25104 (2)(. APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Bull,DIN - LRCTR'ICAL PERMITNO.CITY OF CUPERTINO ON/PERMIT PLUMBNG-MFCH .
BUILDING DIVISION APPLICATItBUILDINGPROdEC'I'IDRNfirICA77ON
25104
C1OA
BUILDING ADDRESS: ^(�/�/J / �! SANITARY NO. APPLICATION SIIBMrrIAL DATE
Z No / -7 Ry4pu% VC UNIT# LOT# S' 3
` OI
NERS NAME: „ro PHONEY- 7
CON ACTOR'SN LIC NO: NEC CON TSOL#
RCHITECT/F.NGNE R: V LIC NO: ADDRESS: ❑
CONTACT: - PHONE: y '
CO QTY: BUILDING PERMIT INFO
ELECTRIC PERMIT' FEE.
BLDG ELECT PLUME MF.CH
WW G PERMIT ISSUANCE -If El 1:10
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
omz Iherebyaffirm[ha[lam licensed ander pmvh,mxofC1np[ar9 fommencingwith
[x+700 Section70010)
and ofDlvlsionJof@a Business and Professions Code,and my license is In PANELS , `-
UU mu rnree and ereect.
F Z W UP TO 200 AMPS
License CItl89 Lo.#
m<a pate Cemmetnr 201-1000 AMPS
zoo r, ARCIIITECTS DECLARATION OVER IOW AMPS SQ.PI',FLOOR AREA $/SQ.PI'.
O Z.G 1indecaarimy plans shell be used as publicrecmds.
r�t'� Licensed Professional SIGNS ELECTRICAL
K OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. r \ IL r�
OiF I hereby affirm that I am exempt from the Contractor's License Law for the i B..
'+�o, following reason.(Section 7031.5,Business end Professions Code:An t [ TEMP.METER OR POUF.INST. 1�
O rclrrr macer r '< �V
which real a permit to constmct,allot improve,demolish,o,repair any moral re
W}� prior to its issuance,also requires applicant for Permit file asi ed statement POWER DEVICES
y1. pp pe gn
1y O that here Beensel p Smile m the).[DiO s or the Grmracness License Law(Chapter -
W 9t hat he is uxemwith eedon 70009he basision 3oftheBusiness and.Any iolaCode) SWIMMING FEEL ELECTRIC VAIlMIf1N
W rn or M1eisexbyapt nyapplicantfmrefirearn add ebasisfonjranshe theaexlicarmn. civil minify of OUTLETS-SWITCHES,FIXTURES (G//�"'”'
�Q
Section
7031.5 a by any applicant(crapertnit+objects the nppliwnlm ecivil penalty of
re own Bvehmmdredrty,ormyempl NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
elm ml,asowneroFlhepropery,army employees with wagesastheirsolecnmpensation,
p, i dothe work,and the structure is not imendedornffered fmsole(Sec.7M4,Business
and Professions Code:The Gmtraetot's License Law does not apply to an owner of
propemyhypea.ldsorimpnmesthimprovndwtismansucandediimselred Outsidhhis OCC.GROUP RES.UNITS
wit employebuildi building
improvement
me earn romp)tion,theo a.If,
howeer ,will avete burden ofprovinishat he id noneycm or ,mprove for the of TOTAL:
are.).,will have the burden of proving that he did not build or improve for purpose of
cele). < . i "
❑ I,as ownerof the pmperty,umexclusvely mntracttng wnhl tensed contrcdo t QTY.: iTLUI.IBING PERMIT,, 'FE& FLOOD ZONE APN
nstruct the project(Seo 7044,Business and Professions Code)no Conhmtm'e PERMIT ISSUANCE
License Law does notapplym sonownerofprrperty whobudds orimprrves rhereo land
who contracts Formch Projects with actionatchi licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EAT :FEE SUMMARY
❑ 1 am exempt under Se. B&P for th's reason BACK MOW PROTFAT.DEVICE OUT IDs FEES
SANITARY Y N
Owner Dat DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT# '
WORT AN COMPENSATION DECLARATION SCHOOLTAX Y N
(:IIhereby uffrnN hu ye a certificate of consent m self-insure,or a cenilicate of FIXTURES-PF.R TRAP RECEIPT'#
Wnrka Campensmum houmnce oro certified mpythammDSm.3800,Lab C.)which PARK FEE Y N
coven all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Pch"# BUILDING DIVISION FEES
Company GAS.EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cerifted copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GRE,SEaNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is furore hundred dollars;(SIM) SEWER-SANITARY-STORM P.A.200FT. ENERGY FEE
orless.)
I cerifythat in the performance ofthe work for which this permit is issued,Iahall WATER HEATER W/VENT/ELECTR
not employ any person in any manner se as to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEMITREATING
Data Receipt#
O Z Appleton,
z NOTICE.TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
FH bmrmeaubjeot to the Worker's Compensation provisions of the Labor Code,you must -
� , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PEE
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
✓✓R I hereby affirm that there is a construction lending agency for the performance of `
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ETECTRIC PEE
u
Lenders Name
OF 'Lenders Add., QTY ;MECHANICAL PER MITe s, ` FEE- F PLUMBING PEE
U I certify that I have read this application and state that the above information s r "?
W emrect Iagreo rocomply with aIle ryand county ordinances and stere laws relating to PERMIT ISSUANCE MECHANICAL FEE
�^ building mnstrumion,and herebyacthodu reptesentativasofthis city loan,,,upon the
U y above-meminned primary for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
rte- (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitiesjudgments,costs and expenses which may in any way recrueagairst said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Sigmamre of Appli...o(Contmctor Data EXHAUST HOLD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I fKBM BTU) Date Receipt
Will Ca.mlicont or future building occupant sore or handle hesitations mmernd
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I HEATING Gist(OVER 100,000 BTU) 0_rAl.
Gide,Section 25532(a)1' VENTILATION FAN(SINGLE RESID)
❑Yes 74.
Will the applicnnmrfuture huilding by the
tay Area
Air orality swhichemit
BOILER-COMP(RHP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
tsvicR
❑Y0ft �o NEW RESIDENTIAL MECIL SQ.1T.
1 have read the hicandous hi regairements under Chapter 6.95 of the PAID California Health&Safety Code,Sections 25505,25533 and 25534. I understand that A
iflhebuildat,he hoouotuu Iwhic e it..at a thrall is my responsibility raffiam.of y ...J�
cement he teluire which most he at prior to issuance of a cenilicate of M Q p
fy the
oda N �7
Ow r rautatrima t Date TOTAL: ISSUEDBY: