25979 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R°ILo]Nc-erb'LTR - PERMIT NO,
APPLICATION/PERMIT PING RINU-MIIDENIICAI. 25979
BUILDING DIVISION BUILDING PNIIJBIa'lilEN'I'IFICA'1'IDS
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O UNIT# LOT _� /
ON
Ow S PHON[A. `L CO IRAC'1'OR'SNAM C LIC NO L/0%01
NIC CO 't
IIHECI'4NGINEER: r LIC NO:
pNESS: I f Je N QS
CONTACT: PHONE: ff``((,'�,.• 1 l.•
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MHCH
PERMIT ISSUANCE
LIC IiNSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
My.Z Ih7")eby ofrmthati amlicenBusinss and
Prprovisofessions
Code,and
mmecensewith
ulOp Section7")of DlvixinnJ o[tM1e Business and Professions Cade,and my license is In PANELS
1ty WE- fall fare-and-fleet.
FZw License Class Lic.# UP T0200AMPS Re , e
moa Dam Commcmr 201-1000 AMPS v
Fyz ARCHITECTS DECLARATION .G TIq.00R AREA SISQ.fT.
7C),,_ I understand m 1 shall be used ss public words.
OVER 1000 AMPS
OZ—O ypanss a
SIGNS ELECTRICAL
Licensed Professional
mQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
il' I hereby affirm that 1 an exempt from the Contractor's License Law for the
'+I+-orG following mamn.(Swim 7031.5.Business and Professions Code:Any city no county TEMP.MEfBR OR POLE INST.
which requires n permit to construct ober,improve,demolish,or repair any straaum
NYF prior It,itsissuancc.11a requires the applicant for such permit o file a signed statement POWER DEVICES
Q that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
4 SWIMMING POOL ELECTRIC
Edo 9(comhe isexempth Section]andthe basisionJofthe Business end.Any vote Code) VALUATION
onhm h7031.5 ymyaefmmand the Permitonhects the appexelicant
to..civil violation of OUTLETS-SWITCHES-FIXTURES
rya rimtiomthn five
hundred
lours ES50rnit subjects the applicanuo«civil penalty of
E90 not momthanrofthcroc ny,ormyem). NEW RESIDENTIALELECIR SQ.FT. STORIES NPI:CONSTRUCTION
CF ❑ I,asowneraRhepmpenY•nrmyempinyecawitb wages eatheinmlernmpensaton.
E. will do the work,sort tbenmca ,isnot intended.rmffered for ade(Sea 7044.Busineas
and Pmfasions Cody.The Contractor's License law does not apply w an owner of
property whobuildsor improves thereon,andododmus such workhimselfonhrough his OCC.GROUP RES.UNI IS
employees,ldingmJthat verrimpmsoldwi arenot intendedmoffered forsale.If,
however,the have
the bur improvement is hath a did
year or improve
omm a forn.t purpose
f TOTAL:
hale.). will have the burden of proving that he JiJ na build or impmve for purymu of
sale.). wmto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ m, he prafthepro. ny,70,4am eninesis said P ftoxigwithlicenmdconaact
Licensor the project(Sec.to an
nerolpu said Pmfasiona Code)Theova,Contactors
License Lawdcexnot apply moan mwnend'propcny who builJs orimprmves thereon,and PERMIT ISSUANCE 2, 0
whocontracaforsuch projects with a cormandfor(s)licrnsed pursuant m We Cinvacmrs ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 an exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FPES
SANITARY Y N
Owner Dat° DRAINS-FLOOR,ROOFAREACOND. RECEIPTp
WORKMAN COMPENSATION DECLARATION , , . SCHOOLTAX YN
❑ I hereby affirm that l have o Lcnifican ofcoment toself-insun,ora certificate of FIXTURES-PER TRAP RECEIPT
Workers'Compensation Insurance or a certified copy dremxof(Sec.3g)4 Lab C.)which PARK FEE Y N
coven all employee s under this permit. GAS-EA.SYSTIiM-I INC.4 OUTLETS RECEIPT 9
Policy#_ BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHF,CK HE
❑ Certified copy is hereby fumisheil.
❑ Certified copy is fled with the city inspection division. GREAS51NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS HE
COMPENSATION INSURANCE
Obis section need numbe completed ifthe permit is torose hundred dollsn UHOB SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or Ips.)
I terrify that in the perfomuntt of the work for which this permit is issued,i shall WATER HEATER W/VIIMLEC1'R
not employ any person in any mammr so p to become subject to the Workers' PAID
Gmghensation lows of Cnlifnmiu. Dam WATER SYSTEMMEATING Date Receipt#
z2 NO'T'ICE TO APPLICANT.If.after making this Confirm:of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
F' T/J beconu subject to the Workers Compensation provisions of the Labor Cede,you must
forthwith comply with such provisions or this penrdt shall be deemed revoked. BUILDING RiE
QSEISMIC FEE
COCDON LENDING AGENCY
I hereby affirm Nat Boom
m I,s a corm ee 3 lending agency for the performance of
U O the work for which this permit is issued(S(Sm.J09].Civ.CJ TOTAL: Q f ELECTRIC FEE
Lender's Natne
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE a PO
U 1 certify that 1 have Thad this application and state that the above information is MECHANICAL FEE
>^ W correct.i agree to comply with all city and county ordinances and state laws totaling to PERMIT ISSUANCE
building construction,and hereby unhorse representatives ofthiscity to enter upon the CONSTRUCTION TAX
UZ above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iinbifties,judgmenu.cnstsand expenses which may in any way reemeagvnst mid City AIR HANDLING UNIT(TO 10,000 CFM)
inconsequence of the granting of this permit.
AIR HANDLING UNIT(GVHR I0.000 CFM) ��.'t(-��/
Signor of Applicant on tar Dau EXHAUST HOOD OVIDUCT) PAID I/]— //--r/t��1��
HAZARDOUS MAI HRIAIS DISCLOSURE HEATING UNIT(To 100,000 BTU) ""° ftcccipmp
will the applicant or!mart building occupant storm or harMle hazardous material V
as defined by the Cupertino Municipal Grade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.00EBTIH TOTAL B e
Cate.Section 25532(x)'1 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant orfmurebuildingmccupnt usecquipmenmrdevices which emit BOILER-COMP(JIIPOR 100.00013TU) P e t D
hmallous air contaminants as dcfned by the Bay Ana Air Quality Management BOILER-COME(OVER 100.000 BTU) }�
WHO? Q 'Io(�C
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.P. APR V IJJdJ
L
read the hazardous materials requirements under Chapter 6.95 of the r
wlth&Safety CW c,Scnions 255U5,255J1 unJ 25534. IunJctaavd thatV11 rg does nm currently have a tenat that it is my responsibility m notify the ser �urarl 1 IND
the requirements which must be met prior to morose of a Certificate of
I,�borixed agent Date TOTAL: ISSUED HY. •`Vt'"f'�r
OFFICE