25227 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOratill .-- PERMIT NO, rI C r�
APPLICATION/PERMIT PLUMB NO L J L
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
IiUII CAO R //(} Cf.
//��'' SANITARY NO. APPLICATION SUBMITTAL DAT
V V O LOT p
O S EI(A ` HONE: C A OR N M17 IC NIL CONTROI,#
RC ITIiCT GINEER: U LIC NO: AD W6V ❑
'ONTACI': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INPO
BLDG ELECT PLUMB MF.CII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DGSCRIYI'ION �ll
CZZ I hereby affirm that l am licensed underpmvisionsofaapter9(commencingwiN
Vas00 Sectiomeavd effgD�iivi�sion 33 ofthe Busincxsand Professions Code,andmy licensei'm PANELS
<" License Close-�1�L�Lic.p ? II((��Y�� "T0200AMPS
ashy Date Contac 1 ,\5 201-II%IOAMPS
1 ONZ. ARCHITECT'5 DECLARA I N OVER 1000 AMPS SQ.M.FLOOR AREA $/SQ.FT.
OZ—p 1 undersand my plans she]be used as public records.
SIGNS ELECTRICAL
�C4 Licensed l'rofasionW OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOe,U I hereby affirm that 1 am exempt from the Contractor's License Law for the
1+13 a et following reason.(Scminn 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ON; which requires a permit'.maltrac',after,improve,demolish,or repair any Monte.
Prior to its issuance.also requires the applicant for such pcnrduo file a signed statement POWER DEVICES
WCC 0 that he is licensed pursuant the Provisions of the Contractor's License Law(Chapter
�'cPt 9(commencing with Section of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W—N or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F-ZQ Seen.7031.5byanyapplicant for a permit subjects theapplicam ban civil penahy of
mol more Nan five hundred dollars($500).
S pmspery,orm In ceswith wages as lheirsolecom NEWRESIDENTIALELECTR S .F .
aN�o ❑ othe%or,andt t yemp y g ,Busies __SQ.F TYPE CONSTRUCTIOD
3=° will dotheandthe he Cortcructure ismot's License
Laaetd fond aMty to an owner
and RofessUns Code:The Comrac'ds License Luw does not apply m un owner of
own progenyloyces ldsnrlmproves'hercon,andwho doesinchwork tended orofficied forsidhhia
employ,buddingor i provement is vements menet earmfomplecred theove.if, OCC GROUP RES.UNITS
however,th<avet eburimprovement issoldwithinoneyear or improve
omm efortheowna-
m1c.).rwillhavethebuMenof that he did mol build or int TOTAL:
pmvin8 Prove for purpose of
s le.). TY. PLUMBING PERMIT
❑ Las the Project
tSce e7 amexduss and
The Contractor's
Q FEE FLOOD LONE Aped
construct the project(Sec.o an o Business and Professions Code:)The Contr n,and
who comawdoeana apply manowncrofpropertywhosed paorimt tompCeseon,and PERMIT ISSUANCE
who Law. ALTER
with acentructnr(s)licmud pursuanuothc Convacmr's ALTER-DRAIN&VENT.WATER EA FEESUMMARY
License Law. ( )
❑ 1am exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O t$IDE FRES
SANITARY YN
owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL.TAX YN
❑Workers'
pensatthat nInschave o ora mint witnessed reof(insure,a Lab C.)c which
FIXTURES-PER TRAP RF.CEIPTp
Worked Compensationrm lo,cenracenified empythereof(Sca3tl00,Lab CJ which PARK FEE Y N
comes all cmployce's under this pcpn�t��t�I�-l-"f!_O GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIfTa
Policyk� l �]T� 1 6 BUILDING DIVISION FEES
Cumpany�� GAS-EA' TEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copyw hereby famished.
❑ Caned copy is filed with the city inspection division. GREASE U PTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
('Otis when need not becompletd ifthe permit is forone hwdred dollars($100) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
os less.)
I verify that in the performance ofthe work for which this primit is issued,i shall WATER HEATER W/VEN/ELECTR
not employ any person in any mariner so to to becosen subject to the Workers'
PAID
O z pplimsation lswa of Celifomia. Doe WATER SYSTEM/IREATING Dec Receip'M
A
zC) NOTICE TO APPLICANT:If,aftermaking'his Cerificumof ExemptionyoushouldgRMID�IALME. SQ.Fp. TOTALVJ became subject to the Workers Compenation provisions ofthe Labor Code,you mustforthwith cumply with such provisions a this pmard,chall he decmed revoked. BUILDING FEF.CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm Nat them is a construction lending agency for rie perfortnarce of
U O the work for which this Permit is issued(Sm.3WO,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
ULmdee,Address ALPERMIT FEE PLUMBING PEE
WI cenify Ihm 1 have rind this application and state thin the above information is
correct.l agree to cumply with all city and county ordinanees and state laws relating m MECHANICAL PEE
N building construction,and hereby authorise representatives ofthis city'oenter upon the I
U z above-memtiund property,for inspection Purposes. ALTER OR ADD TO MECH. COF"—
X
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmen's,costs and expenses which may in any way accrue agates,said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of Ne granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Gsnumctor Da'e EXHAUST HOOD(W/DUCT) tPAI ?�C oHAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.000 BTU) Receipt
Will the applicant nr future building occupant store or handle haxallous maarial
associated by the Cupcom.Municipal Cde,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Care,Sam.M532(a)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will Ne um lintanmr..runt building occupant use equipment m deviees which emit
BOILER-COMP UHP OR 1(X1,000 BTU) ISSUANCE DATE
rdous air contaminants az defined by Ne Bay Area Air Quality Management
Noric'? BOILER-COMP(OVER 100,0(10 BTU)
Din
❑Yes ❑No NEW RESIDENTIAL.MECtI. 5Q.FT.
I have mad the bcrandous materials requirements under Chapter 6.95 of the f/x
Culdnerm Health&Safely Cdc.Sections 25505,25533 and 25534. 1 undersand that
if We built' g James oat currenthave a tenant, tat i'is my msponaibiliry m ramify the
occupants 'he requirements"Inc mush t prior to' uanc�e(a Cenifica'e of
fx pane
Ownc ora..on
zd age Dam TOTAL: I$