25786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1U1EIff,0-7ErTT-re R ICA U PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 25786
]5 O C
BUILDING PROJECT IDEM IFICATION GOv
BUILDING ADDRESS
I: M!I,0 SANITARY NO. APPLICATION SUBMITTAL DATE
UNH'N LOT L s Y,GI-43
OWNERS N /GONE C II.Ni6k
NIC CONTR( .M
Jif
ADDRpw ARCIITECT/ENGINEER: LICNO: 51
36
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
ELECT PI. MB MECH
10 PIiRMIIISSUANCE L��^.f
LICENSED CONTRACI'OR:S DECLARATION APPLIANCES-RESIDENTIAL DESCRIPTION
OCZ I hereby affirm that l am licensed underprovislons ofariptero(commencing.xith
�O(COC, Section Division Sof the Business en Professions Code,and mY)iccnm is in PANELSfull �� A
FZWand effect.o,�z
Licenu Clas LimM� UP T0200AMP5 lZe
y-La ,. Contmctar 201.100o AMPS r yl / fit— _ 11- t ' YYYVVV
'1O'�'n ARCHITECTS DECLAR TIO tr it - r w SQ.FI'.FLOOR AREA EISQ.FT.
OZOG I underranJmy plansshall be mod m Public me do. OVER LAMPS, 1 r II
�^ W SIGNS T:LECTRIC / �/ v .e LAS
or
rf zd License)PrafessiomJ _
�d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M �ltJl
KOyU I hereby affirm that I an exempt from the Contractor's License Law for the
m 3 n y following reason,(Section 7031.5,Business and Professions Code:Any city m county TEMP.METIdLQR POLE INST.
F-u.C 5 which acquires a permit to construct,alcor,improve,demolish,or repair any structure
C�}5to its issuancealmrt res the titan,fmmch no fix diagonal smmment POWER DEVICES
prior 9ui PP peri Bre
W C p that he is licensed pursuant o the provisions of the Contractors License Use(Chapter
�Xo�Ky, 4(cnmmencing with Section]((10)of Division 7nf the Business and Professions Code) SWIMMING POOL ELECTRIC
e) VALUATIf�IyX
WM, or that he is exempt herefrom and the basis for alleged exemption.Any violation of
F;La
Section 0031.5 by any applicant for a peritsubjects the applicant toecivil penalty of O1f11.815-SWITCHES-FIX'IURFS
0 no more than five hundred dollars(5500). NEWRESIDEINTIALELECTR _SQ.FT. STORES I'YPECONSTRUCTION
❑ I,asowncrnfthepmpcny,ormyemployen with wages astheirmlecompensation,
y3.° will do the work,and theswmumisnot intended uroffered for We(Sce.J044,Business
and Professions Code.The Contractors Licenu law does not apply to an owner of
preperay who buildsm improves thereon,andwho Jesssuchwork himselforthrough his
OCC.GROUP RFS.UNITS
wnemployees,providedthat such Impmvemenudart not intendeoffered L
formic.I
however.the building or improvement is sold within one year of commpletion,ui Wcrt purpose
r-
hwill have IM1e burden al proving that he did not buil)or improve for purptu of
solo')' QTY. PLUMBING PERMIT FEE FLOODZONE APN
1] I,as owner ofthe property,am exclusivelycummuing with licensed contractors to
Linstruct the project(Sec.7044.Business end Professions Code:)The Contractors
icense law decant apply torn ownerefpmperty who builds T- PERMIT ISSUANCE
who contracts fur such projects with a comerefor(v)licensed pursuanuo the Commissaries
Licenu Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I an exempt under Sec. ,B&P C for this reason OUTSIDE FEES
BACK ROW PROTECT.DEVICE:
SANITARY Y-N—
o Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT♦
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
7bereby affirm that l have acertificam ofeanvol toself-insure,oracertifcum(f FIXTURES-PER TRAP RLCLII'1N
Workers'Compensation lnsumrecor a terrified copy thercof(SwJeW,Lab C.)which /s PARK ITiE Y N
- covers all employer's under this perm GAS-FA.SYSTEM-1 INC.401JTLETS RECEIITM
Policy It BUILDING DIVISION FEES
Company iJ7 Ta �� GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ rtifiedcopyishemby lhmished.
�Certified copy is filed with Ne city inspection division. OREASUINDUSTRL WASTE INfERCEEfOR GRADING FEE
CFR'I'HICA'1'17 OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe peril is!crone hundred dollars(SHIP) SEWER-SANITARY-STORM EA.20017, ENERGY II7I7.
m IcsaJ
I ploy that earmar the in nuance ora Neo as for which his subject
is the Workers
WATER IIFATER W/vtNT/ELIiCI'R
not employ any permn in any manner so as to become subject m the Workers' PAID
Cnmpcnsmion laws of Celifomia. Date WATER SYSTEM1I/fREATING Data Receiplp
Q OApplicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should NEW RESI DENFIAL PLMB. SQ.FT. TOTAL:
F � become subject n the Worker's Compensation provisions of the Labor Code,you must
� ' I'nrthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PIiP.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
1 hereb rffr thin Iheu u a construction Icndin n enc for Ne perfa—cc of
5 Z y ti b y 'A ELECTRICILE .�
U O the work for which this peri,is issued(See.3097,Civ.C.)
Lender's Name TY. MECHANICAL PERMIT FETE PLUMBING ME
F-'
Lender's Address Q
Lel I certify that I have read this application and state that the above information is MECHANICAL FEE
correct.l agree to comply With all city and county ordinances and state laws relining to PERMIT ISSUANCE
buildingconstruction,:and hereby ardanie representatives ofthis city local' upnmhe CONSTRUCTION TAX
U Z uMwe-mentioned property lin inspection proposes. ALTER OR ADD TO MECI I.
( rcc m s emnify and keep harmless the City of Cupertino against
lir ' res,ja gm s ander n It IS may in atyw,aceme against mid Cit AIR HANDLING UNIT(TO IO,OW CFM)
n fthe r a 't.
// AIR HANDLING UNIT(OVER 10.000 CFMI
Sig ueof pp ac omract a EXHAUST HOOD(W/DUCO
PAID Ugl, '
HAZARDOUS MATERIALS DISCLOSURE fIGTING UNIT(TO IIXI,fKK)BTU) �� UUdA((°�� �� Reoe'P,M
Will IM1e applicant or future huilding occupantstore orhmJle hanardous material HF,ATINC ON]'I'(OVER IWI,I%NI BTU)
us it by the Cupemino Municipal Cole.Chapter 9.12,and the Health and Safety
Cole,Section 25532(.)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will thea liesn,orfuumbuildin tune mernordevices whichemlt BOILER-COME LIHP OR 1W."BTU)
PP B by then 9uip
ha riot? air contaminants as defined by the Bay And Air Quality Management gO11.F,R-COMP(OVE0.100,0W BTU) P�y p
isvim l %
h
El Yes 0 N NEW RESIDENTIAL MECH.—SQ.FT.
I have reed 0m bayous material requirements under Chapter erm of the MY 18 1(19
Celifomia a mth&Safay Code,mommas 255()uireme t runder hapten 6.95 of h e �{) `7y���,,1T//�yJa/)
if the building does not currently have a matent,that it is my responsibility to notify th<
ocratem,of the requirements which must be me,prim to issuance of a Certificate of Cil Y Ut LU, i I
Occupancy.
Owner or authov<J agent Date TOTAL: ISSUED BY:
OFFIC