25357 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU
IIIIILISIN" - PERMITNO.
APPLICATION/PERMIT PLUM
ISIN'C,-MRCHANTCAI. (N r 11 r`7
NUILDING DIVISION BUILDING PROJECT IDENTIFICATION 2 5 3 5 1
BUILDING ADDRESS: SANITARY NO. APPUCiVEONSUBMITIAL DATE
11 ,S70s UNIT# 1,OTp
OWNERS NAME V PHONE: CONfRACTOR'S NAME,: C, LIC NO:oZ NEC CONTROL#
RCHITECf/F GINEER: LIC NO: ADDRESS:
czyA ma All e,
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDGE{,ECf PLUMB MECH
' PERMIT ISSUANCE _JI���r• 110
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OIYZ I hcrebyaffiw that l am licensed under pmvisionsofChapter9(commencing wit �^
W,00 Section 7000)Of Division3 if to Businessand Professions Code,and my license is in Uj , ��
Fz�j, full?%force Clas effect UP TO 200 AMPS
1,i<cnae Class Lia#
Dafe Contractor 201-1000 AMPS 5 IT.FLOOR AREA
ZOy'Z ARCHITECTS DECLARATION OVER 1000 AMPS
Q'
OZ—q Iunderstand my plans shall be used as public records.
F h F w SIGNS ELECTRICAL
Q � Li'm"d Protsslonal '
y�«Q OWNER BUILDER DECLARATION SPECIAL CIRCUIDMISC.
%Oa0 I hereby affirm that I am exempt from the Consents License law for the
at 3 4-vFi following reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F.O Q which requims a pemut to construct,aler,improve,demolish,or repair any structure
'WY2re
poor to itsissuance,alsoquires the applicant for such permit file le a signed statement POWER DEVICES
ce<0that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a 6O4C 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATISI
W_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
FZQ Section 703L5 by any applicant fora perarit mbje.nds,applicant to a civil Penalty of OUTLETS-SWITCHES-FIXTURES .J1
FSp t I mtardien five hundred dollars(S500). NEW RESIOF,NTIAL CLGCTR SQ.FT.
IYFo El1,asown<rmftepropenY.ormycmployccs wit wagcsasteirsolecompensmion, STORIES TYPE CONS'I'RUC'1'ION
y3a will dotewofk,andtbenmcturchour imendedoroffered mrsale(Sce.70si,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whnbuilds Oramproves domm.and whodoessuch work himselfor through his OCC.GROUP RES.UNITS
cmployees,providcd tat such improvemename notimendMo!offered forsdo If,
however.the buildingor improvement is sold within one yemafcompletion,the owner- A
builder will have the burden fproving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepmpeny,ameaclusivelyconwcting watlicerecdconhacturem QTY. PLUMBING PERMIT FEE FLOOD LONE APN
consumer the project(See.7044,Business and Professions Code:)The Contractors
License Lawdocsnm apply to an ownerofpropeny whobuilds or improves thereon,and PERMIT ISSUANCE
whotumracts for.such projects with aconlowtons)licensed pursuant to the Contractors se Law.
Lice ALTER-DRAIN& EA
VENT-WATER( ) PEE SUMMARY
❑
License
ran exempt under Sec ,B&P C for tis rcssov BACK FLOW PRO'T'ECT.DEVICE OUISIDEFFES
SANITARY Y N
Owner Date RECEIPT'#
DRAINS FLOOR. COND.
WORKMAN COMP cnift ofecNDECLARATION SCHOOL TAX Y N
❑ Thereby affirm then ecenificam mfcunummself-insure,orac<nificalc of RECEIPT'#
FIXTURES-PER TRAP
Wwkero Compensa�ionlnsumncc oreunifiedcopy thereof(Sec.Jg00.LabCJ which PAR Y N
�r ers Il employee's under this permit. I' RF.CF,IPI'#
GAS-EA.SYSTF.MIiN .40 l !�� Ili s BUILDING DIVISION FEES
Poli p
Certified copy is hereby famished. GAS-EA.SYSTEM-OV 4�E ) �� �I ' i_pLANECK FEE
led copy is filed with the city inspection division. GREASE INDUS I.WASTE INTERCEPTOR GRADI GFF:F:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPUATE SOILS FEE
COMPENSATION INSURANCE 77
('lois section need not k eempleted if the Permit is for one hundred dollars($1 W) SEWER-SANITARY-STORM EA.200FT. ENERGY
less.)
I cenifythal in to Perfrrommoeofthework far which this perionn issued,l shall WATER HEATER W/VENI'DELECTR
not employ easy person in any manna sur as to become subject to to Workers' PAID
Z Compensmionlawsof Califomia. Data WATER SYSTEM/TREATING Date Reccipt#
Applicant
O C) NOTICE TO APPLICANT:If,after makingthis Cerificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
^ become subjees to the Workers Compensation provisions of the Labor Code,you must
afothwith comply with such provisions or this peraut shall be domed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE `
Z I hereby affirm that hem is a construction lending agency for the performance of
L) O the work for which this permit is issued(Se<.3057,Civ.C.) TOTAL: ELECTRIC 19iE
L.mdcra Name PLUMBING FEE
F Lenders Address QTY. MECHANICAL PERMIT FEE
U I cenify tat 1 have read Nis application and state tat to above m ommu mn is MECHANICAL FEB.
{2-) V:Id mply wit all city and county mrdinanttsand nate laws rclutingm PERMIT ISSUANCE .
n,end hereby eu rnmmpmunanvesoftis<iyoemer upon the
(� 'zpenY for inx tion purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
save.indem y and keep namtes:the City of Cupertino against
costsand ,owes his may ininywayaccmeagrawsaid Cary AIR HANDLING UNIT(TO 10,000 CFM)
h tis it
AIR HANDLING UNIT(OVER 10,000 CFM)
tif APPL v'aur Dna EXHAUST HOOD DMDUC) PAID
HAZARDOUS MA'E FRIALS DISCLOSURE HEATING UNI'P(1'0 100,00)H'rU) Dme -Rec<ipl#
Will the applicant or future buildingtwcuprmsmre or handle mutiodomumucrlol HEATING ON]](OVER fig."BTU) TAh
rasdefired by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
.Section 25532(a)7
11 Yea No
VENTILATION FAN(SINGLE.RFSID)
❑
ISSUANCE DATE
Will theapphernmr funrebuildingxcupaotu..aequipn ntordevitss whichemit BOILER-COMP CUP OR IO0,000 BTU)
stardom no imarma oro as defined by the Bay Area An Quality Management
BOILER-COST(OVER 100,000 BTU)
DinnmT
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hmzvdaus materials requirements under Chapter 6.95 of the N
Califnmio Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
illh<bal of
he nesma currendhich m st a met prior
it mrssuanceofaymnmily the 26 19, )
cthe h d of the mgmremems which mot be met poor m issuance ot,Certificate of {/
Occupancy. q (/� Y
Owner or amhonud agent Dan TOTAL: Is QED
OFFICE