25346 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B "J"NI O-K1,11, ,RICA. PERM] NO.
BUILDING DIVISION APPLICATIONIPERMI'P PLUMBING.MECHANICAL f� C p C
BUILDING PROJECT IDE.N'FIF'ICATION L J 4 v
N 1105;12_ .��� �� AT— UNIT# LOTH M1ANI'rARY NO. AI'I'LICA'IION SUBMITTAL DATE
OW I:RS NAM': 11`{/O/I 11.1
,,, LIC NO:
NN�� el iNOJ_ f✓T C-Tj' N/C CONTROL p
RCIIIIVCVI7NGIbl LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY, ELECTRIC PERMIT PER BUILDING ITRMIT INFO
IILDG ELECT PLUMB MF.CH
PERMITISSUANCL' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby firm that l am licensed under face t f)(commencing ION DF:SCRIPT ON
❑00 Yu pmvisiomso per ed eis in
{+100 Section7000)affect. onJol the Business wJ Pmfessinns Code,nnJ my license is in PANELS
C W full interlard effect. 1 /` ►^
p.,ZW License Clare Lic.# UP T02IXIAMPS 1
mQy Dam Cmntruclnr 201-1000 AMPS
zoos— OVER DECLARATION OVER 10(1(1 AMPS SQ.Ff.ILOOR AREA $/SQ.lel'.
OZ—C l understood my plans stand]beuedes public records.
4YfjSIGNS ELECTRICAL
Licensed Precisions]
L y'WG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOyF 1 barely,Alum thus 1 um exempt from the Contractor's License Law for the
m3n-rn following reason.(Section 703LS,Business and Professions Cede:Any city or county TEMP.ME'1'ER OR POLE INST.
�; which acquires a permit to construct,al tor,improve,dental ish,or repair any structure,
tuur'11Y priorto0x isuaramilsorequimatheapplicam l'orsuchpemiltm Ole oeignul sm,emw,' POWER DEVICES
GJKAO that lie is licensed purauan to the Provisions of the Contractors License Law(Chap¢r
`X=ff9(commencing with Section'000)of Division 3ofthe Business aadProfessions Code) SWIMMING POOL ELECTRIC VALUATION
m_H orihl,he is earmpuhem from and the basis for the alleged eusurfa m Any violation of OUTLETS-SWITCHFS-
p.,ZT Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of FIXTURES
xx rcthan Bve hundrtd dollars(E5W). NEWRESIDINTIAI.ELECIR _SQ.Ff.
arm n I usowna of the pr openy,ormyemplaywswithwagesas,heirsoleoumpansmlon. STORIES TYPE CONSTRUCTION
a3— illdn the work,and,beswcmrcisno,inLndese Law
not
town,Business -
.rid I'ndexsinns CME:The Cunua<tor'a License Law does not apply m an owner of
prnpeny who builds or improve thereon,and whodmessucb work himselfor through his
ownemployces.powided thalsuch improvememsarcnot imendeduro(feral forssle.If, OCC.GROUP RE .UNHS
however,the building or improvement is sold within one yearofcompletion,the owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,asownenifthepropeny,emexcluaivelycontrnningwi,hli<ensedcomrnemntn QTY, PLUMBING PERMIT ITE FLOOD ZONE APN
construct the project(Sec 9(94,Business and Professions Codc:)'rhe Cc' or.'
License Lawd«snot apply loan ovocrofproperty whobulldscrim ovca ihcrcot,and PERMIT ISSUANCE .�
who contracts for such projects with aconhactor(s)licensed pursuant to the Contractor's ACIER-DIYAIN&VENT ( )
License Law. WATER EA 'FEE SUMMARY
❑ I em exempt under Sw. B&1'C for this aason BACK FLOW PROTECT.DEVICE
OUT.IDE FF.I:.
Owner Date SANITARY Y_N__
WORKMAN COMPENSATION DECLARATION DRAINS-BOOR,ROOF,AREA,CONED, RECEIPT#
SCHOOLTAX Y N_
❑Workers
Craaf0mith:nlhnve ucerti0cne ofamsem,n self-insure,oraccrtificmc of PERTURBS-PER'I'RAP ...�� RECF.IPfp
Warkers'Compensetinn lneumncc oracenlfiedcopy thereof(Sw.3SW,1.uM1CJ which PARK PDE Y_N
✓ coven all employee's under this porion. GAS-EA.SYSTEM-I INC.40UILRTS RECEI"k
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 HDG PLANCHECK PEE
❑ Certified copy is hereby furnished.
❑ CcrtiOeA copy is fled with the city inspeninn Division. ORIiASF/INDUSTRI.WASTFINTP?RCEI40R GRADING pill.
CERTIFICATIi OP EXE•MMON FROM WORKERS' G F E A l.. SOILS FEE
COMPENSATION INSURANCE, _
('Otis section need not be completed if,he permit is for one hundred dollars($100) a ISI WEk!SA 1 AHY- T ENERGY FEIi
or leas)
I certify Ilia,in the perform:mceof,he work for which this permit is issued,Inbull A' LCI'
not employ any person in any,mmecr so as to become subject to the Workers' �1 PAID
Z Comperralou Lawsof California. Date WA TEk SY 9 T Data Receipt
Apph e m
z 0 NOTICE TO APPLICANT:If,after making this Camfirale of Exemption,you shoulId - SQ,FT. TOTAL:
P4become sabjectI.me Workers Competition provisions of,he l.nborCMe,you muL
04 ; forthwith comply with such pro visions or this permit shall be deemed revoked. BUILDING PER
tIfl Q CONSTRUC ION LENDING AGENCY SEISMIC FEE
7-. I hereby aflirt Ilan Nero u u construction lending agency for Norormumce of
O the work far which this Penni,is issued(See3119],Civ.C.) O" � ELRC I RIC FEE
Lenders Name
QU Lenders Add.... QTY, MECHANICAL PERMIT FEE PLUMBING PEE
I certify the,I have ad'his applicmion ted eme,ha,fie above information is MECHANICAL FEE
W erect.I agree to comply with all city and county ordinances and see laws relating to PERMIT ISSUANCE
I" buildingcar,ouction,mad hcrchy radamize repssecra tivesmf ilia city,.emerupon the CONSTRUCTION TAX
U Z abovcmea,ioned property for inspection purposes. ALTER OR ADD TO MECPI.
(We)agree,o save,harmony and keep harmless,he City of Cupertino against
Iiabii,ics,judgmcoe,costa and expenses which cony in anyway eccruea ainesaid City AIR HANDLING UNIT(TO 10,M)CFM)
in muq a (the roving of tit}'�pm ,.
AIR HANDLING UNIT(OVER 10,00U CFM)
Signa, of weWCoroomier Date EXI IAUST HOOD(W/DUCI}
PAID
I IAZARDOUS MAT Idit DISCLOSURE HEATING Ott 100,100 BTU) Due kweipt X
Will thenpplicon,.,future buildir,compant.sturc orhandle bazafdous material HEATING UNIT(OVER 100,(00 BEV)
alined by the Cupertino Municipal Cede,Chapter 9.12,aad,he Health and Safety
Code,Section 25532(n)l Vp ILA'r10N PAN(SINGLE RESID)
❑Ye; ❑Nn
BOILER-COMP(AHP OR 100,000 BTU) ISSUeVE.D�TD
Will the up,licon or future huildingoccupuntasecquipmentordeviceswhich emit gyp+/ 6A O
�haasrieCi au conwminanu as define)by,he Bay Arca Air Quality Management BOILER.COMP(OVER 100,000 BTU)
Dixtrictl �UL 211993
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FE
I have read,he hmnrduus materials ns 5505,25533 under Chapter understand
of the hat
if the uil ingd does
nut
cur CMyhave liman,05,25533 my responnd sibility
1ityto notif the Cly Uf UUvtr+I 114U
cambuildinge requirements
yhaveaenem,etmitis myespnceiofa to the V
0
campart of,he reyuiremems which mus,be met prior to issuance of a Certificate of
Occupancy. � -
i
Owner or authorized agent Dae TOTAL: ISSUED BY:
OFFICE