25584 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUIL 1)IN,- A..;IRI A. PERM I'TNO.
CAL
BUILDING DIVISION APPLICATION/PERMIT PLUM IIINO-,IIDENTIICA 25584
558 a�
BUILDING PROJRCT IDENTIFICATION L sV1 `MJ tXJ 4
BUILDING ADDRESS' SANITARY NO. APPLICA'I ION SUBMITTAL Dal 17
�/ I_ UNIT# LOT is
:RS NAM PHONE: 'RACY NAME: LIC NO:
C ` G/ )?Ale
N/C CONTROL#
k IITECI'/ENGINEER: C LIC NO: A DR r D, ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE(J[ BUILDING PERMIT INFO
t 'E
J. / ! BLDG ELECT PLUM MUCH
(�/ PERMIT ISSUANCE El
LICENSED CONTRACT)R'S DECLARATION APPLIANCES-RESIDEN'TIAI. JOB DESCRIPTION
Q=Z Ihereby affirm that l am licenxdumierprovisionsofC'hapmr9(commencing withY
aOp Sectiacciendof Division 3of mu Business and Professions Code,and my license isle PANELS l^�
U full bemused effect. lIP T0200AMP5 `_�( //LJ
QF Z W
License Class tic.p
m6y Due - Conuactor 201-100f)AMPS
ZQNz ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FF.FLOOR AREA 8/SQ.FT.
O Z—❑ I understand my plans shall he used as public records.
F rust F-ul SIGNS ELECTRICAL
Q� Licensed Profia,emnal
OWNER-BsfRDECLARA 'ION SPECIAL CIRCUIT/MISC.OaU 1 hereby arm am that I exomps empt from the Contractor's License law for the
W3LLvFa'J following moral(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE IN ST.
�LLJ m..I which requires u permit to constmcL al tep improve,demolish,or repair any lr.cmre
fya� prior to its issuance,also requires the applicant for such permit to file.signed nmemere POWER DEVICES Ir
O that he is licensed pursuant n.the provisions ofthe Contractors License Law(Chapter�ia 9(rommeremwith Section 1000).(Division 3efohe Bueirm,md Professions Code SWIMMING POOL ELECTRIC
yJ—g rotor he 131.5 by any p,omand the basloomfortheasegedexemant 1.Any violation of OUTLETS-SWH'CHES-FTXTuRES
�Za not Sr,mo than v hundred
cral dollfurapc). subjects the npplicunno.civil penalty of u
�Sp not mom than five hundred dollars(SSW). NEW RESIDIlOT1A1.ELF.LTR Q.FT.
tYto ❑ I,asownerofthepropay,ormyemployeeswimwages.theirsolecompnsaiion, R TYPE CONSTRUCTION
a3=° wi 11 deohe work,amd Ne samemre is not lmended mol'fired for sale(See Ift Business
and Professions Code:The Contractors License law does not apply to an owner of
propenywbebulldoorimproveschcreon,unJwhadoes such .rffinomhrosgM1 his CO C.GROUP RES.UNITS
wperty wholmilds rim thansuch imprdvememo areeatch work mofferedfm.ue.If,
however,the building or improvement is sold within one yearo(completion,the owner- TOTAL:
huddler will have the burden of proving that he did not build or improve for purpose of
aale.),
❑ I,as ownerofthe property.am exclusivelyconuactimg with licensed contractors to QTY. PLUMBING PF.RMI'I' FEC FLOOD AF'N
construct the project(Sec.7044,Business and Professions Cede:)The Contractor's
License Law deviant apply loan manerorproperty,whobuiids orimproves thereon,and PERMITISSUANCE /
wheemtmms for such Projects with a amuaator(s)licensed pursuant rode Cootracrors ALTER-DRAIN&VENT-WATER(G)
License taw. FEE S ARY
❑ 1 um exempt under Sec. ,D&P C bar Nia rteson BACK FLOW PROTECT.DEVICE. SANITARYr--N-
D
4 N
Owner Dam RECEIPT p
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATIONDBCIARATFON SCHOOLTAX YN
❑ ]h'Compeaffirm matlhave coraccateob consem it)pytherof(iee.380r LabC0eme of RECEIPT#
Wmker%Compemetian lnsumncemacenifiW copy thereof(See. CJ which PI%TURFS-1'PR TRAP PARK ITiE YN
covers uIl employec'e under thio permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RI?CEIPT#
Policy,* BUILDING DIVISION FEES
Company GAS-FA.SYSTEM OVER 4(EA) PLANCHECK PEE
❑ Ccmficdcopyi&hmebyfumds,I,
❑ CrnifiW copy is fled with the city iropcction division. GRPASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneednm be completed irthe Permit is farina hundred dollars($100) SEWER-SANITARY-SI ORM EA.2001M. ENERGY FEE
or less.)
I cenifythm bathe parmarramce of the work for whichthis permit is issued,lshall WATER HEATER W/VENDELECIR
not employ any person In any manner so as m become subject to the Workers' PAID
Compensation laws of Califomia. Data C57TPR SYSTEM ATING Dam Receipt#
Q z Applicant
z NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RES]DENTIAL PLM Ii. SQ,FT. TOTAL:
r CO) became subject m the Workers Compensation provisions of the labor Code,you must
R 7 forthwith comply with such provisions or this Permit&ball he deemed revoked. BUILDING FITE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby aBirm that there is u consuuctic n lending agency lob the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FTSE
Lenders Name PLUMBING ITE
E- lc der.Address QTY. l WCHANICAL:PERMIT 17FF
U I cc lify that I have read this application and sonic that the above information is
correct. l agreem comply with all city and county ordinances and state lows nearing,, PERMITISSUANCE MECHANICAL FEE
F' build; waion.and hereby authorize represenedives ofthis city to enter upon the CONSTRUCTION TAX
U ,z menti nal property for inspection papoees. ALTER OR ADD TO MECII.
(We) incem save,Indemnify and keep leas the City of Cupertino against
liabit ea,' s.costaundex ay in any way.ccrue.limmst said City AIR HANDLINGUNITG'O 10,000CFM)
in se encu of grunting t t
AIR HANDLING UNIT(OVER 111,000 CPM)
Slgnatumof ApplicanUComml Date E%11AUST HOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Duro Receipt#
Will the applicant.penurfumrebuplC Cost,Chapter
or huddle hamlth and aterialSafety
HEATING UNIT(OVER 100,000 BTU) TOTAL:
m defiredSc,by the Cupertino Municipal Cede.Chepmr 9.12,and the Health end Safety
Cade,Seetl 8532(a)'t
❑Yes ❑No VENTILATION PAN(SINGLE RUSID)
BOILER-COMP(3liP OR 100(100 BTU) ISSUANCE DATE
Will theopplicanmrfummse
re building necupuuequipment nrdevices whichem ,
it �I pp
Aimpassion;impassion;art contaminants.s defined by the BaA.y AAir Quality Management BOILER-COMP(OVER 100,000 BTU) r I D
District?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.lel'.
1 have read the hazardous materials requirements under Chapter 6.95 of the SEP 27 1993
California Deahh&Safety Cale,Sections 25505,25533 and 8534. T understand Nat
if the building does not currently have a tenant,that it is my responsibility to notify the
Oaeapam arms reyuirenrems which meat be met prior m is&ounce ora Certilicnm of chy Ur GUrth I INU
cc.p.ncy. ,
Owncr or mthorizod ager Date TOTAL: ISSUED BY:
OFFICE