25526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECI RICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHAN'ICAL
IILDGIPROJECI'IDIrMIIFICAT'ION 25526 JCLC
DING ADD SANITARY A / SANITARY NO. APPLICATION SUBMITTAL UNIT
2 2 1 1 G C UNITW LOT#
OWNERS NAME: ð PHONE: C NTN ON'S AME: O
G O NIC CON IROL#
• RC -7 Ailekni
HI"1ECT/ENO NE[R: LIC NO: DDRESS� s ❑
CONTACT: PHON
QTY. BLECTIO ERMIT PEP. BUILDING PERMIT INFO
BLDG E PLUMB MLCII
l. ♦ PLRMII'ISEU C � �Ityl ❑ ❑
LICENSED CONTRACTOR'S D17C ON APPLI S ;SIDENTIAL
,zwz Iherebyaffimm that l am licensed underprovisions of Ch r9(commenci w h IDB DESCRIPTION
�i100 Section andaf Business and ltofessicnsG ,and my littn in ppfullo ��
y.ulC Licaa Class
P MAMPS
6U icense Clers Lic.# r
-*,-Z—
y
Data Contactor arIgs I 1"AMPS
zbr,— RCHITECTS DE'LARATI N Q .FOf�R B E/SQ,FT.
VER 1000 AMPS W!IB
CZ-0 1 understand my plena shall he used a public mounds.
frm(_W.y4 SIGNSIiLECRJCAL II�� //11 f�,�+k
Y26 Licensed Pmfessinnal M L'.aa A , li
ROX OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Yg VV OY 99 Ij� Ij
tr'OR 1 hereby affirm that I am exempt from the Contractors License Law for 'I
u�3ar1"r following reason.(Section 7031.5,Baines and Pnsfeasions Code:Any city or coupO TEMP.METER OR POLE INST'.
DATE
which requires a permit to commuct,elm,,improve,demolish,or repair any shoe x
2;!4(Yg preq
pro to its issuance,alsomuims the applicant for such permit au
o file a signed mmeat POWER DEVICES
a_Q O that he is licensed pursuant no the provisions of the Contractors License Law(Chapter
0'd%oK 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VA�LU8r
WZm Section
701.5 by thercfmmard the Permit sujeasegedexemption.Any.psh—an of OUTLETS-SWITCHES-FIXTURES (��♦1V+/\
F'ZY Section 70hum by anouLadcontfora Permit subjects the applicannoacivil penalty of
G oar moral
fivehmmdrcd Anllurs($SW). NEW RPSIDENT'IALELECTR _SQ.FT.
❑ I,uvownerofthc M(i<rty.rrmyemploymswithwagesustheirsolecompeaation, STORIES TYPE.CONSTRUCTION
0.33— will dothework,and the structure is not intended oraffered fnrsale(Sec.70 .Business
land Professions Cede:The Convectors License law does not apply to an owner of
property whobuildsorimproves thereon,and whirmas such work himselforthrough his - OCC GROUP RES.UNITS
employees,pmvidedthamsuchimpmvementsamnotintendedorofferedforsale.If,
however,the buildingor improvement is sold within oneyearofcompletirn,the owner- TO
builder will have the burden of proving that he did not build or improve for purpose of
,ad..).
[j 1,as ownerofthe property,amexclusively contracting with licensed contrlactoma to Q1'Y- PLUMBING PERMIT FEE FLOOD ZONE APN
onstmci the project(Sec.70,14,Business and Prafessims Code:)The Contreeme. PERMIT ISSUANCE
Licesel.awdoesnmupplymanownerofpropenywhobuildsorimpmvesthereon.md
whoconuacts for such projects with aconhactols)licensed purmantto the Contractors
License Law. ALTER DRAIN&VENT-WATER(PA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SI 6
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ em'Co affimion InsaveacertificateofconsennoselLinmre,or Lah C.)which
RBCF.IPI'#
Worken'Compensaion lnsurermceoracenified copy thereof(Stt.3gW,LeE CJ which FIXTURES-PER TRAP PARK FEF. Y N
covers ell employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Certified copy is hereby famished.
❑ Cenilied rnpy is filed with rhe city inapceimn division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMP MSATION INSURANCE
(This sectim eed not be completed ifmc pemmitis forces hmadred dollen Sloth) SI7WER-SANITARY-STORM EA.200M ENERGY FEI3
or Ico.)
I certify dot lr the perfmmarceofthe work for which this permit isbanned.ishall WATER HEATER W/VENOHLECTR
not employ any Person in any manner so as to become subject to the Weaken' PAID
Compensation Lawsnf Celifamia. Data WATER SYSTEMIMEATING Dam Rmeipt#
Q z Applicant
Z NOTICETO APPLICANT'1[eRermaking this Certificate of Exception,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
!•� to become Subject to me Workers Compensation provisions of the Labor Code,you must
ta•' ; forthwith comply with such provisions or this Permit shall he dmmed invoked. BUILDING FEE
LkI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I herebyuffmrm that there iso construction lending agency for the perfomnenceof
Q the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
L<nd<rs Name
PLenders Address QTY. MECHANICAL PERMIT FIDE PLUMBING FEE
IU1 certify that 1 have read this application and erste that the above information is
2a
como.degree to comply with ell city end county oNinanca and note lawuelating to PERMIT ISSUANCE MECHANICAL FEE
�-' building construction,and hereby anthanze representatives ofthis city to enter upon the CONSTRUCTION TAX
V Z bov
ae-mentioned pm
pamy far inspection purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep harmless,the City of Cupertino against
liabilities,judgmenh,coscrand expenseswhich may in any way seervengg#�r�i►CX AIRIIANDLINGUNIT(TOIQWOCFM)
ire conscyuemm<ofthegrantingofthi it. {A11/e(�00//
AIR HANDLING UNIT(OVER 14W0 CFM)
L7
nemrc of AppbcnnUCnmructar Data EXHAUST HOOD(W/DUCq PAID
it IATERIALS DISCLOSURE HEATING UNIT(TO 100,04(10 BTU) Date Receipt It
Will the applicant or future building occupant store or hurdle hazardous material IIFATING UNIT(OVIiR Ig1,oW PTU) lb L:
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Haulth and safety
Cek,Section M532007 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Willthea applicant orfuture buildin occupant um BOILER-COME QHP OR 100,000 BTU) ISSUANCE DATE
pp g em Air
unlit Man which g
humNous air contaminants a defined by the Bay Area Air Quality Managemcm 44 1 S 0
BOILER-COMP(OVER 100,0110 BTU)
DlstriaIT
❑Yes ❑No NEW RESIDENTIAL MECf1. SQ.FT. (kCe a zs 1
1 have mad the h urn-dous materials requirements under Chapter 6.95 of the H{SP 6 199
Celiforoia I Icahh&Safety Code,Sections 25505,25533 end 25534. 1 unden thr the —CITY 1
if cupant ding des noauents w have a ich must he mb prior my responsibility(if ty m notify the Ur wren l llV�\
Ote pant of she requirements which must be met prior to issuance of n Cenificme of s 'e�.�.-__�`�_`.—/gy�g.�a/�JF'
tkcuponcy.
Owner or automated agent Data TOTAL: ISSUED BY:
UE
i
OFF