25538 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH, ;N s-ELECTRACAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PIAMBNG(Fr MECHANICAL 25538
IIUILDINO PROJKCF IDEIDNMTIEICATION
BUILDING ADDRESS: SANITARY NO. J�APMI�1'110NUBMITTAL DATEZ/852 MONTE CT• �NqT# o LOT4d-g3
OWNERSNAM=: �f�� ,a PHO;. COM' Caf ISNA LIC NO:
VTQLA^.{I K NPC CONTROL g
s NCDI'E /ENGINEL'R: LIC NOI ADDRESS: ❑
A o[• y
'ONTACf:O� 252—!'��O PRI �� QTY, ELECfRICPERtyjJT FEE DUILDING PERMIT INFO
J C LDG ELECT SUCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTI TOB UFSCRIPI'ION
2y�2, Ihembyuffiem Nativmlicensedunderpmvisionsofaapler9(commencingwilh
Ozo Section 701 of Division 3 ofthe Business and Professions Cade,and my license is in PANELS
full farce and effect.
FZz,� License,and Lic.p UP 200 M li, i
8n4 Date CmatmeARCHITECT'S(DECLARATION OIE 11 1 PS SQ.Fal FL A 5/ .FT.
OZ-0 [understand my plare shall be used as public records.
FyS W IG CAL g 2 Licensed Professional
y,w6 OWNER-BUILDER DECLARATION ECTAL CIR S •IV♦V
�qqP((OIyF I hereby af0rm that 1 nm exempt frau IM Cnntncto/a License law for the �`
m3B-ma followingreason.(Section 7031.5,fluidness and Professions Gale:Any city m want. TEMP.METE O LF(NST.
V1OJ which requires a permit m,remirn,other,improve,demolish,or repair any.Imcwre
P )"f prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVI 0
a Q p that he is licensed punu-nno the Provisions of the Continues License Law(Chapter
9(commencing with Section 7000)ofDivision 3 ofthe Businesv and Professions Code) SWIMMING PO ELECTRIC VALUAa or that he is exempt therefrom the buds for the alleged exemption.Any violation of GUI'LET$-SWITCHES-FIXTURES ^' ZA
�ZQ Section 7031.5 by any applicant for a Permit subjects the applicant to a civil pernaty,of 8�f/
g O not mom then fsve hunit ddolian(55W). NEW RESIDENTIAL 6LWrR S .PT.
m ❑ I,vs ownerofthepmpeny,mmyempleyees wills wagesathcirsolemmpensalinn, Q RIBS TYPE
d will do the work,and the structure is notintended confirmed forsale(Soo.7044,Business
and Professions Cade:The Crusrames Licen a Law does not apply to an owner of
property whobuildscrimproves theuon,and whodoa such work himselfonhrough his OCC. RO RFS. NITS
own employees,pros ided that suc b improvements are not intended or offered for sale.IL
however,thnbuilding or improvement is.old withinone yearofeampletion,theowner. T
bullder will have the burden of proving that he did not build or improve for purpose of
soled.
❑ Las ownerofthe Iranian.emexclusively matractingwith licesedcommetorso QTY. PLU TNG PERMIT FEE PLOOOZONE APN
construct the project(Sec.7044,Business and Professions Coded The Canuseuxe, pF.R IS _
License Law does not apply m an ownerof property who builds or impmvn thereon,and
who exurmets for such projects with acomractar(sl licensed pure.......the Cnnlruu-, ALTER IN& EN .A /�
License law. FEE SUMMARY
p 1 em exempt under Sec. ,B&P C fm drier rcaun BACK m. PR ECT.DEV• h SANITARY OMI
Y L N
Owner Data— DRAINS-F — F.ARr;�O I RECEIPfM
WORKMANCOMPENSATION DECLARATION kQ SCHOOL TAX Y N
❑ l herebyaffinn thin l have o cani0cate ofcomennoself-insure,oracemificamof IgXT -P RECEIPTN
Workers'Compensation lnsumncemv certified copy thrmeof(Sec.3800,Lab C.)which AAK— Y N
covers all employee'.unser this permit. GAS-EA.SYSTEM-I INCA OIffLHfS RFCEIPT
PolicyN BUILDING DIVISj6NFE
eY
0 Certified copy is hereby furnished, GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE,
nit 0
❑ Certified copy is filed with the city inspection division. GREASRONDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASHTRAP SOILSFEE
COMPENSATION INSURANCE
(fids section need not be completed ifthe Permit is force-hundred dollars($100) SF.WER-SANITARY-STORM EA.201 ENERGY
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' JPAI�CompenationLawsofCalifomia, Date WATER SYSTEMITREATING Receipt0
Z Applicant
0 NOTICE TO APPLICANT:If.alter making this Certificate of Exemption.you should NEW RES IDENTIAL PLMB. SQ.FT. TOTAL:to become subject m the Wmicre.Compensation provisions of the Labor Code,you mast
forthwith comply with such previsions err this Pmnit shall be deemed revoked.CONSTRUCTION LENDING AGENCY `V zI hereby affirm thatthem is o conswction lending agency for Ne performance of
O Ne work for which this permit is issued(Sec.3007,Civ.C.) TOTAL:Ianders NumeO ( Lender's Address QTY. MECHANICAL PERMIT
I modify that I have read this appllemion and.tale that the shave informed.Is
enorea.I agree to comply with all city and county ordinances and state laws misting to PERMIT ISSUANCE MECHANICAL --EE
Loj building conswction,and hereby sum praenmti.es of this city reenter upon the CONSTRUCTIG TAX
U Z dor ned pony for ireFoidi uopous. ALTER OR ADD TO MECH.
rte- a gm t e n' d keep harmless the City of Cuperrin,against
lie coats de us which may in any wayaccomagdinat said City AIR HANDLING UNIT(TO 10,00)CFM)
eBn n8 ispermit.
AIR HANDLING UNIT(OVER IO,OIXI CFM)
Ti amreof AMlicmVConI for Data EXHAUST HOOD(W/DUCn
PAID
HAZA DO US MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU( Dam Victualg
Will the applicant or future building occupant stare or handle hazardous memriel HEATING UNIT(OVER 103,001)BTU) TO L:
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Tertian 25532(-)7 VENTILATION PAN(SINGLE'RESID)
❑Yes ❑No q�r�
BOILER-COMP OHP OR 100,000 BTU) �S� i Bl TE
Willtair con itarmars as building by the Bay equip Air Quality an igemech it I(" A
hazardous air rnnteninents a refined by the Bey Area Air Quality Management
District? BOILER-COMP(OVER 100,001)BTU)❑Yes 0 N NEW RESIDENTIAL MCCHza . SQ.FT. (kl0\I 1993
�I
1 have mud the hazardous msmm
nals requireenls under Chapter 6.95 of the TVI V S
Coliforms Health&Safety Code,Sections 255(5,25533 and 25534. 1 understand drat F Ch 1 IIVV
if the building does not cunendy have a Rues,drat it is my responsibility m notify the LI I T kir V V
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Ovvner or authorized agent Date TOTAL: ISSUEDBY:
OFFICE