25563 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nu¢mNn—mwr AE PERMrr NO.
PLUMBING
CIIANI
BUILDING DIVISION APPLICATION/PERMIT BUILDNCPROIECT IDENTIFICATION 25563
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DAW,
OAu-qL,,L f UNIT# LOT#
OWNERS NAME: PHONE: CONTRACfONS NAME: LIC NO: N/C CONT'ROL#
e O Wis. M /
ARCHITECT/FNGIN.ER: LICNO: ADDRESS ❑
P -_ o z Sn e
CONTACT: PHONE: "3 d�� a Sl.s- ,�'Y T�'y,
pTY. EL�f?rCfRi PERMIT,#•y *'CAAvv FEE ' - "BUILDING PERMIT INFO
i .4011FA*d f ':.t"-P a BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Ihemhyafftmt that l am licensed underpmvisionsofChapter9(commmcingwith
190{�0[ Section 7000)of Division 3 ofthe Business and Professions Code.and my license is in PANELS - Q
Fry U Lj full force and effep *b rz/s��t_ }� t / e. /
<,, License Class SS Ma Lu,# 81 UPT0200ANIM
w=y Data mea s�—Contrnator 201-1000 AMPS
20r`&n� ARCHITECT'S DE ARAT N OVER IOOOAMPS SQ.LT.FLOORAREA $/SQ.FT.
O Z—p❑ I understand my plans shall IN,used as pu lie records.
qF ui SIGNS ELECTRICAL
�'i LicenseA lhnlbssinnal -
Fp,y a a
OWNER-BUILDERexempt
from
m the Cor TION SPECIAL CBtCUIT/INISC.
gXxOyco 1 hereby affirm that I an exempt from the Contractors e:Any
Taw for the
W 3 R
co following reams..(Serino.mirto]03L5.Business and Professions Code:Any city machine
TEMP.METER OR POLE INST.
which rcyuiresa pennino construct,nlsc improve,demolish,or repair any etmcmrc
priori its issuancgaho requires the applicant for such pemdsto filen signedastemem POWER DEVICES
pj Op that he is licensed pmarromm,he provismiro f the Connacht'.License law(CTapmr
o.6 a 9(commencin liSection700hof Division 3 ofthe Rminessind Professions Code SWIMMING POOL ELECTRIC
xo tz, exempt therefrom
) VALUATION
W_res
or he is 1.5 by aherefromend the basis for bjthe alleged exemption. civil pamItyof OUTLETS-SWITCHES-FIXTURP_S
Sermon ,b n five
hurdrelicollarsS 00). wbjectuhe epplicwnoecivil penalty of (�(�f
s mm orethenfivethapro dollars Weep.
a' � NEW RESIDENTIAL ELBCTR —SQ.FT.
❑ I,asownerafthemopeny,ornryempinyeeswith wages vs.[a(Sele compete mess Q S'I'OftIfS TYPE CONSTRUCTION
a will dothewons Code
The
License La a does of apply to an Business
end property
Professions Code:The Contractors License Taw don not apply tort owner of
own enywhobuimsorimphat euchimpmvcments on tintuch wdMmoffend
ork through his pp .GR DE S.UNITS
howemployebuildivi or impmamsent iovementhin neyear c moftion.theowforiale.if. a II
however,the building order of patent issold a within build of completion,thrower. TOTAL:
budder will have the burden of proving that he did nm build onmprove for purpose f ) -
sule). p Pe Y•amexclurvel contracting Ta-Y. 1+T �Pf:UMBINC-PPRMI'I!h "Pw°I?'e y +.: F1,00 O
❑ las ownerofthe ro n ycon g with licensed contractors ht Qy,.r ,t v,s _ 3tY}' IIc " � �N
construct the project(gee 7044,Business and Professions Ccde)The Con metma 't { l�
License Law does not.pplym anownerofnaperty whobuilds or improves thereon,and PERMIT ISSUANCE D ��
I 3
whocontraets for such projects with acontraosr(s)licensed pursuant to the Contractor's [A
License law.
ALTI3R-DRAIN&VENT-WATER( ) _ _ %;FEfs SUA1MARY''
❑ I am exempt under Sec. ,B&P C for this mason BACK FLAW PROTECT.DEVICE y .r 'SIDE ITES
SANITARY YN_
Owner Dote RECEIPT#
AREA
ROOF
FLOOR
DRAINS- . , ,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N_
—91,hereby offs that 1have acertificate eofconscon
py the of(Sec,38 o.Lab C.)which
RECIiIPI'M
FIXTURES-PER'fRAP
Workers'Compensadnn lwurancemueenificd copy thercmf(Sec.3800,LnFCJwhich PARK FEE YN_
I�co ersallem to e' apder this.ncmtit. RECF.IPr#
Policy# Wcla,0 t� ' GAg-EA.gYST1:M-I INC.40IITL[f5 '
BUILDING DIVISION FIiI35
Company Cf "" GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK PEE
❑ Cenified copy is hereby fumishM.
Certified copy is fled with the city inspection dmvmsmon. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This uctiennealmn barempleted ifthe permit is force hundred do[].($EXh SEWER-SANITARY-STORM EA.200FT. ENERGY FEB
orlees.)
I certify that in Ne performance of the work for which this permit is famed.i shall WATER HEATER W/VF,NT/F.LEMR
not employ any peraon in any roomer so m to become subject he the WorkersPAID
Compensation Lawsof Celifomme. Data WATER SYSTEM/rREATLNG Uma Receipt Q Z Applicant
Z 2 NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
In becomesubjectto me Workers Compensation provisions of the Labor Code,you must
a ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
a (] CONSTRUCTION LENDING AGENCY SEISMIC Mr.
Vz I hereby affirm thnnhem is a construction lending agency for the Performance of
O the work for which this permit is issued(See 3099,Civ.C.) O' ELECTRIC FEE
Landers Name woI�
0 F Lenders Address 2f' x �A16CIIANICAL`PERfviIT o r .FEE• PLUMBING FEB
U I candy that 1 have read this application and ass that tEe above information is >% w"'F "a' d"'r* A t d
�"' 0. correct.l agree to comply with all city and county ordinances and state laws relining to PERMITISSUANCE MECHANICAL FEE
F' pj building construction,and hereby rommiu apreunutiv<sof thirtity mentor upon the CONSTRUCTION TAX
U Z above meminmedpropeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hamiless the City of Cupertino against
iabilities,judgments,costs and expenses which may in any wayaccmeagainst said City AIR HANDLING UNIT(TO iEfIB CFM)
in
consequence of t e granting of this permit.�J
( AL'4 W - I.7A
reAIR HANDLING UNIT(OVER IO,IX1(I CFM)
Sig ofA plicam/Contractor J(Q+••/V__' I Dite EXHAUST HOOD(W/DUCn PAID
IIAZARDOUSMAW..RIALSDISCLOSURE HEATING UNIT(TO 100,000 BTU) ZBYI
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupenina Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)Coda,Section 25532(x)?
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
Ask BOILER Eilli a lican[arrfummbuiliin COMP(3NP OR I(1,0008TU)e pp goccupentnxeyuipmenmrdevices whichemitusaircnn[minams as deEned by the Bay Are.Air Quality Management BOILER-COMP(OVER 10.1100 BTU)
❑Yes ❑No NEW RESIDENTIALMECIL SQ.FT.I have rend Me hazardous materials m1mminems under Chapter fi.95 of theCalifornia Health&Safety Code.Sections25505,25533 and 25534. 1timentandthatif the building dons not cumemly have a tenant.that it is my responsibility to notify the wupant of the requirements which must be met prior to Issuance ofa Cenlficate ofOccupancy.Owna,mm0mfl edagent Date TOTAL:
OFFICE