25089 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'TINO APPLICATION/PERMIT PLHMBIu:.�IecxnNlcnL PERMIT NO. 25089 C O HQ
V
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L J
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
S e �S'74Y fF NIT 0f LO'I'N
OWNERS NAME I PHONE: CONTRACfOR'S NAME: LIC NO: N/C
A CONTROLp
!✓✓ �i/iS� n Cr///Co cJ
RCHITECf/ENGINEER: IC NO: ADDRESS: ❑
4 !l
«. coNTACf: PHONE: BUILDING PERMIT INPO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
S_00 N ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pp:Z I hereby affirm that l ons m
licensed under provisionsofchapter 9(curawasogwiN JOB DESCRIPTION
FOO Section 71X0)of Division Sof the Business and Professions Cade,and my license is in pprypyS
F<K full force and eff D v\-
W License Class CL .omp 5laS S �� UP T0200AMP5 �^
N 7 N Ddlt Contraz 201-1000 AMPS
Z�NZ A CHITELTS DECLARATIO OVER 1000AM SQ.I7.FTOOR ARIA $/SQ.ET.
O y_O 1 understand my plans shall h used w public records.
pLteq SIGNS ELEC i
CAL
6,1 , Licemed professional
qty 0.'Q OWN ER-BU ILDER DECLARATION SPECIAL CIRCUTf/MhS(•L �r 1ip�/��
XO i FU- I hereby affirm Nal 1 am exempt from Ne Comment's License Law for the i/GfM1I
F4 pm¢ following reason.(Section 7031 S,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
,n J which acquires a permit to construct,alley,improve,demolish,oair r¢pany snm
ucre
fWa 7 priormid issmacc,ulso requires the applicant mrsuch pcmdtm file a signed statement POWER DEVICES
ycej e' O that he is licensed pursuant to previsions the pvisions of the Contracmrs License Law(Chapter Is
LYO 9(commencing with Section 7f100)of Division3of the Business and professions Cade) SWIMMING POOL ELECTRIC
,Mo, .,,but he is exempt therefrom and the basis for the alleged exemption.Anyviolabonof VALUATION
FZ_>' Section7U31.S by any applicant fornpermit subjecm th<epplicwnoacivil Acuity of OUTLETS-SWITCHES-FIXTURES tl
i not more than five hundred dollws($500).
NEW RESIDENTIAL ELEC IR
d'co ❑ i,vowneroftheprnpeny.ormycmployecswithwagesnstheirsolecompensarion SQ.FT. STO :s TYPE CONS'fRUCT1ON
a3=° will dothe work,and theslmcwre is nal inmndcdoro(Tared leisure(Sec.7044.Business
and Professions Calc:The Cowmcmrs License Low docs not apply m an owner of
property,who builds orimproves thereon,and whodoes such work himselforthroughhis
wnemployees,pmvid ftisuchimpmvemmts=nolinlendedoroffertdfmsnle.If, OCC.GROUP RIS.UNITS
however.the building or improvement is sold within one yew ofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ 1.asownerofthe properly,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onalraw the project(Sce.7094,Business and Professions Cade:)The Convector's
Uceme Lawdeasnot apply torn ownerofpropeny who builds or improves thereon,and PERMIT ISSUANCE
whocommear forsuch pmjems with aconvoctor(s)licensed pursuant to the Computers
License Law. ALTER.DRAIN A,VENT-WATER(FA) FEE SUMMARY
❑ 1 am enempl under$¢. ,B&P C(or Nis reason BACK RAW PROTECT.DEVICE OUTSIDE PEE$
Owner Date SANITARY Y N
r WORKMAN COMPENSATION DECLARATION DRAINS-BOOR.RIDGE,AREA,COND. RECEIFrN
SCHOOLTAX Y__N
y' ❑ Ihcreby effrm thwlhaveacenificam of conummaf(Sceurt,aaccnificem of FIXTURES-PIiR TRAP R[CEIFTtl
Workws''Compenswionlnsumae� airrpy thereof(Scc.3800,Lab C.)which PARK FEE Y_N
covers ell employee's uadc1�1aape I. RECEIVI'N
PolicyN l l00 ��� GAS-LA.SYSTEM.I INC.40IffLETS
Grsoury� < <'"m BUILDING DIVISION PEES
❑ C ¢d copy is hereby fumishal. GAS-EA.SYSTEM OVER 4(EAj PLANCHECK IEE
enificd copy is filed with the city inspection division GREASEdNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sec tion need not be completed ifthe permit is(oras hundred dollars($100) SEWER-SANITARY-STORM EA.20017.
less.) T:NERGYIEE
I certify shot in the performance of Ne work for which this pnmit is issued,I shall WATER HEATER W/VF.NT/ELECTR
not employ any permn in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Califomio. Date WATER SYSTEM/TREATING
Applicator —
z C) NOTICE TO APPLICANT:If,after makin this Certificate of Exemption, Doc Rcr�iptp
,z .. g p ion,you should NEW RESIDENTIAL PLMB. $Q.FT.
F >41 beware subject to the Workers Compensation previsions of the Labor Code,you must TOTAL:
� ? forthwith comply with such previsionsmNis pcmdt shall be deemed revoked. BUILDING FEL x0�
y Q CONSTRUCTION LENDING AGENCY SEISMIC FEE SJ'
'a z Ihertbyaffiam Out Nem iso construction lendingagency for the yerformanceof
U C)t-� the work for which this pcamit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
LE. P lender's Name �C V
O U Lcndds Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify Nm 1 have mad this application and stem Ibar Ne uhove information is
correct.l agree in comply with all city and county ordinance and slam laws rcladngm PERMIT ISSUANCE MECHANICAL FEE
ret buildingmnnmctiun,andhercby authorize representatives oflhis city to enter upon the
U z above-memmned pmpeny for inspection ponoses. ALTERORADDTOMECH.
CONSTRUCTION TAX
(Welcome to save,indemnify and keep may
the City of Cupertino against
fiabiinconsequence of
expenses which may in anyway accrveegeinn said Ciry AIR HANDLING UNII'(TO IDfN10 CFM)
consequence of the granting of this permit.
I
p;/ AIR HANDLING UNIT(OVER I to"CFM)Signawre of Applican ontren ]Date EXHAUSTHOOD(W/DUCI) PAIDHA'Z,ARDOUS MATERISCLOSURE HGTING UNIT('f01pp,WU B'fU) Doc Reeciptp
Will the appli<anl or fmurt building ocort or hatMle harardoux materialas defined by the CupedinMunicipal CodeyJ�;mad9mffMJmand Safety HEATING UNIT(OVER 100.000 HTU) TOTAL: 122+30
Code,Section SSJ2(e)p❑Yex VLM'ILATIONFAN(SINGLERFSID)Will theupplicuntnrfulumbuildingmcuecluipmentordeviceswbichemit BOILER-COME UHP OR 100,001)BTU) ISSUANC ATEh zsrdons air comaminanas as defined by A _Quality-Management,-� BOILER-COMP(OVER 100,000 HTU) P Ajr byes NEW RESIDENTIAL MECH. SQ.FT.1 hove read the heewdous materials enm under Chapter 6.95 of the _ MAY 18 1993
California Health A Safety Code.Sections 8533 and 255]4. 1 understand thatif thebuilding does nalcurremly have a tenanis my responsibility to notify the CITY Ur l,uren nlryace I of there ich must beor to issue of a Car irisin ofOwner or au0ualad agentDat 1'OTAI,: ISSUED BY J• / ' V( f— h�