25690 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDI .- .L.CTRI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25690
J 5 (]O
BUILDING PROJEC1'IDEN1'IIO
' PICATN GJ J
BUILDING AUI)RFSS: — SANITARY NO, APPLICATIONSUBMITTALDATE
ITP LOT# (0-40
OWNI' Ii: ` PHONE: C NTRACTOR'S NAME' I \ LICN N/C CONTROL#
•'EC IIITLCT/I:NGI F.F.R: LIC NO: ADORES �Gc,SCZrJx'ti ❑
CONTACT: PHONE: QTY. I`ll ELECTRIC PERMIT FLEE BUILDWO PF-RMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OIYZ I hereby affirm that l am licensed underprovisiousidChapier 9(commencing with JOB DFSCRII'J'ION
�a100 fail force
oreODit affectDivision 3of the Business and Profevions Code,and my license is in PANELS
Licar rceandettca. st UPT0200AMPS
<Z uuII License Clss3�p--�--�—Lic.N
y<4 \D— Contractor P�17 201-11100 AMPS
ZOvs•—
ARCHITECTS DECLARATI N IOVER 10010 AMPS
SQ.FT.FLOOR AREA S/SQ.FT.
O Z_C) I understand my plans shall be used apublic records.
Fm W SIGNS ELECTRICAL
, Licensed Profaminnul
y. < OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
Q. I hereby affirm that I nm exempt from the Commemes Lirense Low for the
3111 fnllowingreason(Sectina703L5.Business and Professions Code:Any city memory TEMP.METER OR POLE-INST.
Oy which reyuiren o Permit to construct,alter,improve,demolish,or repair any structure
Y� mitsissuance,also the applicant forsuch Permit file a signed statement POWER DEVICES
prior nt to the
pp pe g
<p that he is licensed pursuant to the provisionsar Ne Ce Business
License Lew(Chapter
n.y Y with Section TfpO fDivixion3o(Ne Business enJ l'rofessiom Code SWIMMING PO0I.ELECTRIC
o�' (can]to ingwi )o ) VALUATION
ty`z]
or 703
3exbytiny rcfromand the beradt sujeans the
to civil Family
of OUTLETS-SWIT'CHPS-FIXTURES
�Q Section more
ID3nfiv hundred
lieu[fora Permit subjats the ePPlicnm mecivil penalty of
t] C1momthan Ovehundreddoll�nyempl NEW RFSIDEbITIALELECTR 5 .fT.
� m ❑ 1,azown<rofN<propeny,ormycmployceswithweges sat hei(Sce.7ompenmtion, Q STORIES TYPE CONSTRUCTION
ywill dothewons aidCode 'Ile aureisnotinmndnas La does
notaply to an Business
uM 1'rywhons ldsori pr Cnmredors License Law doaa such
not apply to an owner of
propenywyees,pdsorimprovesth improvndwho accord ctanded rofficor formicaugh.If,
OCC.GROUP RES.UNITS
ownemployces,providedthatauehimprovementsarenotintendedoroffered far Tris. r.
however,the buildingorimprovemem is sold within one year of completion,the owner-
ble.). will have the burden of rovin than he did nm build tar improve me of TOTAL;
p g pnry pure
sale.).
❑ 1,as ownerofthe progeny.sin esdusivelyconuacting wiN licensed cammcmrsm QTY. PLUMBING PERMIT FEE R OD ZONE APN
construct the pmject(Sec.90W,Business end Professions Code:)The Contractor's PERMIT ISSUANCE:
License Law diesnnt apply to un awnerofproPeny wholumidsorlmproveathercon,ens
whit contracts for such projects with a comramor(e)licensed pursuantto the Controcmr a
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 and exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEV ICESANI'T'ARY Y DErEns
_N
Owner Date RECEIP`J#
IN OR, P R A,C N .
WORKMAN COMPENSATION ofcNDECLARATION SCIIOOLTAX Y N
❑ em'Cyuffirm ton Insurance
cncenbrie commat pythe id(SReff-insure,m Lab C.)ale ofwhich FIX`I RE -PC T P RECEIPI'p
Workers'CumpenemionlmumncemacenifeJ copy Ncreof(Sec.3fl00,Lab CJ which .'� PARK FEE YN
riverside.plrkvris,ugdpr,Rli5yermpi_�� i GAS yRk S • - C.4 ., S RECEIPT#
PolicyN 1 Olt s--I 7l] BUILDING DIVISION PEES
Cn y Q -Bp, 4 PLANCHECK FEE
nified copy is hereby furnished.
Cenifed copy is filed with the city inspection division. GREA TYINDUSTRL F.
WASTE INTERCEPTOR— GRADING EM.
CERTIFICATE,OF EXEMPTION FROM WORKIBil GRF.ASETRAP SOILS FEE
COMPENSATION INSURANCE
(11iis section need not be completed fthe permit is minis hundred dollars($100) SEWER.SANITARY-STORM PA.201l ENERGY FEE
or less)
I century that in the Performance of the work for which this permit is issued,l shall WATER HEATP.R W/VEhIT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Z Compensaion Lnwx of Calif,miu. Dam WAT'ERSYSTEM/FREATINO Date Receipt is
Applicant
OO NOTICETO APPLICANT:IL after making this Certificate of Eaemption,you should NEW RESIDENTIAL PLMB, SQ,Fr. TOTAL:
VJ become subjectto the Workers Compensation provisions ofthe Labor Code,you must
aforthwith comply will,such provisions or this permit shall he deemed revoked. BUILDING FEE
0. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz Ihereby affirm that them is o construction lending agency for performance of TOTAL: ELECTRIC FEE
O the work for wh ich this permit is issued(Sec.3097,Civ.CJ
{. ,r Lender's Name
O P Lenaer's Address QTY. MECIIANICALPERMIT FEE PLUMBING FEE
U I certify that 1 have read this applicmion and state that Ne above information is
r1" 4 coact. Ieareememnply with tall city anA county ordinances end stem laws rcleting to - PERMI'TISSUANCIi MGCIIANICAI.FE.E
building eonamuction,and hereby authorize repremetatives of thiscity toenter upon the CONSTRUCTION TAX
U Z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep hvmless the City of Cupertino against
liabilif meals,costs and expenses which may in any way memeagainstsaid City AIR I IANDLING UNIT(TO J0.00h CFM)
encs or the granting of th 't.
_ C lO q3 AIR HANDLING UNIT(OVER 10,000 CfM)
Ignamre of Appliermt/Contranor Dam EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Remipt#
Will the applicant or future building rampant more or handle hazardous materiel
es defined by the Cupcnino Municipal Code,Chapter 9.12,and the llaulth and Safety HEATING UNIT(OVER 100,000 BTU) AL:
Code,Scali 11 Y,eYes, ❑No
u)P
❑ VENTILATION FAN(SINGLE RISID)
Will lair contaminants
a i ants as building occupant ay Amu Air Quality
Management
BOILER-COMP(3HP OR 100,0X10 BTU) ISSUANCE DATE
• hazmdoua air 000tuminems us defined by the say Amu Air Quality Monagement
DtnricsT ❑Yes CI No BOILER-COMP(OVER 1011,000 BTU) - A 8
NEW RESIDENTIAL MECH.—SQ,FI'. q
1 have read Nc hazardous materials ruyuirements under Chapter 6.93 si theC. Car til8
ifthe uil Ing de&Safety Code.have
a namal,that
it is and 25534. 1 understand Na p�v
ifthebuildingrices nmcurrently haveast Im,,et itnmymspnceoila tonotifythe
Occupancy.p f the rcquirememe which man be met Orion to issuance of o Cenifica¢of CI I Y
�1 l
Owner or nmhorized eaem
Data ISSUED BY:
OFFICE