25013 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUII:UINT.-LT,RCTRICAI• PERMIT NO
APPLICATION/PERMIT PLUMBING-MECUANICAI.
BUILDING DIVISION BUILDING PROJECT'TDEN '1I
TIFICA (IN 5 5O 3
BUILDING A DDRESS: J� SANITARY NO. APPLICATION SUBMITTAL DATE
v GNITN LOT#
O ERSN E: r NONE: DRPV COf p'1t,ALTO NAME: L�e1Cs- l%
O^e1 cC� 7 NIC COMfROLp
RCHITECIEt4GINEF.R: LIC NO: ApDRESS: ����/ ❑
/ S$7 lawl.�llV-/19c0 sw ((L�lLf
'ONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MICCH
PERMIT ISSUANCE ❑ V El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
YC7 C 2. I hereby affirm that l and licensed under provisionsofCbmod!)(commencing with JOB D[SCRIPI'ION
~ontot--.. full farcSection e add fcclvision3of the Bm'inecs add Professions
Pmfersions Code,and my license is in PANELS � � ����
FZyVj Li<mu Class 1_ - l ic.p eV 75' UPTO20GAMPS
.<c. Dmc Contra— 201-RMp AMPS
ZOy Z' ARCHITECTS DECLARATION SQ.lel'.FLOOR AREA SItiQ.FT.
OVER 1000 AMPS
OZ-0 1 understand my plans shell be used a publi<records. I m
- SIGNS ELECTRICAL
Q'Zahiamal l'nffesinnal OWNER-BUILDER DECLARATION SPECIAL CIRCUCOMISC. _
eIN
XOa' I hereby affirm that I am exempt from the Commodes License Law far the I R
W 3 W ti following reason.(Section IW 1.5,Business and Professions Code:Any city ac county TEMP.METER OR POLE INST. Ij
�ON; which requires a permit to construct,alter,improve,demolish,or repair my structure .� w—
Ev)Y� prim to its issuance,also squirts NemplicantfonuchPermittofileasignalstatement
POWER DEVICES
aCthat he is licensed pumuanno the provisions of Ne Con.actOrs License l..w(Chapter
9(commencing with Section 900(Pof Division 3 ofine Business and ProCode) SWIMMING CoSWIMMING POOL ELECTRIC q{- N
W!2 or that he isesemptthemmunand the basisfor thealleged exemption.Any violation of OUTLET'S-SWITCHES-FIXTURES SDS .
FZa
Section 7031.5 lAmyapplicam for.permitsubjaapp
vsthelicanuo a civil penalty of
not more than five hundred dollars.($500). NEW RESIDENTIAL ELELTR SQ.FT.
C Op ❑ I,asowneroftheproperty.nrmyemployeeswiihwagesasiheirsolecompe.,.tion, STORIES TYPE:CONSTRUCTION
and
andtshe Coun snm License
tum,does .,apply
to not Buenas
and Professions Cordite The e.%tmnoet,License Law such
not.pply tom owner of
prop enywhobupro%sled finuesthercon,and whodncs such work himselfarthrougM1 M1f.
own empinyees,pmvided Nmruchimp mvemenu urenotimm�ded oroffered forsde.IL OCC.GROUP UNITS
however,the buildingor improvement ismld within oneyear ofcompletion,Neowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale).
❑ I,mownerofinepmpay,amexclusivelycontmeungwiNlicensedcontr wnto QTY. PLUMBING PERMIT FEE FLOOD ZONEAI'N
construct the project(Sec.]04fea
4,Business and Proiov CadmlrmlaPERMIT ISSUANCE
Carte The C 's /
Lcense Law does not n
apply loanwnerofpmpeny who buildsmimproves thereon,and
whoconaans forsuch projects with a commetoos)licensed Panamint o me-onancems ALTER-DRAIN&VENT-WATER GIA) FLE SUMMARY
Licence Law.
❑ I am exempt under Sec. .B&P C for this mean. BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dat° DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT If
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
1 I hereby affirm that l have acenificate ofconsenuoself-insure.ora certificate ofFIX'T'URES-PIiR TRAP RI-CLIPfX
f kers'Compcnaminn Insurance or a ccnifed copy there.flScc.3800,Wb C.)which PARKFIA7. Y N
covers all to Nt g�iL 3ECHIPTIr
RDIVISION
7f1 GAS-EA.BYSTEM-I INC.40UTLEfS BUILDING DIVISION PICTS
Policy g
Company fa GAS-G.SYSTEM-OVER OIRA) 1'LANCHF,CK FEE
Cenifed copy is hereby famished.
�•Cenifedcopy is filed with the city inspection division. GREASFIINDUSTRI.WASTE INTERCEPTOR GRADING IgiE
CERTIFICA'I'HOF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hu.dred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY ILE
or Tess.)
I certify that in the perfomuna ofthe work for which this Permit is issued,l shall WATER HEATER W/VINT/ELECTR eS
nor anploy my Terson in my summer m as to became subject to the Workers PAID
Compenution Lawsof California. Data WATER SYSTEM/IRFATING Date ReceiptIf
z Applicant
z0 NOTICE I'O APPLICANT:If,after making this Cerificae of Exemption,you should NEW RESIDENTIAL P1-MB. SQ.FT, TOTAL:
Ffq become subject to the Workers Compensation provisions of the labor Code.you must
� ? forthwith comply with such provisions or this permit shall be daemon revoked. BUILDING FEE
6wi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afford that there is a construction lending agency for the perfomana of
U O Ibit work In,which this patnk is issued St 3099,Civ.C.) TOTAL: 2s ELECTRIC FEE
1<.dcex Name MBING FEE
PLU -J
U" F Lander,Address QTY. MECHANICAL PERMIT FEE �•
0 U 1 cenify that I have read this application and sure that the above information is MECHANICAL FEE
r5' W comet lagrermemoplywithalichyundcoonly ordinances and state lawsmhaing m PERMIT ISSUANCE
F building conscription,and hereby authoriu mpesenetivesa(this city roamer upon the
CONSTRUCTION TAX
L1 above-mentioned propeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree in save,indemnify odd kceP harmless the City of Cmenino against
(Ifiabbiilities/,judgmenlamsu mdexpenses which may in my way some against said City AIR HANDLING UNIT(TO 10,WU CFM)
t.
7'l '�' of th���.L/mrila,..Q1_ ��7'43
AIR HANDLING UNIT(OVER 10,1X10 CPM)
awmof AS,I. r/ ammnor Dam EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100l"BTU) Dare Rereipt 0
Will themplicmtorfuture building occupmtsadc ane handle Im umEous mamrial HEATING UNIT(OVER IOO,gX)BTU) TOl'AI.: S
as defined by the Cupcninn Municipal Cade,Chapter 9.12,and the Path and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESIDE
❑Y. ❑No
ISSUANCE DAl'E
Will the applicmtorfuwrebulldingoccupamuse equipmemordevices which reit BOILER-COMPOIIPOR I00.000131T)
huaanlonx.a,amumitems as defined by the Bay Area Air Qualhy Management BOILER-COMP(OVICR]BLOOD BTU) A pp q
District? t Y
I- + ❑Yrs ❑No NEW RESIDGNTIAL MECH. SQ.Ff. p
Lbuilding
havemad the hazardous mneriels rcyuircmentr under Chuper fi.'JS of the q
ealth&Safety Code.Sections 25505.25533 and 25534. I understand than /
g does nor currently have a tenant,that it is my responsibility to notify Ne (�the requirements which nest be met prior to issuance of a Certificate of 0111,(/( %��hIvwthorized agent Date TOTAL: ISSUED By