25858 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDIA PERMIT NO.Ca9Y O$,CUPERTINO APPLICATION/PERMIT PLUMB
BUILDING DIVISION
25858
BUILDING PROJECT IDRN'1'[PIC ATION
BUILDS G/�ADDDRESS: SANITARY NO. A1PPLICATIOJiSUBMITTAL DATE
V UNIT# LOT#
OWN' SN ME PHONE: CONTR CTOR'$NAME: LI
( Il N/C CONTROL#
• RCHITECIENGINE:R: .LIC NO: ADD P .- ❑
CONTACT: PHONE: xs
' QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
J BLD F F, PLUMB MECH
P[RMII'ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
py,Z Ihereby affirmthat l am licensed underpmvisionsofC Vter9(commencing with A JOS DESCRIPTION
8100 Section]UUO)of Division Sof the Business and Professions Code.and my license is in PANELS
c, full lnr deIT s
<, re `_Class-71#-t1��—Lia# 3 / UPT02MAMPS e
m¢d are.L�J I{._q con.CTIDr� �.� 201-TWO AMPS
FyZ // I1�_- -FA CHITECTS DECIA A SQ.FT.FLOOR AREA E/SQ.FT.
QOZ�O 1 understand my plans shall be used res public records. OVER IIXIU AMPS
r'tw SIGNS ELECTRICAL qq � I�
Liccmcd Profit salonal
W'si OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
fix'O a O 1 hereby affirm that I an exempt from the Convectors License Use for the
813 8,h
following reason.(Section 7031.5,Business and Professions Code:Any city memory TEMP.METER OR POLE INST.
1�' O which requires a permit to consumer,alter,improve,demolish,or repair any structure
mhsissuance,nlsorc thea licum far nolle asi toed smtement
POWER DEVICES
prior quires pP permit g
m o'a0 that he is licensed pursuant to the provisions of the Cemracmrs License Lave(Chapter
p.aoLL WIMMING POOL ELECTRIC 9(commencing with Section Division 3 of the Business and professions Code) VAI. TIO
X.
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F
ZSection L5 by any applicant for a permit subjects the applicanno a civil penalty of OUTLETS-SWITCHES-FIXTURES {VQf
C O tnrc tM1an five hundrcJ dollars($500).
NERESIDF,N
_ WTIALELECTR _SQ.FT.
STORIES 'TYPE CONSTRUCTION
m—m n❑m1,mowneroftheproperty,ormycmployeeswith wages as theirsolecon,ameatron,
y3— will do the work,and the stmcmfn lsnm lmendedoroffered forsale(Sec.J004,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
properly whoboildsor impmvestherson,andwhodues such work himselforthroughhis OCC.GROUP RES.UNITS
own employees,providedthat such improvemea¢arenotimendedorofferM tarsale.If,
however,the building or improvement is sold within one year ofcompletion,the owner- 'TO
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,a,uwnerof the pmpeny,amexclusively convecting with licrnsed contmctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pointer(Sec.7050.Business and Professions Coded The Contractor's
License law doesnot apply to an ownerofprnpeny whobuildsorimpr..esthereon,and PERMIT ISSUANCE
who contracts forsuch projects with v contractors)licensed prominent to the Contractor's pLTER�DRAIN&VENT- ATE
License law. W FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason OUI SIDI;FEES
BACK ROW PROTECT.DEVICE $ YN
Owner Date DRAINS-BOOR.ROOF.AREA. N f RECF,IP IS
WORKMAN COMPENSATION DECLARATION hC1IOOXAY N
❑ Ihereby a[RrmhhwlM1uvcaccnificate of conscm msclf-insvre,or usxnificumof �RECHIPfp
EIXI'UR13-PER TRAP
Workers Compensation lnsurence oracenifiedcopy thereof(Sec.3gW,Lab C.j which AIV �RECFIPT# N
coven allemploy�undtt this perm q 1-Q (�/�� �[• GAl-EA.gYSTEM-I INC.S —Il BU16PKG DIVISION FEES
Policy# S I(/l] _Tf/I l -.
GAS-EA.SYSTEM-OVER a(EA) PLANCHECK FEE
fed copy is hereby Tum a city
[ICcnifed copy is fled with the ciglpterion division. GRE4S171NUUSTRL WASTE INTERCEPTOR GRADING FEF /e
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE sea iT
COMPENSATION INSURANCE
(This union need not be<omplemdif the permit is for one hundreddollao(b 100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I cenify that in the p alamance of the work for which this permit is issued,l shall WATER I SEATER W/VE.NT/F,I,ECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compenmuonlawxof Cnlifomia. Date WATER SYSTEM/IREATING Date Receipt#
z Z Applicant
Z 0 NOl'ICE TO APPLICANT: making this CenifcmNEW RESIDENTIAL PLMB. SQ.FT.e of Exemption,you should 'TOTAL:
r c,, her onm subjecterm,Worke,Comlcnammnprovislets.of the Labor Cade you must
forthwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE D r+
LS1SEISMIC FEE
� Q CONSTRUCTION LENDING AGENCY
z I hereby affirm that there is a construction lending agency for She performance of TOTAL: ELECTRIC FEE
CJ 0 the work for which this permit is issued(Sec.3097,Ci,C.)
Lender's Name
Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING 1'Iili
0 f..) I cenify that 1 have mad this application and sham that the above information is MECHANICAL FEE
>" D] correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE:
) buildingcons[ruction,and herebyamhonu representatives of this city menmrupomhe CONSTRUC IONTAX
U z ubmementioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keup harmless the City of Cupertino against
liabililics,judgments,costs and expenses whichmay in any way accrue against said City AIR HANDLING UNIT(TO 10,10,000OCPM)
c c f'he'ramm,of this permit.
AIR HANDLING UNIT OVER 10.000 CFM)
ggrigmairfsoral icant/Contionoa Doc EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.000 BTU) Date Receipt a
Will the applicant or future building occupant store or handle haevdous material HEATING UNIT(OVER I W,000 BTI) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P VENTILATION FAN(SINGLE REM DI
Cl Yes ❑No
- ISSUANCE DATE
Will theapplicamen future building occupmose,iiipmentordeeices whicheran BOILER-CONIC(3HP OR IM."BT U)
waAoua an contaminants as defined by the Bey Area Air Quality Managemem BOILER-COMP(OVER 100,000 BTU)
District?
❑Yea 0 N NEW RCSIUENTIAI.M[CI1. SQ.FT. R4(]
LI read the by vous metcriab reiremems under Chapmr h.95 of Ne - 1994
alth&Safety Cade,Sections25505,25533 and 25534. lundendndthat C/I /g dors not earnewly have a erne.that it is my responsibility to notify the `� Lur
he requirements which must be met prior to issuance of a Certificate ofhadaed.,.at Date - TOTAL: ISSUED BY:
OFFICE