. JUN 07 1993
1 have and the huurdous materials requirements under Chapter 6.95 of the
California Health&Safety Cede,Sections 25505,25533 end 25534. I unIntenI mat 111
ifshe building does rot currently have a tenant,that it is my responsibilitymr::'ydm 0111 Vf riaAWL"
oscupant of the requirements which mus,be met prim ro issuance of a Certifica a of
Occupancy.
Owner or aum0drtd agent Date TOTAL: TSSUEDBY:�