25195 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
D CITY OF CUPERTINO nllanlNcrEcecTRLCA PERM"No. 25195
APPLICATION/PERMIT PLUMBI.N'G-,MF.CHAMEAL
BUILDING DIVISION BUILDINU PROJECT'IDEN I IFICA'nory
BUILDING ADDRESS: e Y `►� SANITARY NO. APPLICATION SUBMITTAL DATE
n LU9ya E�cFoeS /1w C� a�LhIT#
OWNERS NAME: '// /,PHHONE::.^ CONTRACTOR'S. ML': /� /LIC/NO:
ill�1Q -S K G/s+ 713 �:30E 17= . .? N/C CONTROL#
RCHI'IECT/FNGINEER: LIC NO: ADDRESS:
'UNTAC.: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
amz I hereby affirm that l am licensed underprovisionsofChapter9(commencing with JOB DESCRTPI'[ON
POC Section]000)of Division 3 ofthe Business and Professions Cade,and my license is in PANELS /if-. ow.,full force and effect. (00416 L)
Q7ut License Cl s ZO Lit.# UFTO200AMPS Pr er
to Dam r_ COmmrr„r l�iR bSsSN 201-1000 AMPS
ZOy7 - ARCHITECTS DECLARATION OVER IOOpAMP$ SQ.TT.FLOOR AREA $/SQ.IT.
OZ—❑ IunderxinnJ my plans snallboused as public re<mNa.
r`=F; i SIGNS ELECTRICAL
ELY Licensed Professional
o;atQ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
Nis-
e�d OyU I hereby affirm that I am exempt from the Contractor's License Law for the
r1'3ay following reason.(Section?031.5,Business and Rofessions Code:Any city orenunty, 'TEMP.METER OR POLE INST.
O¢ which requires a Permit to construct,alter,improve,demolish,or repair any structure
Ss�}, to its issuance.also then applicant for such Lia fileasi dstatemem POWER DEVICES
m prior quires pp Perms gne
00 that he is licensed pursing to the provisions of the Contractors License Law(Chapter°i 6�e 9(wnmmnuing with Scnlnn]000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_y
or he is exempt thcmfrom and the basis for the alleged exemption.Any vialetion of OUTLETS-SWITCHES-FI%TURFS
F Z Q Section 7031.5 by any applicant for a permit xubjeets the applicant m a civil penalty of
ESO not more than five hundred dollars(5500). NEW RESIDENTIAL ELECTR _SQ.FT.
ni�Ow ❑ I,asownerofthepropeny.ormyemployeeswithwagesastheirsolecompcnsation, STORIES TYPECONSTRUCTLON
a3— will do the work,and the sbucsure is not intended or offered for sale(Sev.?044.Business
and Professions Code:The Contractor's Livense Law does not apply to an owner of
prof uny who builds or improves premon,and who daes.such work himsel for through his
mwnrmployprs,provided that such improvcmc it arenot ew ofcl mpictised Tarsale. r-
OCC.GROUT' RFS.UNITS
hawcvegillhathe building tidem ovcmpmtissold wi idradcyearor cprove ran tM1,poom of O
builds will have the burden of graving tsar he did trot build w improve far purpose of
ole.),
❑ I,.aownwonne prupcny.amexpmaivdypontracdng wim horsed wnvawors ro QTY. PLUMBING PERMIT FEE n.00D ZONE nrN
construct the project(Sec.7044.Business and Professions Code:)The Comment's
Uvensa Law does not apply to an ownerofpropeny whobuildsw improvesthesmn,wit PERMIT ISSUANCE
who contracts for such projects with a commctor(s)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date RECEIPTp
DRAINS-FLOOR.ROOF. GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihembyperowwobromhave ecm.verve m(canscnuowf(Ssum,w Lab C.)whicteofh
FIXTURES-PP,R TRAP RECEIPI'p
Wmrkeri Cnmpcnmtinn Insurance mrsccnified copy thcmof(Sec.JgpO,LabC.) PARK FEE YN
coven all employee's under this permit. GAS-EA,SYSTEM-)INC.4 OUTLETS RECCIPI'#
Policy p BUILDING DIVISION FEES
peoy '7 T N GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
G
Cedified copy is hereby famished.
0
fi.T Coshed copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INTI' GRADING THE
C17RTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP L SOILS FEE
COMPENSATION INSURANCE
(Yhissechm mast..be wmpleted ifthe permit is forms,hundred dollars(SIM) SEWER-SANITARY-STORM G.210112 ENERGY FETE
eg ar lend
I petrify the,in the perfxtrunaoffle work for which this permit is issued,Isnall WATER IIEATER W/VFNT[ELEC]t
not employ any person in any prourne,,an as in became subject m the Wake.' PAID
Compensation Laws of California. Date WATER SYSTENUTREATING Date Receipt#
Applicant
zC NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
CA become sub)wua Oe Workers Compensation provisions of Nc labor Code,you must
a > forrhwith comply with such provisions or this permit shall be deemad revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm Nm them is a construction lending agency for the perfsmmmcc of
U O the work for which this permit is issued(Sul.3(97,Civ.C.) TO'T'AL: ELECTRIC FEE
Lcadw's Name
TY. MECHANICAL PERMIT FEE PLUMBING FEE I<ma,r:Adores: Q
U I verify that 1 have read this application and state that the above mfmrmadmm is
wrre:t.L agree to comply with all city and county unbosom and stele laws relating to PERMIT ISSUANCE / MECf1ANICAI.PCF.
building construction,and hereby authorize mpresentativesofthiscity m enter upon the CONSTRUCTION TAX
U Z wo r-mew,mord property for inspection purposes. ALT ER OR ADD TO MECI E.
(We)agree to save,indemnify unit keep hafmleas the City of Cupermom against
dinfidincs,juJgmcros.costand expenses which may in any way accrucagainw said City AIR HANDLING UNU(TO 10.000 CFM) /
inc stseyuencc of it granting of th' permit.
4_f) — /r/h-3 AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Dole E%HAUSTHOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HLCUNG UNIT(TO 100,000 BTU) Data Receina
Will the aeCuperor tino Mu Municipal
n,upant Ourpostore.or handle hmnksYsmamrial HEATING UNIT(OVER 100.000 BTU)
as refined io the Cupertino Municipal Code,Chapter 9.12,and the Ilwhh and SePoty
Cole.$,conn 25532(a)? �No VENTILATION PAN(SINGLE RfSID)
❑Yea
ISSUANCE DATE
Will the applicantwfuwrt buildingwcupantuxequipmenwrdwiceawhichendr BOILER-COMP(JIIP OR I00,gN1 BLV)
hazwdmis air eonmmimantr as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IM.0M BTU)
Dislria? .,c
11Yes �IeK. I NEW RESIDENTIAL MECIL SQ.FT.
1 have read the huzmdous materials requimmenis under Chapter 6.95 of the V '^
California 1lealth&Safety Cale.Scctiwis 25505.25533 and 25534.I understand that.
if the building does not currently have a tenant,that it is my msponsibility to notify the
CoJIMJIM11 1
OSsm mf the myuimmems which must b,met prior m issuance of a Cenificme of
awpanpy.
Ownerorwropiredagent Date t tl3rolr_�_
ISSUED BY: .111DIV