25387 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHIm:Hills- .EL MICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL C O O
BUILDING DIVISION BUILDING PROJECT IDEN'D FICATION J J o
BUILDINGyAADDRES E.
o SANITARY NO. APPLICATION SUBMITTAL DAT
G U V/✓ UNIT. I,OTN
OW F SNAME: ONE CONTRACTOR'SNAML': LIC NO: (V
B/ NYC CONTROL#
ARCHITECT7ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: 1 ?,;I }' - HUII:DING PERMIT INFO
QTY. - X+ ELECTRIC 'FEE
' BLDG ELECT PLUMB MF,CII
PERMIT ISSUANCE ❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nozz I hereby affirm lust l em licensed under provisions mChi pommencingwith JOB DESCRIPTION
r-00 Sectiou'll")of Division 3 ofthe Businessand Professions Code,andmyliceremis in PANELS
1W Full Force and t �y
QZW License CIn Lic.p S�Q UP TO 200 AMPS R
ILL-
ISD? D.IC.'.B ECTtrS D1 C^ 201-I"AMP$
0z ZqZ ARCIfITECTS DECLARATION OVER I"AMPS
$/SQ.IT.
O Z—G I understand my plans shall be used as public records. IWC AA
W SIGNS ELECTRICAL
Licensed I'ndessinnul
L� Q OWNER-BUILDER DECLARATION SPECIAL CIRNIT/MISC. 11�II'I
XaOaF I hereby affirm that 1 am exempt from the Cosions Co License law for the t
1 5 which following beaoa permit
to constr.Bua1tc,.simprove,demolish,
h,or Code:Any city oronunty TEMP.METER OR POLE INST.
Cern whichits vemn.elmil town theblolter. d for suite ematt,orretid,reany
tatememachine
Ke5<0 pnortoitiensedpursuant to the
thevisios of the ContrminoLiease La statement POWER DEVICES DATE
y(C p that he is licensed pursuant b the provixions of the Contrecbrs License law(Chapter
d p 9(cnmmencing with Section 70M)of Division 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
—m Stent 7031. byanmpt y refr.mand the basis farthe
etsalleged exemptlnn. civil l rby of OUTLETS-SWITCHES-FIXTURES
CZG not non103L5ivehu dyed d.ntfm$500). subject the epPlicenuoacivil penmry of `J
not morethanfivehundreddollenyemp. NEWRESIDENTIALELECIR 5
qC o ❑ Les work,a the sperty,ormottrou leeswith wegesastlei(See7ompBusiness —SQ.FT. STORIES TYPE CONSTRUCTION
°'r will dothnsimis adtheToeCureiactotsLicesed e offereoesout ppl,,.an am,,
and Dmf h.bs Code:The Contractors License Law does not apply 1.an owner of
ownp. crtywhob.porvi imphat Inch emagandwhndaessuchwmkh offeor for sale.
OCC.GROUP RES.UNITS
tun employees,provided that Inch improvementoresolintendedoroffered forsale. rL
however,the
ave thngmimprovementisholdwithinoneyear or Improv for the.oso of TOTAL:
builder will have burden of proving that he did not build or improve for purpose of
sale.). :'a
❑ I,as ownerofthe property,am exclusively contracting with licensed contractors to QTY: ,PLUMBING PERMIT FEE FLOOD ZONE APN
consuuct the project(Sec.7044,Business unit Professions Code:)no Contractor's pFRMI'T ISSUANCE License Lawdoesnotapplytoanownsofprop ywhobuiIdsorimprovesthereon,and
who contracts for such projects with a cono-nctoga)licensed pursuant to the Corsnctoes ALTER P PEE SUMMARY
Locase Law, PA) -
❑ 1 am exempt under Sce. ,B&P C for This rcawn BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECE1Pf#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
e❑ Iherebyuffrrm that l have a certificate ofconsem toself-insure,orecemFIXTURES RECIIPT#
URES-PER TRAP
Warkebs'Compenxtion Insurance aracenified copy thereof(Sm.JB00,IabCJwhich PARK FET? YN
arsaIle loye�m_der 0lis rmi4 ` / GAS.EA.SYSTEM-I INC.4 OUTLETS RECEIPT
Policy# lL BUILDING DIVISION FEES
'c-1--Y—��� GAS-PA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
Cenbfierl copy Is hereby furnished.
Certified copy is filed with the city inspection division. GREASFF%INDUSTRL WASTE:INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRtP SOILS PEE
COMPENSATION INSURANCE
This senionneWnot be completed ifthe Permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.2WFC ENERGY FEE
or lass.)
I certify that in the perfix.re of the work for which this permit is issued,Isball WATER HEAT ER W/VENT/ELECTR
not employ any person in any mamter am as to become sub- to the Workers' S. PAID
Compcmmion Lawsof Celifomia. Date WATER SYSTEMJTREATING Date Receipt#
Q z Applicant
z NOTICE TO APPLICANT:If,after making this Cenibcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FI', TOTAL:
became subject to the Workers Compalsalion provisions of the Labor Code,you must
a forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aA CONSTRUCTION LENDING AGENCY SEISMIC HE
Z 1 hereby afi that there is a contusion lending agency for the pertortnance of
L) O the work for which this permit is issued(Sec.309,Civ.CJ TOTAL: -� ELECTRIC FEE
(r larder's Name
C L)) Lenders Address Address QTY, MECIIAMCALPERMIT ' ` FEE PLUMBING FEE
LI codify that 1 have read This application and arm that the above information is
I2-I covect. Iagree to comply with ell city and county ordinances and state laws reining to PERMIT ISSUANCE MECHANICAL FEE
h.ililm,nmxtbrod n, it herebyaathonze rcprescreatives.fthis city to enter....the CONSTRUCTION TAX
L) Z above-mentioned property for inspection purposes. ALTER OR AILD TO MECH.
(We)agree m save,indemnify and keep tombless the City of Cupertino against
{iinhii�litice,judgment,coatsund e ,mrxswhich may in any any sttmeagainatxid City AIR HANDLING UNIT 6010.000 CIM)
AIR HANDLING UNIT(OVER 10,000 CFM)
,/gnnwrenf ApplicanVContnaor pate EXHAUSTHOOD(W/DUCT)
(/ PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicant or future building occupant score or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the l lealth and Safety HEATING UNIT(OVER 100."BTU) TOTAL: S
Code,Section 25532(a)? ❑No VENTILATION FAN SING LLa RESID) to '
BOILER-COMP QHP OR 100,000 BTU) IS$ A C: ATE
Will the applicant nr fmure building a:cupnm use equipmenmr devices which emit '
harandom air conmminumc as defined by the Bay Arco Air Quvlity Management BOILER-COMP(OVER 100,000 BTU) OCT $5X993
District?
m
❑Yes ❑No NEW RESIDENTIAL MF.CH. SQ.FT. ,Y
I have mad the hamrdous materials requirements under Chapter 6.95.f the w CITY Vr UUrth i 114U
Calf1he uil health&Safety Cade,aveimts 25505,a it
and 25534. 1 undersand that nonfood '-
the building does urn cunently haven tenant,that it is my responsibility to fflem the
.pan of the reyuirements which must M met prior m issuence.f a Certificme of
.eaw.ay.
Owner m i mhonaed agent Data TOTAL: ISSUED BY:_
OFFICE