25642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOIL I. -EL CTRI AL PERMI'PNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2
n C C n
BUILDING PROJECT IDEN'TIFICAI'ION' G J v L� G
BUILDING ADDRESS: �� //�� \'�` ���y�/'� SANITARY NO. AFPLICA'DUN SUINUTTTAL DATE
I Oq ` �WWJP UNIT# LOT# _C10.3 L
OW 'RS NAME: _ PHONE: ACT SNAM�EE: � .1 TIC NO 4�
O N aa�62t -s�-2Y4 ANJ/� RO✓J� yo �� NIC CONI'ROLp
A CHITECT/ENGINEER: LIC NO: DDRESS: ❑
JONTACf: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALrYa�yN TOR DESCRII'T )N
OZ I hercbyaffitm that l am licensed under provisions of Chopter9(commencing with / Aw
P02 Section 7000)of Division 3 of the Business and Professions Came,and my license is in PANELS
TY"R
FCUF full force and effect. J 1 `
F6ZUV1 I-are
nu�Cl��aagg��—LIC.a UPT0200AMPS
w<d Dam/J�Comracmr 201-1000 AMPS
ARCHITECTS DECLARATIONSQ.IT.FLOOR AREA S/SQ.FT.
ZOvt-
1 understand my plans.shall le used as public records. DVER IOW AMPS
_oz-o
til SIGNS ELECTRICAL
Liccn,uJ Professional '
OWNER-BUILDER DECLARATION SPECIAL CIRCUI'ONUSC.
XC W U E hereby affirm that 1 our exempt Ismailia Conmacnr's License Law for the
3 a on following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F-0 Q which requires a permit to construct,alter,improve,demolish,or repart any swenrc
,WY7 prior to its issuance.also requires to applicator for such Permit o file a signed statement POWER DEVICES
ca, <C) that he is licensed pursun
ano the provisions of the Contractor's License Law(Chapter
u Ko4 9 leomncormg with Section]OW)of Division 3ofthe Business and Professions Cede) SWIMMING POOL ELECTRIC VAlpp'@gpl,
m—mro or that he is exempt hemfmm and the basis for the alleged exemption.Any violation of
FZQ Section 7031.5 by an,applicai.
m for a Pere subjth
ectse.,pi tion to a civil penalty of OUTLETS-SWITCHES-FIXTURES
5 Gnomore un
r than five hundred dollars($500),
NEW RGSIDEN'DAI,BLECTR SQ.FT. STORIES TYPE CONSTRUC I'ION
ML ?o ❑ othe%oer andteSmmaoris ycmtendeeswithwed forsalei(Sec.compensation,
p'3=o will dothewons Cdd, structuress notiamndcde offeredfor
apply to car Business
and Professions Code The Contractorem.,and
Law rims not apply to an owner of
ownenywhobril&es.par orimpnvcs thereonandwhoacessuchwork himselfor through his
employees,Prov orithat such improvemcmeartnot iendedoroffeml for sale.If.
OCC.GROUP RES.UNITS
builder .,the building or improvement is sold a did cone year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sI
❑-I;as owner ofdhc propcny.am exclusively contracting withlicensed conuactomm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
nsauct the project(Sec.7(66,Business and Professions Code:)The Contractor's
vPERMIT ISSUANCC
License Law does not apply to an ownerofpropeny whobuddsor improves thereon,and
who contracts forsuch projects with o manowtor(s)licensed pursuant Comment's se Law.
License
ALTER-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ l am exempt under Sec. ,B&P C for this hours. OUTSIDE.F!FS
\ BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-FLOOR,RODE,AREA,COND. RECF;IPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm ueif
that T have a cenificate ofconm dosinsure,or a cenificii FIXTURES PER TRAP � RECI]PI'p
Workers Compensation Insurance ora cenified copy thercof(Sec.3900.Lab O)which PARK FF.F. Y N 'Q
all employee's under his permit. GAS-EA.SYSTEM-1 INC.6 OUTLETS RliClill'l'#
b,coresI
policy# BUILDING DWISION FEES
Crni'my r, GAS-pi, YS'1'EM*OVER6 E ) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. REA Ir \US xA$ �p C.1'f0 r GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP� /� rl " II u SOIISFEL
COMPENSATION INSURANCE _
(This section need not be completed fire permit is for one hundred dollars(SIM) SSEWER�SANITA Y S 1 ENERGY FEB
nr le".)
.Icenify that in the performance of the work for winch this permit is issued.)shall WAIWVJ.jTAWV1
noI employ any person in city manner so as to became subject to the WorkersPAID
Compensation Laws of Califomia. Date y^-WATERSYSTEIARREATING Dam Restart,,#
O Z AppliNOTE wt
Z 0 NOTICE.TO APPLICANT:IL afar making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,PT. TOTAL:
1--' IA become subject 1.the Worker's Compensation provisions ofthe labor Coda you must
forthwith comply with such previsions or this permit shall Its,deemed revoked. BUILDING FEE
WSEISMIC TEE
0.. Q CONSTRUCTION LENDING AGENCY
1 M1creby affrm,hm,M1erc is n consdmnion lending agency for the perfmmancc of
U O ,he work for which thisELVCTREC FEE
permh is issued late.307,Civ.CJ
Leaders Name
I'i' F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �r
V 1 certify that 1 have read this application and sere that the above information is MECHANICAL FEE
.�" "J correct. Iallee to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building commutation,and hereby audience nepresenteivesdthis city to enter upon the
V] CONSTRUCTION TAX
V edry enrioned property Ter inspection purposes. ALTER OR ADD TO MECH.
(W
f We)agree n save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments.cosec and expenses which may in any way accrve against said City AIR HANDLING UNIT(TO 10.0011 CFM)
amcyuenc ting his perms,.
o 0 AIR HANDLING UNIT(OVER 10,00)CFM)
ISgwmre of Applicant/Conus sur atet EXHAUST HOOD(W/IIUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the opplicam or future building mcup.,same or handle hazardous minimal OTA
as defined by the Cupcnino Municipal Cade,Cbapter 9.E2,and the Health and Safety HEATING UNIT(OVER 100,0110 BTU) pp��
Curie.Section 25532(a)'! VEN TION FAN(SINGLE RESID) Y� A FL
❑Yes ❑No
ISSUANCE DATE
Will theapplicant or prime buildingoccupann use equipmen,nrdevices whichemil BOILER-COMP QHP OR 100,000 BTU)
hazardous ale contaminants as definod by the Bay Amu Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District, ` c OCr 18 1993
❑Yes ❑Na NEW RESIDENTIAL MECH. SQ.IT.
a
I have d the hazardous materials requirements under Chapter 6.95 of the Ur `ur
du1:M111Vu
California Health&Safety Code,Sections 25505.25533 and 25536. E undersand that
if the building does not currently have a warm that i1 is my responsibility to notify the V/
occupant of Rat requirements which must be,met prim to issuance of a Certificate of
Occupancy.
Ow authorized agent Dau TOTAL: ISSUED BY7 :
OFFICE