25805 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUn,mNc'anull ICAIHANIC . PERMI"F NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT CENnPICA 2 5 O O 5
NU11,131NC PROJRC'1'IDEN'I'IFICA'I'ION J o J
BUILDING ADDRESS:: t, SANITARY NO, APTLLICATIONSUBM2TALDATE
2 otwc, UNIT'# LO'I'N
WNERS NAME: PHO'NC: LJ QONTRACI'O 'S NAME: LIC NO;
SOIL f/�" J' GO 6 7.5-7(aD NIC CONTROL#
ANCIIITI'.CT/1?NGINEI;R: LIC NO: AgflRESS
^ .O q,l llctez /Q�' ❑
CONTACT: PHONE: QT N- Y W
QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
BLDG ELECT PLUMB MF:CH
PERMIT ISSUANCE 11T
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
yz I herebyafOrm that l am licensed underprovisians of CTopter9(commencing with OBDES�j-1�g
00 genion 7000) if Division3of the Business and Professions Cade,and mylicrnseis in ppNEIS
yffrr��II.� full fuse and if t. _
6uW Licenu LIC.N IIP T0200AMPS
y�y Dam Cantractdr 201-1000 AMPS
ZOsyirZ _ `�ARCIIITECTS DECLARATION OVER IfN)O AMPS SQ.FT.FLUOR AREA S/SQ.PT.
1 understand my plans shell be used as public records. (A, 1�
�N PJ SIGNS ELECTRICAL G N L E ® IN
Coe< Licensed Ftaf<saional OWNER-RUILDHR DECLARATION SPECIAL CIRCUR/MISC. /�MLED
)µ50y F 1 hereby Se that 1 am exempt from the Contractor's a License Law for le j' V\/� �'
t++31+-sn
following....(Sation?0]LS.Business and Profession Code:Myciry or county TEMP.S�fER OR POLE INST.
x V
viol which rcyuires a permit to construct,alter,improve,demolish,or repair my structure a
-} priormits issuance,Wso rcyuires the applicant for such permiuo fileesigned emmment POWER DEVICESnATF
O that he is licensed pursuant to Ne provisions of me communes License Law(Chapter
R' o� 9(commencing with Section 7fX)l of Division 3 of me Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
rxs of that he is exempt herefmm and the basis for me alleged exemption,Any violation of DUREIT-SWITCHES-FlXTURES
t } Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
<
nt mom 111..n five hundred dollars($500).
C o ❑ 1,nownemfineprnperty,ormyempinyeeswimwageees leirsolecompenauon, NEW RESIDEiNTIALELECB _SQ.ITE STORIES TYPE CONSTRUCTION
y3:a will do the work,andthe structure is not inteadedoreffered forsale(See.?044,Business
and Professions Code:The Corwcrors License Law does not apply to an owner of
property whobmildsorimproves thereon,and whodocssuch workhimselforthrough hisOCC GROUP RES.UNITS
van employees,prov ided Nat such improvements are nest i Dandled or offered for sale.If,
however,the building or improvement is sold within mayeafofcompletion,the owner TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
vale).
❑ l,asownendmepmpony,umexclusivelycmmraningwimlicensedcontmamsto QTY. PLUMBING PERMIT IEE Fl.00DZONE APN
construct the project(Sec.7044.Business and Professions Code)The Contractor's
Licenu Loved..noupplym anownerofpropeny whobulldsm imprevesmercon,and PERMIT ISSUANCE
whocnnwets for such projects with acoulanor(s)licensed pursuant mthe Commetors ALTP.R-DRAIN&VI'NT-WATER(EA7
License Law. PEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Chia mason - ID .FS
BACK FLOW PROTECT.DEVICE SANITARY Y_N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION ofere DECLARATION COLTAX Y N
❑ have orificamof o0nsentmse(Sec,re,0r Lab C.)which
RECf;IPfR
Worken'Com nsnion Insurance ars certified FfX'1'UNCS-PI?R TRAP
pc opy lerenf(Sec.Jg00,lab CJwhich PARK FEC YN
covers all employee's under lis permit. GAS-PA.SYSTEM-I INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Cmified copy is hereby famished.
❑ Cedified copy is Tied with the city inspection division. GREASP./INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CI?ROFICATE OF EXEMPION MOM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not becomplcted ifle permit is for one hundred dollars($100) CE50L SANITARY-STORM EA.20(IFL ENERGY ITS
esIr
Icert,int,that so in
an,mann r work for whim is Permit is do,Work ' WATER IIIA"FCR W/VCNT/ELEC R
not employ any person li any mariner so as to becoom subject m me Worker% pAlp
ComApplitant on laws of Celifomie. Date WATER SYSTEMfOlEATING Data Receipt#
Q C) NOTICE
Z 0 NOTICETOA to th.WNker'safiermakingmis Certificate of ofExemption,Labo,tiodr.youshould
not, NEW RESIDENTIAL PLMB. SQ,Pf. TOTAL:
lisom(n
forthwith
comply
with
Workers Cumns or s.
prmisionofleemed evoked, must
ai 1 fonhwim comply wit such provisions or mis permit shell be deemed revoked, BUILDING WE
in CONSTRUCDON LENDING AGENCY SHISMIC FEE
I hereby affirm that hem is a construction leading agency for the performance of
the work for which this permit is issued(See.34bG,Civ.CJ RLECTRIC FEE
Des lenders Name
F lender's Address QTY. MECIIANICALPERMIT FEE PLUMBING EEE
U I certify,that 1 have rad this application and nam art the above information is
correct.I agree to comply with all city and county,onirances and state laws relating to PERMIT ISSUANCE MECHANICAL ME
y building construction,and hereby amhorime representatives oflhis city banter upon the CONSTRUCTIONTAX
V Z above-mentioned pmpeny or inspection purposes. ALTER OR ADD TO MECU
(Wa)a5mv n nmify and keep hmmless me City of Cupertino against
liuhilitics,ju n dex n e hi hmayineny way acme rgninsaidCity AIR HANDLING UNIi'(T010,(1(IOCFM)
in corsuq g n ng >/ AIR HANDLING UNIT(OVER IgOOBCFM)
f
I amreof Applicar/Cormm�or Dam CXHAD$T HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE 1113 ATING UNIT ITO Ifq,1100 BTII) \\ Uam Receipt
Will the applicantw
or for=building occupant store or handle hadous material IILATING UNIT(OVER I00,W BTU) TOTAL:
x fined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
CsNe,Section 25532(n)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will meepplicumorfuwre buildingwcupnm use cyuipmenmrdevices whichemit
BOILER-COMP(MPORIM,M)BTU) ISSUANCE DATE
haaardon air contaminants as definW by the Bay Ana Air Quality Management BOILER-COMP(OVER 100,00)BTU)
'District?
❑Yes 11 No NEW RESIDENT JAL MCCIL SQ.FT. �nq�
I have read the hoar ms materials mummm<ms under Chapter 6.95 of the � 34 199Vn�f
Culifor in IEahh&Safely Code,Sections 25505,25533 and 25534. 1 understand that IV®
if the building docs not currently have a moral,that it is my responsibility to notify he
occupant of the requirements which must be met prior to issuance of o Certificate of CI IY ser Uurr 1I
Ownermumhmixed agent Dam TOTAL; ISSUED BY:
OFFIC