25182 XPPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ,
I nun. I 'I A L I rERMIT NOCITY OF CUPERTINO ION/PERMIT PLUM B NG-MECH ANICA , 25182
BUILDING UI VISION APPLICAT BUILDING PRfIFC]'IDIYTI W CA TION
BUILDING ADDRESS. SANITARYNO. I APPLICATION suntorITAL DATIi
lbL 1. �+ • ' � '�Ull�g 1 LOT# wq 3
OW S NAME _ PIIONIi -- - I N/C CONTROL#
ARC I�LNGINHER:
LIC NO: ADDRESS. ❑ J
CONTACT: PHONE.
QTY. GLECTRIC PIiRMIT FEE BUILDING PERMIT INFO
@1. G ELECT' PLUMB MUCH
' PERMITISSUANCE I 1 11 1
El
LICENS17D CONIRACI ORS DECLARATION APPLIANCES-RESIDENTIAL t�� �,�I���,�.SI/(I' �OJJ
IM1Wgrf ffDi that 3 of the Blunder — " " f
Matz yn provfamnsofChapmr9(commencing with
cis W—(=. Seaton](YJ91 of Divinon3of the Business and Profesainns Code.and my license lam pgrygl-S
atUA2License nseennA eOect UPTO20i
(Q„ZU1 Dole Class Combat—
F<<=� Dale Condreco• I 12111-11gq AMPS _ 1FF$/SQ
mZ ARCHITECT'S DECLARATION OVER 1000 AMPS r 5 IT.I Otill S/SQ Nf
O'z!rn I undoodmd my plim,dall be used as public recmds '� h w
f(AtW SIGNS ELECTRICAL L'
�yC2C,'aj LmcnxJ l'rofesnomil OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/AIISC. Y� •�
dOpw,vGV I hereby affirm that 1 am exempt form the Conaretoh Luccuse Law for the I' I
3 to, mhowmg reawrn(See,do7 031.5.Bmmew and Profession,Code:Any city or county TI!MP MEIiR OR POLE BEST
C to which require,a pdamt to construct,hirer,improve,demolish,or repair my swnum MOWER DEVICES VA I t
Wa� prorto ms issuance,of co r.....ca the applicant forsuch perntuo fleasigneJ Smdemem I ` j
os fled he is licensed fursaannothe provisions of the Carl maor's License Law,(Couple, -+•1
aryry eq 9 [at he,, Station ssiou of Di, Yd the e,, svn.a,Any annaCMe) (SWIMMING POOL ELECTRIC ,,,I
_q or met M1e rceaempnherefrom and lbe basis for the alleged aempuon.Any violation or pUTLEI'S- FIXTURES
/U_]`r�V A
�zQ Seatnn]o11.56y any npplmvm fora lmnnn sublcaa the eppbcanl loam.d PtrWt,of SWITCHES-
not more than Eve hundred dollars(S500).
❑ I,nanwneroftheproperdy,ormyempinycen wiN wageam[hevsolecompensabon, NI?W RISIDI'NTIAL F.LECfR _SQ R. I STORIES TYPECONS'IRUCTION
y3— will do thework.and the amaurc isnointended croffcrel fur sale(Sec.704,1.Business
and protestation,Code:The Contmemr's License Law it., apply m an owner of
propcny whe buJds nnmprm ea theremn,anJ whodces such work himaelforfhroughhis I _
employeca,p building or improvement fhrsale.IL OCC.GROUT' R!S UNITS
however,the live the onmprovemem m sold wnhmon build, cnmpletion,mcowner- TOTAL:
budder will have the harden of proving that he AW not build, improve for purpose of
sale.) QTY. PLUMBINGPERMIT FEE I FLOOD ZONE APN
❑ Las the uwaeT
pmjcct property,am Business an contracting signs ode:) he Contra,
License et the projcn(see.]tan4,Pusmcss and Professions Code:)The Confroaor's
LmcmaeLaw duesnm aPPlyro with acrofpriperq whnsedEuor improves
to the Conti theresor ord I PERMIT ISSUANCE
who commasforsuchprvjecewimacomtri¢mnaHtcrnxd parsuammme iontncmra ALTER-DRAIN&VENT-
LicemeLaw. WATER BA) 1OUTSID P1,Fq
❑ I am exempt under Stt. ,B&P C for this maxn BACK FLOW PROTECT.DIiVICIi
ISANfI'ARY Y N
Ow, RECEIPI'M
WORKMAN COMPENSATION DIiCLARATION DRAINS-FLOOR,ROOF,AREA,COND ISCHOOLTAX Y N
❑ Thereby effirtn tM1allhaven cmdicam ofconxm to ulfansum,ors mnificem of FO(TURES-PER TRAP I RFCI_IITp _
Wnokerd Compemutinn lawmarcera retitled copy lhcreoffgec.3g00.Lab C.)whmh I (PARK FEE Y N
ers all employee's under this Mora. GAS-EA SYSTEM-I INC.40UTLEI'S RECEIVE'*
Pori M BUILDING DIVISION FEES
11 rt�
Ce ffM 1.1,,hereby handshcd GAS-EA SYSTEM-OVER 4(FA) IPLANCHECK FEE
Confied copy is filed with the citylnapelmr division. I GREASRnNDUST RL WASTE INTERCEPTOR (GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE!
COMPENSATION INSURANCE _
(Thnxcuonneedma be complaed tithe permit is Intense hundml dolian(5100)
orls ) SIiWEft-SANITARY-STORM FA.2(pFT. ENERGY FEE
a. J
Icemfythat In(M1e performance ofthe workfor wbmitthispermit is issued,)shall I WATER HEATER W/VENT/IiLF.CR
nnl employ any person In any manner ei toe b became subject o the Workers' 'AID
Z Carr,nxmon Lawsof Cehfomia. P' WATER SYSTEM/TRPATTNG Data Resecipfa
z0 NOI'ICFTOAPPLICAN'f l(afmr making lhn Centfcam of Exemption.you should NEWRESIDI?NTIALPLMB. SQ FT. I TOTAL I
V] become vublecito the Worker's Compensation provisions offhe Labor Code,you must
7 forthwith comply with such provisions or this permit shall be deemed revoked I BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm that them Is a construction lending agency for the performance of _ JJ
L) Q the work for which this permit is issued(See.3(19],Co,C.) TOTAL:( ELECTRIC FEE
C1. ,r lender's Nam-
O l^ Lender'.Add, (QTY. MIiCIIANICAL PERM IT FEE. PLUMBING FEIl
U I moldy that I have read this epplmaicn sodium that the above information is
cored la fee w cum with all city and count g MFCI IANICAL FEE
4 B comply y y doves of and slam laws m PIiRhRT ISSUANCE
U Z above-mentioned M1Crehyauctomcrepmxnmtives of lhisaryfoenmr upon the — CONS'fRUCT10N TAX
U z uhnv(We)agree pap e,undo nify add keep harp ALTER OR ADD'fO M1IECII.
(WO)agree m seas,mdrnmify and Attp hvnnless the City of Cupertino agutml -- - _—
In cot q)enm of lse gam!'IpN§ofpcnxs wmh;'hmny loony way nccm CI AIR HANDLING UNIT(TO 10,0(g)CFM)
x c � ,AIR HANDLING UNIT(OVER RE"CFM)
,
gnouu fAppbcam/Gimracmr Date EXHAUST HOOD(WNUCI) PAID
HAZARDOUS MATERIALS DISCLOSURIi HEATINGUNIT(TO100,11tX1 BTU) I Date Reccip4a.
Will lheapplicant rfutam buddmg«xupant smbe or handle hazadous amen.' HEATINGUNIT(OVER Ift"BTU) T
as defined by the Cupertino Mora ipul Cn)a,Chapter 9 12,and the Health add Safety
Code,Sodium 255320)?
❑Yes ❑No I VENTILATION FAN(SINGLE RISID)
Will the applicator orhame budding occupamusceyulpmemnrdevices which emit I (BOILER-COME(31111 OR 100,0(1(1 BTU) I ISSUANCE DOM
sailor air contaminants as defined by the Bay Area Air Quality Management I BOILER-COMP(OVER 10(i BTU) I r A
lisdricdl D.
❑Yes ❑No I NEW RESIDENTIAL MECII. SQ ET.
1 have read the hazardous mmemms"moment,under Chapter 6.95 of the JUN 0, 1993
Cxlifornta Hcallh&Safety Code.Sarlfons 25505,25533 and 25534 1 aadersfand that
if the bolding does not currently have a mutant.that n is my respomibllny to notify the
occupant of the requirements whmh must M1e met prior to Issuance of a Cenificmc of V'I Y V f VUfLTY
occupancy. I I II
Owner or authorized agent Date I TOTAL ( ISSUED BY.
OFFICE