25031 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '•' PERMIT No. ^ O^
BUILDING DIVISION APPLICATION/PERMIT PLUMB IDENTIFICATION
[ s
BUILDING PROJECT IDENTIF7CATIfIN
BUILDING ADDRESS: �/�� �'1� ,, a� SANITARY NO. APPLICATIONSUBMITTALDATE
V Y f� LTY7e D R, UNIT. LOT# 3
OW FIRS NAMF eV [TONE': CONTRWACTOR'SC4s
NAME: reG�D LIC NO:
n� N/C CON3'ROh#
•ARCIII'ECT/ENGINIitilt; LIC NO: ADDRESS: ❑
rod Po
GgNTA � M��
PH
IO'NE QTY. �-ELECTRIC PERMIT' FEE,
r BUILDING PERMIT(NPO
R/J�O p�r� 7T/ 27" ELECT ft.UMB MECH
r•rte PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
-
Qmz I hereby affirm that l on licensed under provisiamofChupter9(commencing with JOB DESCRIPTION
19900 Scott..7000of Division 3offle Business and Professions Cole,and my lfcrnse is in PANELS
14 [4EE[5�1 full force and office"
1
�AMPS
DiZN DatenuCie
s Cont#iactr 4 aat ' 201�I000AMPS
I—'z aARCHITECPS DECLARATIONSQ.IT.FLOOR AREA I$/SQL FT.
O Z�_p❑ I undatm
sd my Plans shall be used as public records.
FNOVER 1000 AMPS
_ W�� Licensed
ELECTRICAL
gw< OWNER-BUILDER DECLARATION SPECIALCIRCU yMISC.
ip�,OdF 1 hereby from that 1 um exempt from the Contractor's License law for the
nl a s�rn following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
ty.fJo'l which rcyuiresa pomis to coretowt,after.improve,demolish,m,ormir any stmcoro
'� prior,.its issurmardsrrequirmtheopplicantforwchPer mit1.fileasignedstatemeat POWER DEVICES
a0 that he is licensed pursuant to the Provisions of the Columbus License Law(Cullum
2 °�a 9be,mntrcing with Section 7000)OfDIViHon 3ofthe Bueinesiiad Professions Cade) SWIMMEVG POOL ELECTRIC
VALUATION
.da ,ey
yYj_y orthat he isotemps therefrom and the basis for the allegedexsmption.My violation of O UT1REST V D V 0
Z,f Sasion 1031.5 by any applicant fm a pemtit subjmu the applicant toe civil penalty of FIJ�DIIn i
C not more Nan five hundred dollars(5500). -
y ❑ I,ae owneroftheproeny,ormyemployeawithwMesmibeirsolemmpnsadon, NEW AL BLE _S4,17fir 51UKIES TYPE CONSTRUCTION
y _ willdome work,and the structure isnotintembdoroffered forsde(See.7044,Business ) II III
and Professions Code:The Contractor's License Law does not apply to an owner of h
Embody whoboldsorimproveatherentrand whodueswch work himselforthrough his
OC .GROUP RCS.UNITS
n employees,providedthat such improvements ase dol intended proffered for sale.If,
however,the building or improvement is sold within one yemofcompletion,theowner-
huilder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.). s e.
[3Lmownaroftheproperty,orn exclusivelycorraning with bicrnsedwattaztorsto 91 ,I,"t 1.`�-PLUMBINGPERMIT, FEE FLOOD ZONE APN
construct the pmjmi(Sec.7044,Business and Professions Code:)The Can..—us PERMIT ISSUANCE
License Law does not apply manownerofpmpony whobuildsorimprovea thercan,and
who commets forsuch projects with acontmcmr(s)licensed pusauannothe Convector's
LicenuLaw. ALTER (EA)
FEE SUMMARY
�- empt under Sec. ,B&P C for this as. BACK FLOW PROTECT.DEVICE ID"
�A O CTI I S� SANITARY Y N
nw„a. 0/Z 7Z Z RECEIPT'N
• WORKMAN COMPPNSATIONDECLARATION DRAINS-FLOOR,ROOT;AREA,COND. SCHOOLTAX Y N
❑ Homily.
l how eecediftcate.[content m sel6insum,ora mr-ificem ofRECEIPTN
Werkers'Compensation Insurance ma unified copy thereof(Sm.3800,Cab C.)which mXT"�'g-PER TRAP PARK EEE Y N
ewers all employmoa minder this Permit. GAS-EA.SYSTEM-I INCA OUTLETS RECEIPT N
Policy N BUILDING DIVISION FEES
Company
CI Codified copy ie hereby fumiehW. GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is Bled with Ne city inspection division, GREASFANDUSTRI.WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is release hundrWdollam($100) SEWER-SANITARY-STORM EA.20017. ENERGY ME
orlona.)
I conifythat in the perfomamaidthe work for which this permit is issued,IshsR WATER HEATER W/VENTIELWM
not employ any person in my insurer m as to become subject to the Workers' - PAID
Compensation laws of Celifemie. Date WATER SYSTEMIME.ATING Date Receipt
0 O Applicant
y 2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
H FEll-i become subject to the Worker's Compensation provisions of the labor Code.you most
a fodhwidt comply with such provisions in this permit shall be doemed invoked. BUILDING PER
zCONSTRUCTION LENDING AGENCY SEISMIC ITH
1 hereby affrmr Nat there is a construction lending agency for the perfonnance of
(, C) she work(or which,his permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
Leader's Name
u" F Lenders Address QTY i„ MPCHAQIICAI PERMIT- PEE PLUMBING FEE
W 1 codify that 1 have mad this application and same thin the above information a '-
nsa I agree to comply with ell city and county ordinances and state laws relating to PERMITISSUANCH + MECHANICAL FEE
building consvmctirn,and hereby sullied=ropmsentatives of this city to enter upon the
f, 7 above-mentioned property for inspection purposes. ALTERORADDTOMECN. CONSTRUCHONTAX
G (We)agree to save,indemnify and keep hmmlesa the City of Cupertino against
limulities,judgmenw,costs and expenses which may inanywaymem.against said City AIR HANDLING UNIT(TO 10,M CFM)
in con rnce of the granting of this rT
�� Y. / S/3�R3 AIR HANDLING UNIT/OVP.It 10,000 CFM)
Signame, APPlienavconsmc,n Date EXHAUST HOOD(Wm3UC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Recoil,a
Will the applicant or future building recurrent atom or handle hnsardotn material
usdefined by the Cupertino Municipal Code,Chapter 9.12,and the l lealth and Safety I(EATING UNIT(OVER I W,000 BTU) TOTAL:
Cade,Section 25532(a)'I
13 Yes El Na VENTILATION FAN(SINGLE RESTD)
Will thea applicant orfummhuibdin escu omose ui BOILER-COME 3HP OR 100,(KKI BTU) ISSUANCE DATE
pp g p eq pment mdevittswhich emit p
• herartlomin
us air contaminants as defined by the Bay Arta Air Quality Mallag111Gg BOILER-COMP(OVER 100,000 BTU) �
Miami? PA
10
❑Yes C3 No NEW RESIDENTIAL MECH.—SQ.FT,
I have read the hazardous materials requirements under Chapter 6.95 of the MAY NJJ
Cmif nod.Health&Safely Cole,Sections 25505,25533 and 25534, b understand that
if the building does net currently have u tenant,that it is my respnnsibilily to notify the
cupric of the requirements which Trust be met prior to issuance of a Certificate ofgl sUrtn I IIVV
Occupancy.
Owner mmthodmd agent Data TOTAL: ISSUED BY: a