25379 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO rpunpTNo.
BUILDING DIVISION APPLICATION/PERMIT TING PROJECT
ATECUAIOCnI. 25379
?,.BUILDING PROJECT IDENTIFICATI(IN
BUILDINGA ESS: 1 SANHARYNO. AN'LICATON SUBMITTAL DAM
rk UM1ITM LOT
OWNERS HUNG: RACTO RS LIC NO: IIROL//
J Q' a4l,s — NIL' CUN'IROLa
ARCHTECT/ENGINEER: LIC NO DRESS:
•COh-I'wCT: PHONE: r.'rt. y ry,.rC.`rr;acs<rY..x.rs-.t gty'yy. -�n'tit,. E:�-s ,.(yt_~.i0.'r'•'BUILDING PERMIT INF0 J
97T .tip :�s�v.-RIC PyER�,.T—?ey ' 4f �?� FE y.',':;'
pLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
7y.Z IherchyafGrmthatl um licemeduode,mmsienso farmler9(cotmnmciagwith L0B DESCRIPTION
-00 Section7M)
andefecivisionJoflhe Business and Professions Code.and myliccnscisin UP TO
<UG full forcea deft t. Up TO 200AMP5 %l`/�✓I�/�1�
License Class Lie,# 1
j y Date Conveetm 201-1000 AMPS SQ.FI.FLOOR AREA S/SQ.FT.
Jy� ARCHITECT-S DECLARATION OVER I"AMPS
_ 1 understvtd my plans shall be used is public rmmas.
z tpsc SIGNS ELECTRICAL y
n jLicensed Professional
Sect OWNER-BUILDER DECLARATION SPECIALCIRCUMMISC. F r . n ^ T7 �, r
7aU I hereby affirm that I am exempt from the Contractor's License law for the
3 a y< following onsion.(Section 703 L5,Business and Professions Code:Any city or coLnty TEMP.METER OR POLE INST. 4
prom
anequimsaperamin coam,The dmr.i tforsu h ens l o nrnpzh enytumctent POWER DEVICES
'v;>� priorm its issuance.slsoregwru The applicant for such permit to fileaugnd statement • ��
z p thv he is license Pursuant to Ne provisions of the Contnctor's License Law(Chapter S WIMMDIG POOL ELECTRIC
« 9(emnmencingaith Section7000)of Division3of Ne Businessand Professions Cade)
on that he is exempt therefrom and the basis for the alleged exemption.Any violation of
_ZY Section 7031.5 by anyapplicant for a pcmtit subjects the it,liam or a civil'really of OUTLETS-SWITCHES-FIXTURES Jt
e=7 n«more than five hundred dollars(ESo0). NEWRESIDENfIALELECIR —SQ.FT. STORIES TYPECONSTRUCTION
%z=� ❑ Luownk.and
the
poperty,ormy<mpinyxawiNwedforsafei(See7ompewness
3_ anBae Neavmk.Cool .wcmrcisnor a Limaeraffetdu fomale(ply 7o an.ownBuser of
and Rofeshiobu Cee:The Contractor s red who Law sucdueh
not apply m an owner of
pmperrywhobuilasorimprovea thinaproentern mcsauchwork edermelfm Through his OCC.GROUP RES.UNITS
employees,provide tharove int issomwtsan notiearofsmof(emafcassale.cown IL
budder will have
or improvement the withinone yworimproveforNeownv-
builder will have dm burden of proving slut he did not build m improve for purpose of _
--x'+-xeT l=:_;Dy'•P" FLOO_ZONE
APN
�)I.uown<rofthe propcnY.emexclmivelywnoaning withlicensdconuacton to Y PLUNNMING PERMITi^naI'r'i
consumer die Project(Sec.7014.Business and Professions Cade:)The Cantranors PERMIT ISSUANCE
Vcrns wd� notaWlytoanownerofpropertywhobuildsocimprovesthcreoh,and
w1mversams nonsuch pmjecs with aconuamor(s)licensed pursuant mNe Conmmoui ALTER-DRAIN&VENT-WATER(EA) 1' ,}{'';
License caw. .t3A6^I"bYltfLe.-. .. .__
❑ I em eumpt under Sm. .B&P C for This reason BACK FLOW PROTECT,DEVICEOUTBID
SANITARY Y N
Owma Dara DRAII:S-FLOOR.ROOF,AREA.COND. RECEIPT
la WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihmeby off dwlhavee«nifi®te ofwnscm to ulf-insurt,ma«nifinm of Fly .Ppg�p RECEIPI'X
. Wcakers'Comen
psatien lnsunnce macenifed copy thm
mf(Sec.3800,Cab C.)which PARK FEE Y N
era all employee's under this permikDIVISIO a
Y GAS-EA.SYSTEM-1 INC.INC40VD.ETS BUILDING DIVISION FEES
Policy p
Company GAS-EA.SYSTEM-OVER 4(EA/ PLANCHECK FEE
❑ Cmified copy is hereby fm city
❑ Cenifidcopy is fled with rhe city inspection division. GREASFIWDUStRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Ibis section rtadmt becompletd ifthe portent is Interne hundred dollars(SI00) SEWER-SANITARY-STORM EA.20)Ff ENERGY FEE
o I..)
Icertify that in the pcifoemom of The work for which Jr.permit is issued,Ishal] WATER HEATER W/VENT/ELECTR
not employ any person in any marutcr so as to someone subject To the Workmi PAID
Comimustienlawaof Califomia. Date WATER SYSTEM/BEATING Date Receipt
> Z Apphcant
O NOTICE TO APPLICANT:if,after making this Certificate of Exemption.you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
become subject n The Workers Compensation provisions of thc Labor Cee,you must
= �
forthwith comply with such Provisions m this permit shall be d«md revoked. BUILDING FEE
rt
Q CONSTRUCTION LENDING AGENCYru
SEISMIC FEE
3 Z I hereby aft that then is a construction lending agency for thm perfomunce ofTOTAL: ELECTRIC FEE
O the work for which this Permit is issue(Sm.309J,Civ.C.)
Leader s Name ^n-.. 'rv'z.^.a:.-.RA '-•da+e;.Jy'._<S"t. ' ' - PLUMBING FEEfender's Address Q77-. ''(uv' MECHANICAL PERMIT;a-'r=s."'C'•,�FEEd' YU 1 certif Nat I have read this a lication and state Nat Ne above information is goe. fs•a.�'"° " -ter ms'~ v ( s s•y PpMECIIANICAL FEE0. builder coni«mcomply with acity and
orimcounryordimncesand sm¢lawner upinge PESSUANCEbuilding mnxumction.and hertby authorise mprcsenNives ofNis city torn¢r upon teeCONSTRUCTION TA%Z above-mentioned propcny for inspection purposes. ALR ADD TO MECH.e hanNess dm City of Cuvtino aganstliabiliim' mayor wayacerueagdrimsridCiry AIDLING UNIT(T0 TO."CFM)me I ispew. AIDLING UNIT(OVER IO0X CFM)EXT HOOD(W/DUC) PAIDHAZARDOUS MATERIALS DISCLOSURE HEUNIT('fO IIXL(Np BTU) Dam RecmiptpWill the apdimmor future hudding occupant store or handle haaataous materialTAL:defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and SafetyHEUNIT(OVER IW.IXq BTUICode.Section 25532(a)? VETION FAN(SINGLE RESIDI❑Yes ❑NoISSUANCE DATEB000MP(311P 0R 100.000 BTU)hare ous air conmMmnts m define by the Bay Area Air Quality Management BO -COMP(OVER 100,000 BTU) A ! D
. DisWn?
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ,FT.
1 have read the huvrdous materials requirements under Chapter 6.95 of the JUL 2 9 19
Califomla Health&Safety Code.Sections 25505,25533 and 25534. 1 undersand Nat J
if the building does,not eurmndy have a tenant.that it is my rcspcimiblloy to notify the (�
emupmt of Ne oquiremcns which muse be met prior m issuance of a Certificate of \•� } �i l� '•'Cf11
Occupancy.
Owmr m authodeed agent Date TOTAL: ISSUE Bl':
OFFI