25731 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' - "' PERMITNO.
APPLICATIONIPERMIT PING PROJECT IDENTIFICATION
- 25731
BUILDING DIVISION BUILDING PROJECT IDENTIFTCATI(IN
BUILDING ADDRESS: /J / SANITARY NO. APPLICATION SUBMITTAL DATE
1115'5- 1 /1/6 UNIT# LOT
OWNERS ME:/ �PH.ONEL�O� is_ CONTRA OR'S NAME:c� hL$f-' ��� NIC C TROL1
ARCHITECT/ENGINELIC L5ICCN11O: OOYY _ D ESS(s ,GG�-- 9s- ❑
CONTACT: PHONE: QTY. f i ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB s ECH
PERMIT ISSUANCE ❑ ❑ ❑ IgT/MS
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
oaz Ihembyaff thail mliccnsedunderpmvisionsofaapter9(commeneingwith TOB]DESCRIPTION
WOO Section]000)of Division 3 of the Business and Professions Code,add my license is in PANELS
FW Licnse fall E Clnd elle L UP TO 2M AMPS
6 7ly License nCluxx t_7"_ Lic.k aw,�� UP-1000 AMPS
w,<n. Date b ^�r��4�Contractor 14 4 411 201
Z FON Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ,FT.FLUOR ARBA $/ML FT.
0 P_0 I understand my plans shall be used.public records.
P,Fy W SIGNS ELECTRICAL
gq .'.4.I Liceoaul Professional
Eo� OWNFR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XaU 1 hereby affirm that 1 am exempt from the Contractors License Law for the
W 3 a ti following mason(Section 7031.5,Business and Professions Code:Any city miscarry TEMPTE
.MER OR POLE INST.
F u'O Q which rtyuires a pemi r m comma,alter,improve,demolish,or repair any saucare
f WYE to its issuance,also the applicant for such tto file a signed statement
POWER DEVICES
K prior quires pp permi g
yp W<0 that he is licensed pursuant in the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC 6Ke� 9(commencing`+'ith Section 900(8 of Division 3 of the Business and Professions Code) V WTION
m orat he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F•Za Section 9031.5 by any applicant fora permitsubjats theoppticant ton civil penalty of
WEp not oras than Eve hundred dollars($500). NEW RESIDENTIAL ELECFR _SQ.F E STORIESTYPE CONSTRUCTION
aCFa ❑ Lmowncrtitheheropcny,ormyemployecswoffend orsalei(sole 044.8 sins.
3= and Pr thework,ande: etnmareisnot r's Liceed nse
Law does not
ply 9n 44.Nosiness v
and Professions Code: The Contractor's License Law does not apply to an owner of
pmpeny who builds or improves thereon,and who does such work himselfor through his
employees.providedthat such improvementsamnot intendedoreffared fortune.If, OCC.GROUP R UN 1S
however.the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not builder improve far purpose of
%ale.).
❑ I,asownerofthepropeny,amexclu%ivelyconvactingwiNliceasedcommaors. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
crmWct the project(Site.9014,Business and Professions Cade:)The Cmimmum's
License law does not apply roan ovenerofpropcny whobuildsorimproves thereon,and PERMIT ISSUANCE
who contmers fmsuch projects with a coommirms)licensed pursuant tothe Contractor's ALTER-DRAIN&VENT-WATER(EA) FEE AR
License Law.
❑ 1 um exempt under Sec ,H&P C for this mason BACK FLOW PROTECT.DEVICE EES
S TA N
Owner Dom DRAINS-FLOOR.ROOF.AS B, 'CV PTp
WORKMAN COMPENSATION DECLARATION SC W N
❑ IherebyaRrm that l have acenificam ofeonscnno self-insure,oracenificaeof FIXTURES PER TRAP ECEIPTp
Workers'Compensation Insurance or a cenifed copy themcf(Sce.3800,Lab C.)which P RK yi N
cover,all emp ee'gom• l� �+ �� GAS-EA.SYSTEM-I INC.4 OUTLETS RC
Pon,4 l- L BUILDING DIVISION PEGS
Company $ GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Cl Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATL OF EUIiMFFION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
('Oris section need not becomphned ifthc permit is forome hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
orIsof
I cenifythat inthe performance of the work for which this pemus is issued.l Shull WATER HEATER W/VENT/ELECTR
ors employ any person in any matter so as to become suhjecm to the Workers' PAID
Compensation Lavesof Califomia. Dale WATER SYS'I Izly fRFATING Dam Receipt#
O Z Applicant
z0 NOTICE TO APPLICANT:IL after making this Cieificam of Exemption,yoishorld NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-' become subject o the Worker's Compensation provisions of the labor Cade.you must
> forthwith empty with such provisions or this peons shell be domed revoked. BUILDING FEE
004 ~n- SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Z) z I hereby afPom that there is a consmuaion lending agency for the peraTmence of TOTAL: ELECTRIC FEE
Q the wad for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name
4L F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING HE
U 1 ccrify that I have read this applicamn and arare that he above information ie MECHANICAL FEE
>1 W correct. l agree to comply with all city and county ordinances and state laws refuting to PERMIT ISSUANCE
h N building construction.and hereby authorice representativesofthix city to Lyn CONSTRUCIIONTAX
U z above-memioned pra vim,for inspection puryoses. ALTER OR ADD TO MECIL
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judg ms,costsoon expenses which may in any way aermeagainst said City AIR HANDLING UNIT(TO IBM CFM)
or eo scquci of the grunting of In
_9`V�3 AIR HANDLING UNIT(OVER MOW CPM)
of Apptican move., Dam EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 103,0110 BTU) Date Receipt#
Will Ihmmpplieam of future building mxeupunt store or handle hazzNoun material IMATING UNIT(OVER IBOOM BTU) TOTAL:
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Salary
Code,Section 25532(x)'!
❑Yea ❑No VEMI9LATION FAN(SINGLE RPSID)
ISSUANCE DATE
Will thcapplicanm rr fuwm buildingnccupantuse equipmemordcviceswhichemit
BOILER-COMP(3HP OR 100.000 BTU) pp
hazallons air emineelnams us defined by the Be,Are.Air Quality Management BOILER-COMP(OVER 100,00)BTU) P A
DiarsO
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the leardoas materials re,tiremems under Chapter 6.95 of the NOV -8 1993
California Health&Safety Code,Sections 25505,25533 and 25534. I undersand that
if the building does nom entirety have a tenant,that if is my s,,,risibilily m notify the "
meapan(of the rewimmem%which max(be,mer He,to Isx.ana of.Cenifieate of CM Ut UUrtn I iin
Occtipaney.
Owner or amhomeed agent Data T F � : ISSUED BY:
OFFICE