25014 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING .L A' PERMITNO. 25014
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEN'J IPICATION
BUILDING ADDRESS: /I SANITARY NO. /APP+PLICAAlION SUBMITTAL DATE
19 q UNITN LOT# 1_ /1I
0 ERS R 11
t PII E' g1,11A OR's NAME: /I/�x / LIC NO��� — NIC V CfOM'fROL4
:�ARCIIITG 'PiNGINF.F.R: LIC NO: ADD RESS: L>q-" 01 S
a ❑
CONTACT: PHONE:
Q1-Y. ELECTRIC PERMIT ry.;E BUILDING PERMIT INTO
BLDG ELECT PL MECH
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRIPT
oneg I hereby affirmrhat l an licensed underprovisionsofC'hzpter9(commencingwith
PBOO Section i000)of Division Sof the Business-it Professions Code,and my lL«nse is int PANELS
PZW Lce11 nseCas `z Lic.# 6 5
--,,II�� UP TO 2001AMPS
mQy Date Conrrna�'fkkl9 201.1000 AMPS S((
Z.O rn 7� ARCIII'fF.CTOVER 1000 AMPS
S DECLARATION r Q.FT.FLOOR AREA $/SQ.PI'.
O Z_p I understand my plans shall he used as public records.
F.—Lj SIGNS ELECTRICAL r A
QCw'� Licensed lhofeasionel LE D
aay'' OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
A IN
X3F 1 hereby affirm the,I.m exam,,from the Commetor's Licenm Law for the
Ibllowing maxon.(Section]1131.5,Business and Professions Code;Any city or county TEMP.METER OR POLI?INST. p /I C
��o which requires a permit to contact, imprnve,demolish,or repair any swemre POWER DEVICES \V/� G
prior to its Maurice,aisorequires theapplicanl fmsuch permit m fleasigned statement
_ p
that he is licensed pursuant to the provisions of the Commences License Law(Chapter I
S 9(commencing with Section]1100)ofDivision3oftheBusiness and Professions Cadu) SWIMMING POOL ELECTRIC pp
�M,o or that he is exempt heremarn and the basis for the alleged exemption.Any violation of
f� a Section 7031.5 by any applicant for a permit subjects the applicant to Ol1Tf Ill's-SWITCHES-FIXTURES a civil penalty of
^� nor more ahs five hundred do)[.($500). NEW RESIDENTIAL ELIiC1R _SQ.FT.
X ❑ hasownttnfNepropeny,ormyemploy«swish wagesaa theirsolecampensaaion, STORIES TYPF.CONSTRUCITON
y322 will do the work,andthe saroctumisnot ancededoroffered forsale(Sec.T014,Business
and Professions Code:The Commemes Lieeme law does not apply to an owner of
property who ImIdsnrimpmves nhereon,and whodomianch work hintselforthroughhis OCC.GROUT' RES.UNIT'S
ownemployees,provided thin such improvementsumnot intendedoroffered hassle.If,
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 tut build or improve for purpose of
sale.).
❑ I,ssawnerofthepmpeny,amexclusivelycontmcungwirhli«nscdconlmctnnto QTY. PLUMBING PERMIT ITE FLOODZONE APN
constant the project(Sec.70vPL Buavess and Professions Code:)The
Camrecmr'I
License Lawdoes not apply to mtnwnerofprnpeny who builds or imprnvesdisc ,and PERMITISSUANCE
who contracts farsuch projects with a commeur(s)licensed pursuant to the Contractors ALTER-DRAIN&VENT-WATER BA
License law. ( ) FI7E SUMMARY
CI 1 am exempt under Sec. ,B&P C for this reason BACK MOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Data RECEIPT p
WORKMAN COMPENSATION DECLARATION DRAINS.FLOOR,ROOF,AREA,GOND. SC11GOL TAX Y N
I& Iherebyufr,.thur)have acenifcate of consent to self-insure.nraceniftcme of RECEIPT#
14 FIXTURE'S-PER TRAP
kers'Compensaaion lnsumn«macertified mPy thereof(gec.3M(NI,LebCJwhich PARK FEB YN
Covers all emrinYJ� yn this peJmir GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FE
Company -~' �)A/�T GAS-EA.SYSTEM-OVP.R 4IPA) PLANCIiF.CK IEE
❑S'inmul copy is hereby furnished.
Certified copy is filed with the city inspection division. GREASEl1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not b,completed ifthe Peoria is for one hundred dollars THRs) SEWER-SANITARY-STORM EA.2fM1I7. ENERGY FEE
mr less.)
I certify dun in the pedionance of the work for which this .all is issued,Is h.1 I WATER IIEATER W/VENT/ELECI'R
not employ any person in any manner so as to became subject to the WorkersPAID
0 O Compcnstarm Lawsof Califomie. Date WATER SYSTEM/IRFATING Dam Receipt at
Applicant
ZZ�I NOTICE TO APPLICANT:If,arm,ntskirgthis Cenificare of founnumm,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL;
become sobject o the Workers Compensation provisions of the Labor Code....mu at
lei ; loan.I th simply with such Provisions.,,his permit shall he deemed revoked. BUILDING FEE
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby aff rn thatthem is a construction lending agency for the performance of
0 the work for which this permit is issued(S«.31191,Civ.C.) TOTAL: ELECTRIC FEE
LI. ).�-s Leaders Name r
O t-' Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify thm I have read this application nod state that the shove information is
correct,l agree to comply with all city and county ordinancu and state laws minting to PERMIT ISSUANCE MBCf1ANICAL FEE
buildingeonstruction,and hereby amhoriam rtpse«motives of Nis city to eamrupon the
V z above-mentioned propeny for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)agree to save,indemnify and k«p hurmless the City of Cupertino against
Indilitics,judgmenla,coas and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,00)CFM)
in consequence of the granting dthis permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicanl/Cmiractor Date EXHAUSTHOOD(W/DULT)
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dale Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW,1Xq BTU
as defined by the Cupertino Municipal Code,Chapter 9.12,unit the Titular and Safety ) TOTAL^
Code,Section 25532(e)?
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will @etipplicanmrfmuru building occupant useequipmemnnleviceawhich antis
BOILER-COMP OHP OR 100,000 BTU) ISSUANCE DATE
haaardarr air commutations as dufined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
D'ISITCIT
❑Yes ❑No NEW RESIDFJ4TIAL Mf:CH. SQ.FL � h, p
I have read the hazardous mertrials rtquimatents under Chapter 6.95 of the ID
Califomiu Henna&Safety Code,Sections 25505,25533 and 25534. I understand that Q -#
if th�h,gdce'not curently have.annual,shut it is myrespmoibilityto notifyrhe /� �a ryuiremenu w �h must be mej prior to issuance of a C<aifimte of VI/�� ��2 3
OwthorisN em me TOTAL: ISSUED BY: r IYV