25803 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RT[NO eUMDRiG-eEecrrz PF.RMITNO.
APPLICATIONIPERMIT PING FROG CI IDENTICAL 25803
BUILDING DIVISION BUILDING PRO,II'.CT IDENTIFICATION
BUILDING
�ADDRESS: / '�- Ta.#.x-C/`r SANITARY NO. APPLICATION SUBMITTAL DATE
�� / 97 ci�DI�'C'x✓rl'/A/i/Y//Jv—I UNIT# LOT vt-14r"f�
NAMIi: PHONE: CON CTOR'S NAML': LICNO: — v V/
NIC CONTROLp
ARCIIITECI'/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: X=p a -T
QTY.,G^ jT�E�ECTRICPERMIT FI31i HUILDING PERMI'1'INFO
2 "'x B'PLDG ELECT vi
PLUMB MECH
PERMIT ISSUANCE. U ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Mcci Horebyaffimt that l am licensed under provisionsofChapser9(commencing wish JOB DESCRIPTION
Pt�400Section 7000)of Division 3 ofihe Business and Professions Code,and my license is in PANELS
<Zfall
W licennu CaaJ ic# UPT0200AMPS
y 6 h
Date .7amntre .. 201-1000 AMPS
)Q�Z, ARCHITECTS DE LARATION OVER)000 AMPS SQ.FE FLOOR S/SQ.FT.
CZ-0 1 un 'lo be used as blit a rets^ ao�
_ ou u �— SIGNS ELECTRICAL
/jam^w.,7L�
54 iccnsd PrUfasional
q o'6
OWNER-BUILDER frmEC Contra ON SPECIAL CIRCUIT/MISC.
px,O yF I hereby Epson that 1 um exempt from the Contractor's License Law for the
FLL LLO w following reason.(Section emet Business and Professions Code:Any city a county TEMP.METER OR POLE INST. �
m which requires a permit m construct,elmr,improve,demoliaM1,or mpeir any atrucmm
a�Q� prior to its issuance,also requires line applicant for such Permit file a signed statement POWER DEVICES
HCC That he is licensed pursuant to the provisions of the Contractor's license Low(Choice 4L C 9(cotmnencin NSection]000)of pivision3ofthe Businae and Pro(anians Code SWIMMING POOL ELECTRIC
OP:ts. ew' ) VALUATION
mind oheis ac by it any applicant
fmmnt and he basPermit s Ne Alegedexempti to Myl penalty of _
Y Section then h any a I'c Yore emit subjects besot to al of OUTLCfS-SWITCHES-FIXTURES /Y1.cd
Z a Y Y PP t an pe jet pp' penalty r L77((����
^y0 not mom then roftheFee drcd Dollars yemp.
tin ❑ I,aownernfthepropeny,armyempinyas with wegesastheiraolecompenufion. NEW RESID[NTIAL ELEGTR Q.11, S S I. PE CONSTRUCTION
a3— will do the work,and the structure is not intended proffered fora]](Sec.71ki Business
and Professions Cale:The Contractors License Law does not apply to an owner of
progeny who builds or improves Nercon,and who does such work him,ollor through his
employees,Movided(liatsuchimprnvcmencsurenotintendedoroffercdforade.IL C. RO RES.UNITS
however,the bunting or i en mvemrnt is sold within one year or hapro etifar the owner- TOTAL:
builder will lout the burden of proving that he did nm build or improve for purpose of DATE
sole.).
❑ 1,asowner ofthepmpeny,am exclasivelycnamining with licensed contractors to Q; c PLUMBING PCRMI I ,FEE I$ G LON APN
connote,the project(Sec.7044,Business and Professions Code)The Contractors
I.icenu Lawd«snotapplyloanownuofpmpcnywhobuildsorimpmva$cmon,and PERMIT ISSUANCE
who contracts forsuch pmic,da with acomrecmrod licensed pursuanuo the Commences ALTER (EA)License Law. .FEESUMMARY
❑ I am exempt under Sec. ,B&P C for This reason BACKFLOW PROTECT.DEVICE 11 IDE ffFT
SANITARY YN
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION
co DRAINS-FLOOR,ROOF,AREA,COND.
SCHOOL TAX YN
❑ IbercM1y ufOtm Nmlhmee ceni0cnte of rnnsenno self-insure,arattrtificem of RECEIPT'#
Wmkee%Compcnaation Insurance or o ceniftd copy thereof(Sec.3800,Lab CJ which FIXTURLS-PER TRAP PARK FEE Y—N
—
coven all employees under this Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'g
Policy# HOLDING DIVISION PEES
Company GAS-&3.SY9TIHM-OVER 4(PA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEIINUUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
This sectionncdnm be completed if Ne Permit is for one handled Rollos(5100) SEWER-SANITARY-SI'ORM EA.20(FT. ENERGY FEE
or less.)
I certify that in the Performance ofthe work for which this Permit is issued,l shall WATER HPATER W/VENT/ELECTR
not employ any person in any mapper so10 heemtethe workers PAID
Care, WATER SYSTEMOREATING pain RaciPtp
O z Applic / Q_
z —I NOT'IC TO APPLICANT:IL after making this Ccnificate of Exemption,you should NEW RESIDENTIAL PLM). SQ.FT. TOT
rte-. become subject to the WnMees Compensation provisions of the Labor Code,you must
> forthwith comply with such Provisions or this Permit shall be dated revoked. BUILDING ITIS
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 Z
1 hereby affirm N a game is a construction lending agency for the performance of
L) O the work for which this parent is issuW(Sac 3097,Civ.C.) TOTAL: ELECTRIC FEE
Isndels Name PLUMBING FEE
26
W I e Isnd Address QTY, [_ , _' MECHANICAL PERMIT FEE
enil'ym NI beve read this application and stage That Ne mt
above infmndon ie
W correct.Iagleetocomply wiNallchyand coumyntainmcaeng stem le enter
upingm PERMIT ISSUANCE _ MECHANICAL FEE
Uy hbo,e-enconn edpro and herebyauNanureregin.udva ofthis city to enter upon the CONSIRUCTIONTAX
V7 nMv(We)iunce incanyformnify Ind peep harmless
ALTER ORADD TO MECII.
tom- (We)ngrec nt uvc,indemnify and keep may
the City of Cupertino against
liubilities,judgmrnm,costs wdexpenseswhich may in any way uccmeegainst said City AIR HANDLING UNIT IT 10.000 CIM)
in emseperme of the gmndn Nis pcmti�
AIN HANDLING UNIT(OVER 10,000 CFM)
Ignuwma Applic UContmetor ) e BXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00.000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hannedous material HEATING UNIT'(OVEN 1(81,000 ITT U) (T
m defined by the Capeninn Municipal Core,Chapter 9.12,and the health and Safety
Core,Section V 532(aTl VENTILATION FAN(SINGLE RCSID)
❑Yes ❑No
Will(ltcapplicam or fmure buildingmempanmscequlpmmh
enlnrdevices wldche
BOILER-COMP(3HP OR Ilk,"[]TO) ISSUANCE DATE
hazardous or contaminants a defined by the Bay Area Air Quality Munagemem BOILER-COMP(OVER 100.000 BTU) q
District? a'.Y
❑Yes ❑Na NEW RESIDENTIAL MECII. SQ.IT, p.
1 have tend The hemrdous materials requirements under Chapter 6.95 of the o
California Health&Safety Code,Sections 25505,25533 and 25534.1 uNat
nderstand
if the building does not currently have a Imaging,thug it is my responsibility to notify the �_ C//y 1%,
ccumart of lic requirements which must be met prior to issuance of a Certificate of
Occupancy.
SFU
kh—
Owner or auNanssd agent Doc TOTAL: ISSUED BY:
OFFICE