25945 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO H°2°rna'PTP:u 111 1 PERM I']'NO. 25945
APPLICATION/PERMIT PLUMtlING.M F,CHANICAL
BUILDING DIVISION BUILDING PROJF,CIIDKNI IF'ICATION
OUILDING ADDRESS:O l p1
43 LOT SANITARY NO. APPLICATION SUBMITTAL DATE(� UNIT# T
OWNERS AMI'y PUGN7". C YTRA OR' NAME: LIC NO:
LG_ N/C CONTROL#
3
AR'H .CT/FNGINEER: LIC NO: S: ❑
L
CONTACT PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El 56 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL J�
M=Z thereby of ren that l am licensed underprovisions of Chapter9(commencing with JOB DESCRIPTION
WOO Seelon 9100)ol Division 3 fine Business and ProQfessions Cede.and my license is in PANELS
=aWF�. full Tara unA cl v l� 1 ��#
U hi cense Class �.r.�,-�Lic.N 1 UP TO 2W AMPS
L,<, Dato Cont xa,,T� 201-PXX AMPS
z8o"Z ARCHITECTSDE.. TIO OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.Pr.
O Z L O I radcrsund my plans shall be used as public records.
r 4 t=W SIGNS ELECTRICAL
Qy2j Licensed ProfnsiunW
OWNER-BUILDER DECLARATION SPECIALCIRCUM)MISC.
XO W U 1 hereby affirm that I am exempt from Ne Contractor's License Law for the
W 3 W y following ounces.(Section 7031.5.Business and Professions Code:Any city or county TEMB METER OR POLE INST.
I_a ON mit which requires a perto construct.tribes,improve,drnwlish,or repair my structure r 1
lwY� prior to its issuance.alor requires the applicant for such permit file a signed Wiscon in POWSRUEVICPSI /\ � 1—s ^r l
,=<0 that he is trig W pursuant o the previsions of the Contractor's License law(CTaper s
ado# 9(commencing with Section 000o)of Division J ofthe Business and Professions Code) SWIM MING POOL ELECTRIC -
W M, ♦ - VALUATION
W_m or that he isexcmpnhcrtfmmand the basis for the alleged exemption.Any violation of I S'-SWRCHE$-
FZSection 7031.5 by any applicant for a planned subjects the applicant a civil penalty of 0� FI' -R 7 1
5E<O am noontime fve hundred dollars($500). NEW RFS ENTIAL ELE , S
yFo ❑ LasownenJthepmpeny.ormyemployeeswith wages tae theirsole compensation, STORIES TYPE CONSTRUCTION
a3°—° will do the work,and the structure is not inrendedorofferm forsale(Sce.1044,Business 1t
and Professions Codc:'I'he Contractor's License Law does not apply to an owner of
pimperty who builds or Improves thereon,and whodoes such work himself orthmughbis
nployces.proem
provided that suchimprovems seemed intended oroffercl for sale.If, I OCC,GROUT' RES.UNITS
howcever,the building or improvement is sold within one yearofcnmplener,theovener TOTAL
builder will have the burden of#swing that he did not build or improve for purpose of
rola), QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lm the Project
thepm�Sec. ny.7(abc. usinesvelycorofesio with licensed Contractor's
License the project plym J4,Rosiness and Professions Code:)The Csnlmetor's
License Lawdoesnm upplytaanoh ismer property whmandpsodmpro he theewnand PERMIT ISSUANCE
wband,Law. such pmjauwiNawntrador(s)Iicenscd pursuant the Conuactor's ALTER FEESUMMARY
License law. (EA)
❑ 1 am exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ Thereby om ffrthat have acenifcate of conumto self-insure,oraunifcam of RECEIPI'p
Workers'Com tion Insurance ora carried copy theard(See.3800.Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
#cyan
covers all emplemployee'sundcnhis permit. GAS-EA.SYSTEM- INCA OUTLETS RECI:I PT p
Pat icy# BUILDING DIVISION FEES
Comfort
Candied copy is hereby furnished. GAS-EA.SYSTEM-OVER 4(G) PLANCHECK FEE
Camped copy is fled with the city inspection division. GREASFgNDUSTRLWASTEINTERCF,PfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(I'hivsection need rot becouniAmeat ifthe permit is for one hundred deltars($ILO) SEWER-SANITARY-STORM EA.201 ENERGY FEF,
or less.)
I certify that in the performance ofthe work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner as as in become subject to the WorkeriPAID
Compensmion Eawsof Califne iv. Date ATERS STEMIMEATING Date Receipt It
Applicant
z0 NOTICE I'O APPLICANT:IL after making this CanHimme of Exemption,you should NEW RESIDENTIAL PLM B. SQ,PT. TOTAL:
f— y become subject to the Worker Compensation Provisions of the labor Code.you most
a � forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
LLI a ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE
_D Z thereby affom that there is a composition lending agency for the performance of
U O the work for which this pemdt is issued(Sec.3091,Civ.C.) L ELECTRIC FEE
Lender's No. as
QU Lendcri Address QTY. MECHANICAL PERMIT FEE PLUMBING PEE
I certify that I have read this implication and state that the above information is
connect.lagrecmcomplywirhalleityandcountymi inancesand,mesinwsadma,te, PERMIT ISSUANCE MECHANICAL PER,
F-' y building construction.and herchy authonx rcpresenwtives ofthisety to enter upon the
U move-mem le nal prepeny for inspection purposes. ALTER OR ADD TO MECH. CONSI'RUCHONTAX
(We)agree to save,Indemnify and keep h:umlass the City of Cupertino against
Land itics,jn gmelnw.costs and expenses which may in my way acerueagainstsaid City AIR HANDLING UNIT('1'01 g0(yt CPM)
oe '�'yu cof the gmntingof. rib's—cemtit. 1/_
metal\\ I//7svfY _ AIR HANDLING UNIT(OVER 10,000 CFM)
SiSrgoatr ppwi VCma.hu AV_ _ _�DDattaa 11E"-111 EXHAUST HOOD(W/DUCII
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Rtteipt p
Will the applicant or forum building de.Cap atom or handle broadcast su material
as defirsell by the Cupertino Municipal Code,Chapter 9.12,and the HeUtharM Safely HEATING UNIT(OVER IOO,IXIp BTU) TOTAL:
Cade,Smion 25532(a)I
El Yes El No VENTILATION FAN(SINGLE RPSID)
Will theopplicantorfvturc buildingoccupant use equipmemordevices whichemit
BOILER-COMP(3HP OR 100,fp0 RTU) ISSUANCE DATE
haaardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Disarm?
11p O D Yes CI No NEW RESIDENTIAL MF.CII. P P9 SQ.FT.
1 have real the hmardous materials requirements under Chapter 695 of the
California Health Se Safely Code,Sections 25505,25533 and 25534. 1 understand that FEB 2 3 1994
it the building docs not curcnlly have a tenant,that It is my responsibility to notify the
occurred it he reyulrcm on,which rodeo he mel prior to Issuance al a Cedifcum of
Occuxnrcy.
CITY V vl
owner or authonzeJ agent Dale
'TOTAL: ISSUED BY:
OFFIC