25895 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO our e..-.:-m:FCrRICn. PERMITNO.
APPLICATION/PERMIT 25895
BUILDING DIVISION BUILDING PROJECT IDEN'TIFICA]]ON
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
I UNIT# LOT+#
O N' P CO ACfO " N✓ LI RK �:
✓\ N/C CON'TROLN
AR III
'CT
+ER: IC NO: A # El
Co CT: 1, BUILDING PERMIT INFO
i/1, •� QTY. ELECTRIC PERMIT PEE
BLDG ELEC7, PLUMB MECII
PERMIT ISSUANCE X ❑ ❑
LICF ED CONTRACTOR:SDF.CLARATION APPLIANCES-RESIDE IAL JOB DFSC O I
Oy�7 IhWFd'hc1
r,carder PmvisinnwfCM1ptar9(commencing with
�00F Sectionliusinc dmyliscme is in PANELS #Y (/ ffi'fffl//!'
��V full forcUPT0200AMPS �I� + �� �7I 1FZ W LieenseLic.p Wss y Qc. Datetractor 101-Io00 AMPS
F'z S D 1 A O OVER 1000 AMPS SQ.F .F �,RE'A $/50 i• .
ZOv,— 1ande,1 my pF sshull used.,publismemil, /AjI�S/ ��
CZ-0
P F; SIGNS ELECTRIC n
<Y7,� Licensed Professional I a 1`?4
Cm rJ,xQ OWNER-BUILDER DECLARATION I SPECLV.CIRCUCOMISC. ^—Q
J
K06U I hereby uffirm that I an exempt from he Committers L.iccom Lute for the
tn4�r�is following mason,(Section]031.5,Business and Professions Cale:Any city or county TEMP.METER OR FOIE IN ST.
which mymres a permit toc...mu t.alter,improve,dermich,or mind,any swnWE
ure POR DEVICES
X22 7 prior..its issuance,alm requires Neupplicam for such pemritto Bleu si,ceimement
y C G O that he is licensed pursuantto Be provisions of the Contractees License Law(Chapter SWIMMING POOL ELECTRICVALUATIO
o.ao� 9(commencing with Section 7W)ofDivislon 3 ofrhe Business and Professions Code)
W=m mind he is eeempOhrmfvai the basis fnr the alleged excandar.Anyviolatinn of
Permitl�.
Zr Section 9031.5 by any applicant for a Permit subjects the applicant to a civil penalty of /.) TS-SWITCHES-FIXTURES
es: not morcmM1unfivchundred
opery.ars($5m). �x lj RESIDENTIAL ELEC11t _ Q.FT.
CFo ❑ LasowtmrofmhepropmY•ormyemployees with wagau Neirwlecomprn• :P it// F S' RIES TYPE CONSTRUCTION
a3= and do Ncwons cod Ne he Coreisnnr',License Lawred forsale(Sec.9l�}'s`% 'av
'
and R.fessions Calc:The Cnmruanr'x License Law does nm apply D`�
prupcny whobuilUsor improves lM1erenq and who dux,such work hlm:•"> V�rtls
employees•Pmvided them suchimprovemenmsem nomimendeJ oror,�� sde.If, OCC.GROUP RES.UNITS
however,the building m improvement is sold within one yearnfcnmTleNm,the o� T
builder will have the burden of moving that he did not build or improve for Paris
t "QTY. I 1 C..e 'fIMB1G P&MI FEE FLOODZONE APN
❑ I,as owner,f NcPmpeny.am exclusively armruaing wimh licensed commie m
un.+oun the projat(See.]044.Business end professions Code:)The Co. cmalr,
Licenselawdcesnnrapplytoanownerofpro,nywhobuilds.f improv.Ne mid % si"M! 55 E
wmcontructs forsuch projects with aconpactods)Ilcalscdpursumttiodm Conmactor's A D ATER(G) FEE SUMMARY
License Law. p yqy
❑ I:mt exempt under Sec B&P C for lik o usnn BACK FLOW PROTECT,DEVICE O LSIDE FEES
C SANITARY Y N
Owner Date DRAINS •O# IIFA COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that i have 14inwre,oravcriGcam° FIXTURES-PEW RECLIPT#
Worker'C room ! }S of(Sec.3&sh Lab C.)wh' PARK FEIi N
I. .BIfTb
r GAS-EA.SYS .4 TL ' BUILDIN DIVISION PHI
PoI cy N
CmmPamy GAS-EA.SYSTF,M-OVER 4(• PLANCHF.CK FEE
❑ Certifie c y is hereby i.
S +INTE
Certified copy is fled wit rimy inspection division. GREASE%INUUSTRL WARCIiPI'OR GRADING Fl3E
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEF,
COMPENSATION INSURANCE
(1ltisxmi.n need net acon trod ifN<permit is foronc hundred dollars l510B) SEWER-SANIT -STORM EA.2a1FT. FNERGYFb-
or less.)
I.nifty thin in tl nncc.f�bew rg,FpCwhic{ 'sP ,Ishull WATER 111?A' tR W/Vf:NT/ELECIR
nw employ any per y m er w 4(�J��]'{, sl s orkess' PAI
Compensation Law C f e tea WATER STEMMEATING am Rampt#
C) z APPlicanm
NOTICE PP term rx Cd f f mmpmon, ush.uld NEW ESIDENTIAL PLMB. SQ.FT. TOTAL:
F-' rte.
bar onm sub' nNc orker's Cnmpe .tion pmv.+ons of the laWr Coda you must
> forthwith e 1 such Provisions at his pemdttshall be domed revoked. ILD G11iF: # /�
LL7 F CONSTRUCTION LENDING AGENCY SEISMIC Flit: O
z1 hereby affirm that then is a construction lending agency for the performance of
O he work fnr which this isns�d(Sa.309].CIv.C.) TOTAL: IiLECfRIC FE
lender's bards— �y,, PLUMBING IE
u" F lender's Addre IJLLA: QTY. MECHANICAL PERMIT FEE
V I ernify that 1 have rad Nix application and sum that the above information is MECHANICAL.Ap
>w H-1 correct.l agree to comply with all city and county ordinances and sure laws riming to PERMIT ISSUANCE
building construction,and hereby aumodm representatives of this city to enter upon me CONSTRUCTION
MX
(J Z a ,ve-mcnmioned propcny for inspection purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilities.judgmoms,c.msendeapenwswhich may in any way a¢meagalnst said City AIR HANDLING UNIT(TO 10.000 Cr
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10, CPM)
Signature of APPlicvnVComm Date PAID- PAID
I IAZARDOUSMATERIALSDISCLOSURE FI ATINGUNIT(TOI .l V) Date Receipt It
Wi 11 the applicant or future building occupant store or handle M1azmdous material ❑EATING UNIT(O iR 100,000 BTU) T 1
a,defined by the Cupertino Municipal Code,Chapter 9.12,and the Deadith unJ Safety
Csdc,Section 25532(a)? ���/// VENTILATIO AN(SINGLERFSID)
11 Yes PNo
BOILER- MP(3NPOR 100,000 BTU) ISSUANCE DAVE
Will the applicant or future building occupant use equipment or devices which emit Ifjt q I D
Journalists,air contaminants as defined by the EdY Arca Air Quulimy Management BOIL .COMP(OVER 100.(X1)BTU) Ir W
District? �/
❑Yes I - N' RESIDENTIAL MECH. SQ.FT. 7 t/yE
1 have read the hazardous mmcrials requirements under Chapter 6.95 thFEB _ " 1•��
Gllfnmla llealN&Safer Co ,Stmionn 25505, 25534. tun st dth
if.he building docxm yna.eamnanLt mspnnxibi't if e Cf1Y Ue CUrt . I
mcupam of Ne mq m bich must ct isRa e
OccuPwcy.
Owner ora rdugcnt
[)got
TOTAL: ISSUEDBY:
OFFICE