25314 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B H.itl .-P...CTRI A PERMIT NO.
APPLICATION/PERMIT PLUM IDNG-MFIDENTCHANICAL 25314
BUILDING C DIVISION - BUILDING PN(SdKC1'' IFICA'fII1N
BUILDING ADDRESS; SANITARY NO. IIIAPPLICATION SUBMI TIAL DATE
Qo P e UNITO LOT 7-� �3
OWNERSNA 'I.- PHONE: RAC9'OR'S NA E: LIC NO: _`
t L� NIL CONTKOLIN
�AR IT IiCT/PNGINEER: IC NO: AD S:
CONTACT: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
B ELECT PL12MB ME❑CH
PERMIT ISSUANCE /� 'Ike-`y /1r/��/
LICENSED CONTRACTORS itSDECLARATION APPLIANCES-RESIDF.NTAI. `R=09�
Qmz I hereby affirm that l am licensed underprmisionsofChapter!)mommencingwith ��FOO Seaimecaud).f Divi' tot he Nosiness end l4ofasinns Code,end my lic<nu is in PANELS
y full tome recd a �1 �F
Fz Licenu Class c ` LIC.g {Oq 17`x- UPT02W AMPS
tFoad p�Cnmmnnr -e 201-RXIDAMPS
ZOyN / - ARCHITI:CTSDE ATI OVER IBBU AMPS SQ.FT.FLOUR AREA S/SQ.FI',
CZ-0 1 undersmnJ my plans shall M uud i s public records.
r—m t w SIGNS ELECTRICAL
I.icemeJ Professional
OWNER-BUILDER fo nDECLARATION SPIiC1AL CIRCUIT/MISC.
Xa u.V 1 hereby affirm that 1 oat exempt from the Commctoro License law for she
W3Ls.ti whichfollowing re,iman.(Section]BJLS,Bus ler,im rove,dermli C,monyciryoreoamy TEMP.METER OR TOLE INST.
he J Om
which rcquircs o permit¢r.answer,alter,improve,demolish,nr repair any swcmre
2 rp�Y� prior to its issuance,also requires Ne applicant for such Permit o rile a signed statement POWER DEVICES
p0 that he is licensed paimannothe mokims.fthe Ciarmcmr'a License Laic(Chapter
W c4o�' 9(oma,u611g with Section]W0)nf Division 3nfthe Busincssand Profaslne,Code) SWIMMING POOL ELECTRIC VAfAA'I'IO
tXy_y onhat he is exempuherefrom and the bmis fonhe alleged exemption.Anyvi.buionof OUTI.ETS-SWITCHES-FIXTURES / ]
Y Section]031.5 byonyapplicamfor.permit sobjectsim.pplicennoacivil penaltyof
0 not mora than five hundred dollers(S5(XB.
tL�m ❑ I,usowncmftheproperty,ormyemploymswithwagcsastheirsoleconi erasion, NEW RESIDENTIAL BLECTR _SQ.FT. STORIES TYPECONSTRUCTION
a3— will do the work,and the structure isnot intendedoroffercd for sale(Sm.]fH4,Business
and Professions Cale:The Contacmrs License Law does not apply to an owner of
property whobuildsorlmproves thereon,andwhoduessuch work himselforthroughhis
tun�mpinms,pmvidedthetsuchimpmvementsarenotintendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyearof cnmpdetion,the owner-
builder will have the burden of pmving that he did not build or improve for purpose of
sale.).
1. owner nflhepropcny,am exclusively contracting with barmaid amtacronm QIY. PLUMB]NO PERMIT x PEE FLOOD ZONE APN
construct the project(Sec.](44,Business and Professions Cmh,)The Contractor's f
License Law does not apply toa.owo,.Tmperty who builds.,imprwathcrcan.end PERMIT ISSUANCE
who conttactsmusuch projects with amnwclons)licensed pursuant to the Contactors AL'1'IiR-0RAIN&VENT-WATER EA)License Law. FEE SUMMARY
❑ I um exempt under Sec. B&P C for this rtm.nTMD EES
BACK FLOW PROTECT,DEVICE SANITARY YN_
Owner Dale RECEIPT#
DRAINS-FLOOR,ROOF,AREA,CONE).
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ th'Courmasmthatnhrance ora ecamedcopynu.self-insure,.rattnificate.f FIXTURES-PER TRAP RECIJFT.
Worken'C.mpensali.n Insurance nracertified eopYthereof(Seca JABQ Lub CJwhich PARK ITE Y
.wars all empinym,under this Pamir' GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT M
Policy N BUILDING DIVISION FEES
Company
❑ GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ITE.
CenlOed arpY is herehy fumisheJ.
❑ Cmificd copy is filed with the city inspection division. GREASIVINDUSTRL WAA IC
DI
CERTIFICA'I'EOFEXEMPDON FROM WORKERSGREASETRAP if If 1. �.3 Senn LTrE
COMPENSATION INSURANCE
(T;issectionnmdnot k seemplctedifthepmmii isfo,imnli morld.11oa($100) SEWER-SANITARY-STORM CWIT.
lass.)
Iemifyrhn infle perfmmence of me work for which this permit is issued.I shell WATER HEATER W/VENT/ELECTR _
not employ any person any manner so u m be`tynp�ubjyhM the Wake., -�
O Z Cnmpensmiarlarwso ,corm. Date` 1Y r1 J WATER SYSTEM[FREATI G Ua Ramiptk
Applicant IIPP
y 0 NOTICETO (CANT:ILe <r mekmg This Cenificum of Exemption,you should NEW RESIDENTIAL PL65B. SQ.FT. TOT41.:
FV] become subject to the Workersradon pmo isions of the Labor Code,you must
� ; linthwith comply with such provisions or this permit shall hedeemedrevoked BUILDINGFEE
W CONSTRUCTIONLENDINGAGENCY SEISMIC FEE
Z
�r
5 I hereby affirm lhnnhem is a construction lending agency for the performance of
U O
the work for which this r is issued(Sm.3(19],Civ.C.) ELECTRIC FEE
p i
Lenders Nome
U. H Lenders address - QTY. 'MECHANICAL PIiRtv1IT' . FEE PLUMBING FEE
U I cenily that I have read this application and state that the above information is ..
carat.lugreemcomplywimidleityande...ty.minancaands...a laws rcladngm PERMIT ISSUANCE MECHANICAL FEE
building commartion,and hereby authorize representatives ofrhiscity to enter upon the CONSTRUCTIONTAX
U 7-r above-mentioned property for inspection NoWars. ALTER OR ADD TO MECH.
(We)ogre,to save,indemnify and keep harmless the City of Cupertino against
Iadn Imx'judgmrnt, nstsand expenses which any in any waynwrueagainst said City AIR HANDLING UNIT(TO 10,000 CPM)
wof r gaming [his permit.
AIR HANDLING UNIT(OVER 10,000 CIM)
etrfApp am/ a�or Datecun1 u�or hate EXHAUST HOOD( /DUCT PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CTO 1(X1,000 BTI]) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
a9 defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BI U) TOTAL:
Crate Secfon 25532(q+
❑Yes El No VENTILATION PAN(SINGLE NI351D)
ammi
Will the sec oliaim ,it,building by the
tay Are.
unlit ttswhich emit
BOILER-COMP IMP OR 100.0(X1 BTU) ISSUANCE DATE
� haetrict?air rnntuminams ns def ncJ by the Bay Arcu Air Quality Management BOILER.COMP(OVER 100,000 BTU)
District? D
11 Yea ❑No NEW RESIDENTIAL MGCH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the J44 1 n
California Health&Safety Craft,Sections 25505,25533 and 25534. 1 understand that yT, �1 eQC
ifthe building snot currently hevea¢nam,that it is my rcsp.mihilitymnotify the /s/yY
ant of r nonemenls which most be at prior to issuance of a Carillon.of b I
kc icy. ry
nmhmize o Uum TOTAL: ISSUED BY:
OFFICE