25677 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUU,InNr LLP. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25677
BUILDING PROJECT]DENT'IFICATION
BUILDING ADDRESS' Gtlll! l77AJO SANITARY NO. APPLICATION SUBMI'PI'AL DATE.
O fio ��/e /Y SIV/ v UNIT# LOT#
OWNS AME: PHOS: CONTRACTOR'S NAME: LICNO: N/C
/G L /✓�PSo.V - /S CONBOL#
R HIIECT/FI4GINEER: LIC NO: ADDR/ /41/4501'ESS-
/w le / 11CON'I'ACT: PHONE: Grl'1'RM /�
QTY. ELECTRIC PERMIT FER BUILDING PERMIT INFO
Bllp ELECT PLUMB MECH
PERMIT ISSUANCE �L1�('. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Mzz Thereby affirm thetlam licenudunderproviaiananfChapter9(commcncing with
PJOO Section 7000).1 Division 3o(the Business and Professions Code,and my license is in PANELS
CV full force and effect. IIP TO 200 AMPS
Gz, License Class Lic.#
vFi« Dale—Contractor WI-1000 AMPS
zOyaARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my plans shall to used m public records.
r w I SIGNS ELECTRICAL
Nj Licensed Hafusional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Xd O n V I hereby affirm Nat 1 am exempt from the Com rwe.License law for the W 3D,y following reason,(Section 7031.5,Business and Professions Code:Anycity or County TEMP.METER OR POLE MST.
C a OCo which require a fa mtit to consumer,alter,improve,demolish,sn repair any marcwre
!!n prier to its issuance,also inquires the applicant forsuch Fermium file aligned reatemrnt POWER DEVICES
�OK that he is licen.al pursuant the provisions ofthe Convectors License Lew(Chapter
op. 9(commencing with Section 7(108)of Divided 3 of Ne Business and Profeuions Code) SWIMMING POOL ELECTRIC VALUAT
W❑y or he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES I
�7,Y Section 7031.5 by any applicant for a permit subjects the applicant to a civil pi of ISO
aC not more than five hundred dollen(SSOo). NBW RESIDENTIAL BLECIR—_SQ:FT 1 VVV
uu11 `� ❑ ofhewrk,adtheSpucturemyempindedconf wage ortudei(Sm.7ompBusinen, S'TORIFS TYPE CONSTRUCTION
a will dOthewmk,and the IM Commencernot Liven a Law conferral sin apply
to ap Womr a
and Professions Cade:The Commencer Licence Law domain apply to i owner is I
LJ I
pntpeny wyear,prom impnweath impar mtdwhodassuclt wmderof lfonhrnugh his
ownem It eer,p building
ori improvement
'�- - \ I OCC.GROUP RES.UNITS
p y prov<mrntserenm imrndedaoffered(orale.If.
huweer Will avetn holds. pmentiss.t he diinet bon one r or improve fa,theowner TO
builder Will have the burden of proving llmt he did not build or improve for purpose of
❑ 1,asuwncndtheproperty,nm exclusively convecting with licenuJ contnemmto QTY' M/AT E FLOOD ZONE APN
cormuct the project(Sec.7044,Business and Professional Cade:)TIo,Contractors ERMIT ISSUANCE
License Lu w does not apply than owner o(ppe
rorty who builds or improver thereon,and
who contracts mrsuch projects with aconuacwrts)IicensedpumuanOothe Contmctoes
License Lew. AL'T'ER-GRAIN&VENT-WATER(PA) FEE SUMMARY
OUTSIDE MES
❑ I nm exempt under Sec. ,B A P C for this mason BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dau RECEIPT#
DRAINS-FLOOR,ROOF. COND.
WORKMAN COMPENSATION ONDECLARA'f10N SCHOOLTAX Y N
❑ Ih*Corro alationtlhevea ora certcafc copy
PER RECEIPT'#
Workehe'Compcnsation Insurance oracerifieO cnpY Nereof(Sec.3800.lab C.)which FlXTURFS- PARK FEC? YN
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 0UTLEfS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA'.SYSTEN-OVER 4(HA) PLANCHECK FEE
Ccrified copy is hereby fumishal.
Certified copy is filed with the city inspection division. GREASEINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This ambimmam not be completed ifthe permit is fdere hundred dollen($100) SEWER-SANITARY-STORM BA.200FT. ENERGY FEE
or less.)
I certify,that in the pedmmaream'de work for whichthis permit is issued,l shell WATER HEATER WIVENT/ELECTR
not employ any person in any mount so as w become subject to the Workers' PAID
Chmpevmion laws of Celifamia. Dam WATER SYSTEM/IREATING Data Receipt#
0 Z Applicant
0- NOTICE TO APPLICANT:If,after making this Cmifmaul Eaemption,you should NEW RESIDENTIAL PLM. SQ.FT. TOTAL:
V) become subjecno the Worker's Compensation provisions ofthe Lsbor Code,you must �.
; forthwith comply with such Provisions or this pemdt mail be deemed revoked. BUILDING PEE
Wt-1
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
C� I hereby affirm that there is a Construction lending agency fa the perfantuna of TOTAL: pECTRIC FEE
O the work for which this permit is issued(See 3097,Civ.C.)
tr Lenders Name
Ur Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that E have read this application end shite that the about information is
correct I Agra In Comply with all city and county OWinaacea erat SUM laws other,1. PERMIT ISSUANCE MECIIANICALFEE
rA building construction,and hereby authorize representatives ofthis city theater upon the
U Z uhove mentlooed property for inspection purpores. ALTER OR ADD TO MSCI I. CONSTRUCTION TAX
(We)agree to save,indemnify shat kap humleas the City of Cupertino against
Nimbi lines.jndgmems,assts andexN swhichmay ima
n any way aceegaid 0 CF
ainsuCity AIR HANDLING UNIT 10,00M)
co uyu fthe gr bngof Perms /// f AIR HANDLING UNIT(OVER 10,000 CFM)
ignawmof Applicantn nor oDem ( EXHAUST HOOD(W/DUCT)
PAID
fAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt as
Will the applicant in future building occupant store or handle havrdons materiel HEATING UNIT 100,1X10 BTU) TOTAL:
is defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety .w
Code.Section 25532hu? VENTILATION FAN(SINGLE RFSID) I A
❑Yea El No qq
BOILER-COMP(3HPOR I00.0NBTU) Oct ISSUANCE DATE
Will theapplicant nr(evert builJingoaupantuuequipmemordcvireswhichemit 'tvs((l�� ��
hazardous ab contaminate as defined by the Bay Arta Air Quality Management BOILER.COMP(OVER 100.0W BTU) ' L
Diamet? c�rY�r (� 1993
Cl Yes ❑No NEW RESIDENTIAL MECO. SQ.FT. G�Pit. Cry`
I have read the hazardous materials requimmems under Chapter 6.95 of the r•
Culifomin Health As Safety Code,Sections 25505,25533 end 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior b issuance of a Certificate of
Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY: