25528 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'T'RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25528
BUILDING DIVISION BUILDING PROdECr IDENTIFICATION
BUILDING
9ADDRESS: ^''/�(.�7{� SANITARY NO. APPLICATION SUBMITTAL DAD
Lo
&5— L ' eS— /1V�-D UNIT# LCHa
OWNERSN ME P O E: CO 'SN LIC NO: N/C 1 CONTROL#
�� �li,E
•ARCTTITF. /F.NGINF,ER: LIC NO: ADDRESS: ❑
CON'I'ACI': PHONE: QTY. ELECTRIC PER IT BUILDING PERMIT INFO
BCT PLUMB p1EC11
1'F. IT ISSUAN F,
LICENSED CONTRACTOR'S DECLARATION AI S ESIDENTIALnwz /I��V.
Ihcrah ffrmthat LnnlicenseJ under ESCRI
WOO yn provisioesions Coder laid my filemgwl l I , YAG/
FOO Sectio IF
Divisor am fire Business and Professions Cak.("amicrnuisi
CUf- Ino tune and errecr :
IQ.,L.m Liana Class Cmu 201-IUPT00gMPS
F?y Dae Contractor 201-I000A
yL_ ARCHITECTS DECLARATION / SQ.FT.FLOOR AREA 3/gQ.FI'.
ZOy lunderaandmpianissimi4 used us public records. OVER 1000 ���
OZ F-W Y
1=.nnFus SIGNS BLE AL
Licensed Professional
�CIy�jV OWNER BUILDER DECLARATION SPECIAL CIR UIT/MISC.
XOy 1 hereby affirm that 1 am exempt from the Contractors License Law for the
m�Oy following reason.(Section 7031.5,Business and Professions Code Any city or county TEMP.METER OR POLE INST.
F' y J which requires a permit to construct,eller,improve,demolish,or repair any structure
t�>� priurm its issuance,also requires the applicant forsuch permit o file a signed statement PO .R DEVICF,S
pj K
MO that he is licensed pumuant to the provisions of the Cantmctor's License law(Chapter
2XaF� 9(commencing with Section J000)of Division 3 oftbe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,_y or that he is exempuherefloto and the basis for the allegedexemption.Any iWationof
F Z' Section 7031.5 by any applicant fern permit subjects the applicant ma civil penalty of OUTLETS-SWITCHES-FIXTURES
4not mom than five hundred dollars($500). w
W ❑ I,aeownerofthe ycmP Y 6 pensation, NEWRESIDENTIALL'LEC'fR S .FT.
property,arm In res wiN wa esus0eirsolceom Q STORIES TYPF.CONSTRUCTION
am
3— will do the work.and the sauclum is net intended or offered for sale(See.7 4 .Business
and Professions Cade:The Comractor'a License Law does not apply m an owner of
pmpmy who builds or impmves thcmom and who docs such work himselfor through his
cmployce...... ided lh:a sued imprnvementsnre not imm�Jedoroffcmdforsahe.If, OCC GROUP RES.UNITS
however,the building urimprovement is sold within one yea ofeumpletion,the owner- j��
builder will have the burden of that he did not build or improve \OTAL: b
proving prove for purpose of
ale.).
❑ Las owner oflhe prnperty,vm excluaivdycontracting with licensed calibration to QTY. PLUMBING PERMIT FLOOD ZONE qpN
eumtmct the project(Sac.7140,Business end Professions Clude:)The Contractors
Liccnu Law docs not apply toanowner of,impenywho builds or improves thereon,laid PERMIT ISSUANCE
who contracts for such pmjec¢with ncontmnons)licensed pursuanl to the Comraanr's
License pLTER-
Law. DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ I am exempt under See. ,R&PC for this mason BACK FLOW PROTECT.DEVICE OUTSIDE ES
NITA Y :N
Owner Dam DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCH LTAX Y_N
❑ Ihertby affirm thmlhnveacmificam of crtuem as selLimmx' ra cenificam of FIXTURES-PER TRAP RECEIPI'N
Wofkcra Compensation lnsumneeora cmroab
ified copy Ncrf(See.3810,LC.)which PARK FEF Y N
rostritJl employee's under this pctmit. GAS-EA.SYSTEM-1 INC.4 OUTLET'S RECEIPT#
Policyy# BUILDING DIVISION FEES
Company
El Ceniged copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHBCK FEE
❑ CmiOad copy is filed with the city inepcaion division GREASEdNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKL'RS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thisucliondeed mol be completed ifthe permit is failure hundred dollars(81W) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or les")
Icenify'bar in the perlbrmanceof the work for which this .it is issued.)shall WATER HEATER W/VENT/ELECTR
of employ any Person in any manner ss as to became subject m the Workers PAID
Z Compensation Lowsol'Caldmids. Dam WATER SYSTEM/TREATING Aero Rmeipl#
O O Applicant
z No]'ICH TO APPLICANT:IC after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
L" �2 become subject m the Worker's Compensation provisions of the Lada Cade,you mux) TOTAL
� > 'forthwith comply with such provisions or this permit shall h deemed revoked. BUILDING FEE
6W. CONSTRUCTION LENDING AGENCY SEISMIC ME
'DZ I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
lenders Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FE17
W 1 cenify that I have read this application and state that the above information is
F0. catmea I agree m comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE MECHANICAL FEE
rq buildingcoou,ucmar,and hembyauthorixe representatives ofthis city mender upon the
U Z rine-mentioned property for inspection purposes. ALTER OR ADD TO MUCH.
CONSTRUCTION TAX
(W)agree to save,indemnity and keep harmless the City of Cupertino against
liabilil dgme t I dexpenxs whicIs mayinany y crucagalnstmdd City AIR HANDLING UNIT(TO 10,(00CFM)
In. isene, Ot .a mid&of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
nature of ApplicanVCnntm' EXHAUST HOOD(W/DUCI')
PAID
HA9ARDOUS MA - ALS DISCLOSU IIGTING UNIT(TO 1011.000 BTU Date Recelpl#
Will the applicantorfurm buildin cupsat stare or handle haaardous material
as defined by fire Cupcnino M unicipal Code,Chapter 9.12,and the l leallh unit Safety I MATING UNIT(OV M. IMUW BTU) T T
Calc,Secran 25532(e)Y
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will the applicamorrmure building memant useequipmem mdevices which emit BOILER-COMP(31 IF OR 10,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Ana Air Quality Managemem
piatBOILER-COMP OVER 1f0,UW BT'U
HetP PAI D
Lbml8i,�d.
Yes ❑No NEW RESIDENTIAL MECIf. SQ.FF. SEP
9 IV ' read the hazardous mecca s requirements under Chapter 6.95 of the V�r 9 10 3
calth&Safety Code,Sections 255115.25533 and 25534. 1 understand that W
gdoea net cunently have a tnant,that it is my msprmeibility to notify the _the regdlfemcnls which must he met prior to issuance of a Cedificam ofCIl Y UY bUfGM 111 'wairN agent Date
TOTAL: ISSUED BY:
OFFIC