25095 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOMull";11rF.I.VC1R PERMIT NO. O
APPLICATION/PERMIT PLUMBING-IMF-CHANICAL
BUILDING DIVISION BUILDRG PROJECT'IDENTIFICATION
95
But],DIiG ADDS SANITARY NO. APPLICATI IO/N SUHMfI'IAI.DATE
M��� UNIT# LOTp
OWN IIS NAME: �J PHONE: �s CONk7RA�CI'ORR SyN�AAMEE' LIC NO:
T 3- 30 & ' `z-x-11 �sN0."+ WMA 1 N/C CONTROL#
ARCHITECf/ENGINEI;R: LIC NO: A19Ts 5rb'jft-&-7' cr I,- ] El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEC BUILDING PERMIT INFO
BLDG ELECT' PLUMB MIECII
PERMIT ISSUANCE ❑ 1:19L ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
cmz l hereby affirm that l sm licensed under provisionsofarder9(commencing with
F100[ Scaion]000)of Division 3of the Businessand Profcssime,Code,and my license is in PANELS
lyUE
up force and effect '�tt S.er-
FZw I.iccnse Clms•1"3h6 "CZL7 Liop �ct UP T0200AMP$ �--'
,v,6y Dane{-Z�-� Cmume r_/�iT. 201-1000 AMPS
b-noi ARCHITECTS DECLARATION SQ.FT.DOOR AREA $/SQ,ET.
ZO_m- l understand my plans shall be used as Public records. OVER Ig10AMP5
OZF W SIGNS ELECTRICAL
N
P
Yee j Licensed Professional
E:= OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO W U I hereby affirm that 1 am exempt from the Contractor's License Law for the n'
W31a.y following reason.(Smurn7031.5,Business and Professions Cde:Any city orcounty TEMP.METERORPOLE INST. m ^ IV
"g which, mm,a permit to consuic%afar,impr..e,demol ish.ornumd,cony Muma ., ,• 1) it
Com $ 'ser m its issuance,alsore requires be Meant fursucM1 coo file a signedsaament POWER DEVICES =
prim 9 PP Penni
.'<0 0that he is licensed per ami the provishme of the Contractors License Law pastas, SWIMMING POOL ELECTRIC
a Xo� 9Rommmcing with Section 7000)of Division 3 ofthe Business and Professions Cade) LUATION
Ig_y or that he is exempt therefrom and the haresis for dre alleged!exemption.Any violation of OUTLETS-SWRCHES-FlXTURFS 2�
F Z_Q Section 7031.5 by my ap dicam for a permit subjects the applicant to a civil pe al"of
not more Mw rive hundred dollars P$500).
Kc, C3 1,asowncrofthe property,nrmyemployces with wagesaslheirsole compensation, —NEW RESIDENTIAL ELECTS SO Pf. STORIES TYPE CONS'IR ACTION
wi 11 it,,the w.,k,.nd,hc structure is not intended m4fivmd for sale(Sec. Business
and Professions Code:The Contractor'a License Law does not apply to M owner of
propc ry whobuilds or impmvevhcreoa and who dorssuch work himself.,through his
employees,provided Nm such improvcmrntsarenm imm�dW oroffemd fmsale.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneye crof completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
sale). QTY. PLUMBING PERMIT FEE
❑ La..wnendthe progeny.ant cadusivdymmracting with licensed convect ors to BLOOD ZUNI: APN
construct IM1e project(Sec.7010,Business and Professions Code.) Use Commnors
License law does not apply manownerofpropony who builds.,impowestherean,andPERMIT ISSUANCE _Q
whoconuactsfarsuch projmawithaconuutor(s)lit<nudpursuantmNe C.mr ,.ea
G
License Law. ALTER-DRAIN&VENT-WATER( ) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C foe this maven :SIDE FEES
gpCK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-R.(IOR,ROOF. COND. RECEIPT#
WORKMAN COMPENSATION DECLARA'PION , , SC11001,1 A YN
C] n
I hereby affirm that[havencenilicatoofmsento self-insure,orattnilicamof FlXTURES-PER TRAP w RECEIPT'#
Workers'Confirmation lnsuance ora cenifiW coIr
copy therf(See.3800,lab CJ which iUU PARK TLE Y N
covers all empin¢'s under this tECESI #
Y permh GAS-EA.SYSTEM-1 INC.INCd OUTLETS BUILDING DIVISION FEES
Pol cyp
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Cenifiedeopyislumbyfumished.
❑ Cenitied copy is fled with the city inspection division. GREASE/1NUUSTRLWASTE NTERCEPTOR GRADING REE
CERTIFICATE OF EXP,MPUON FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(TM1issection need nolbe completed if Ne Permit is Intone hundred dollars(SENT) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in The per6rnarme of the work for which This permit is issued,l shall WATER HEATER W/vE /ELECTR
not employ any person in any manice so as to become subject to the Workers' n PAID
Cona,aa mianlnwsof Califoma. Dan I WATER SYSTEM/IREATING 3L�V Dam Receipt#
Applic
zant
Q NOTICE TO APPLICANT:IL after making his Certificate of Eacmption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
become subject To the Workers Compensation provisions of the Labor Code,you must
BUILDING FEE
forthwith comply with such provisions or This permit shall M deemet revoked.
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEF,
I hereby uffon that there is a consumerism lending agency for the performance of
U O the workfor which this permit is issued(Sec.3097,Civ.C.) TOTAL: UD ELECTRIC FEE
Lenders Name PLUMBING FEE
L2. QTY. MECHANICAL PERMIT FEE -DU
t-' Landers Address
U 1 certify that I have read this application and sae sat dre above information is MECHANICAL FEE
curtest I agree To comply wish all city Mal county ordinances and Hale laws Mining m PERMIT ISSUANCE
F-' huilding construction,and hereby radiance mpeesemasveso(chis city to enter upon the CONSTRUCTION TAX
U Z above-mentioned progeny far inspection Purposes. ALTERORADDTOMECH.
(We)agree to mve,indemnify and keep harnless the City of Cupertino against
liabilitiea,judgmenls,rosy nndenpenses which may i way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
c ucncc nl lhc�rana g of(bo peat'.
AIR HANDLING UNIT(OVER 10,000 CF
m�5-
5 ria roof Applicam/Centrsetor Dale EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE: HEATING UNIT(TO 100.000 BTU) Date ReccipT# p ,q
WIIl the applicant of future building occupant store of handle haemdous material HEATING UNIT(OVER IW,IXNI RTU) f� 6x�V
o defined by the CnpMIM Municipal Code,Chapter 9.12,unit the health and Safety TOTAL:
Code,See,...n 21532(a)? VENTILATION FAN(SINGLE RIzMD)
❑Yea ❑No
ISSUANCE DATE
Willtheapplie ntorfut r huildingmcupantus uipnxntordeviceswhichemil BOILER-COMP(3HPOR IBMBOBTU) P A I D
k odoua air comaminares u defined by the Be,Arca Air Quality Management BOILER-COMP(OVER 1(0,0(0 BTU)
District'
❑Yee ❑Na NEW RESIDENTIAL MECfI. SQ.FT.
I have read the hazardous malaris,reyairemems ander Chapter 6.95 of tat MAY 19 1993
California health&Safety Code.Sections 25505.25533 and 25534.1 underaland Nut
if the building docs not currently have a tenant that it is my responsibility to notify the Ci I Vr ukarrn I ave
occupied of The restatements which as,te me,prim in issuance of a Certificate of
Occupancy. J `_
Oictimmnmhmleed agent Date TOTAL: ISSUED By:
" Tf\ ��