25029 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .HING_ME - PERMITN°. 25029
APPLICATION/PERMIT PLUM RO JE TIDE TICAL CK
BUILDING DIVISION BUILDING I'ItU5EQ1'IDENTIFICATION
BUILD ADDRESSSS``ywwwy`n' '� Oma �,�^ SANI'T'ARY NO. APPLICATION SUBMDTAL DATE
W�/W UNUNIT# `�•�l�_/_ LOT J,
OWN S AMI?: PHONE: COST'R TO :S LIC NO:
NC CONTkOLa
ARCHI'IEC/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMITINFO
QTY c4-4 �I *,EnLECfRIC PERMIT FEE ` �'
ELECT PLUMB MI CH
PERMIT ISSUANCE. ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIA
0=z Ihereby affirm that l son licensed underpmvisiomafChapter9(commencing withJOB DESCRIPTION
�OO Section 7000)of Division 3 of the Businessland Professions Code,end my license is in PANELS
y_ZF fulllseClndeftmt. 21^iT. �UA•L�
Q�za full pace anss LiL.M UP T0200 AMPS
m=y Date Co..,,,_ 201-1 s
ZOryZ ARCHITECTS DECLARATION OVERT MP SQ.FI.FLOOR AREA $/SQ.FT.
OZ^p IundernunJ my plamamllbeusedmimblicrecords.
N_ WW SIGNS EL I
gYW< Licensed Professional
yQ OWNf:R-BUILDER DECLARATION SPECIAL I C.
0:xO p�,F I heresy air,.that I.m exempt from the Contractor's License law for the
,a following reason.(Sectien7031.5,Business and Prolbssi.re Code:Any city.,county TEMP.ME OR LE ST.
1
t 4,21 which requires it permit to construct,alter,impasse,demolish,or repair any structure
aMM 2 prions its issuance,also requites tbcti'dicent(.,such parmitm file.signedstamment POWER DBVI
that he is licensed pursuant t.the provisions of the Comrictots Licerse Law(Chnpmr
a�pa 9(commencirg with Sectlm,V00shm'Division 3oflhe Businessland ProfssaVom Code) SWIMMING POOL ' E TRIC
iC tx. VALUATION
m_m Sethe,h7031.5 by anythere(romand the basis t'subjects
thedeaemientto civil
of OUTLETS-SWITCHES-FIXTURES IIS. �D
H Z Q notion film by any applicant for.Permit subjttu the applicann.a civil penalty of ice` W
t mom Lai,,a hundred dollars($500). NEW RESIDENTIAL ELEC R S .FT. ,
p n❑ I,asowneroftheproperty,ormyemployceswithwagesmtheirsolec.mpensation, Q STORIESTYPE CONSTRUCTION
d3— villdo the work,and thestoolvre isnot iatendedomffeold I..lo(Se.1044,Bvaraas 11
and Pmfessions Code:The Contractor's 1-icense Law does not apply To an owner of Eilm
propenywhobuildsmimproves there.nardwh.daessuahw A himulforNmugh his
hoemployees,providedthtsuch improvements are not ineendelmoffercd forsale.If, I C.CROUP RES.UNITS
wever,the building or improvement is sold within one yearofc.mpledon,the owner- I,
ladder
er will have the burden of provpurpose proving that he did not build or improve for puose of
Elm)I,asowner ofthe propeny,nemlusivelycomracting with licensed contracmen to QTY, LUMBIDA' .11T Y ` LOOD ZONLa APN
retract the project(Sec.70I4,Business and Professions Code:)no Contractor's
Licemel.aw does not apply manowner.l'propenywbobuildsorimpr.vesthercnn,and PERM]TISSUANCH
who contracts forsuch Projeets with acomr.emrbo licensed pursuant to the ConwetMa ALTER-DRAIN&VI3NT-WATER EA PIiE SUMMARY
License law. BEAT
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE I TSID: :..
SANITARY Y N_
Owner Dam ORAINn-ILOORROOF,ARCA,COADRECEffvr#
,
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y N
❑ Thereby afOnn Natl haveucertifimm of consenno ulf-insure,ora«ni0cme of FIXTURES-PER TRAP RECUIPfN
Wnrken'Cnmpcnsvdon lnaumnce urs certified copy lherenf(Sec.]800,Lab C.)which PARK FEE, YN
covers all employee's under this permit. GAS-EA.SYSTEM. INC. OUTLETS RECEIF T p
Policy at BUILDING DIVISION FEES
fe
ficd copy is heresy famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
third copy is filed with the city impectlom division. GREASIy1NDUSTRL WASTE INTERCEPTOR GRADING THE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREcSGTRAP SOILS FEE
COMPENSATION INSURANCE
('This section need none completed if Ne permit is for one hundred dollars($100) SEWER-SANITARY-STORM P.A.200Ff. ENERGY FEE
or less.)
I rectify that inthe perfomunce of Nc work forwhich thispumit isissued,l shell WATER HEATER WNE.NIDPLECIR
not employ any person in any manger so as to become subject to the WorkersMITE
Compensation Lnws of Culifnmiv. Data WATER SYSTEM/TRCATING ReceiptN
Applicant
Z 0 NOTICE TO APPLICANT:IL.fter making this Cenific.tn of Exemption you should NEW RBSIDE HAL PLMB. SQ,FT. TOTAL:
F' fA become subject to the Workers Compensation provisions of the labor Code,you must
(Y. forthwith comply with such provisions ruins permit all be deemed revoked. —�
y (] CONSTRUCTION LENDING AGENCY
Z I herebyaffirm that there is a construction lendingagemcy fm the peAarrtunce.f TOTAL:
U 0 the work fm which this permit is issued(Se.3092 Civ.CJ
I.eader.Name
u-' larders Arbors, TR.Q1'i, T MECHANICAL PERMIT 5 PEE; PLUMBING FEE
U 1 rectify that I have read this application slid auto that the above information is
coMECHANICAL FEE
nt (agree mcomply with ail city eM cowry oNinenem and stnelaws mlmingm PERMIT ISSUANCE
building construction,and hereby ambories representatives.fthiscity to enter upon the
U Z above-mentioned property for inspection purposes. ALT'Ek OR ADD TO SUCH. CONSTRUCTION TAX
(W<)agree t.sassy indemnify and keep may inae the Chyof C
liabilities,judgments,costs
ramorgexpenspernal mayinany we t AIR HANDLING UNIT(TO 1(I,IXq CFM)
inconsequent of the granting of this permit.
AIR HANDLING UNIT(OVER Iq(X10 CFM)
STlitshalle of ApplicanUContmlor Date EXHAUST HOOD IW/DUCIO
' PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T'O 1D BTU) Date Recciptp
Will he vpplicwt or future building occupant stow or handle hneaN.us malarial
is dafined by the Cupertino Municipal Code,Chapter,9.12,and Ne Heals and Safety HEATING UNIT(OV ER 100,000]11 U) Is-TOTAIJ
Code,Section255R(a)1
0 Yea ❑No
VENTILATION FAN(SINGLC RFSID)
Will Neu licamt.rfumrebuildio BOILER-COMP(3111'OR 100,000 RTU) ISSUANCE DATE
pp gby the BayA equipment esanagemeit pQ pp
�Dm mrdi1s air conwNnants m defined by the Bay Are.Air Quality Management BOILER-COME(OVER 100.000 BTU) r M
❑Yes ❑No NEW RESIDENTIAL MF,CH. SQ.PI.
1 have read the haeard.us materials rcyuiremems vada,Chapter 6.95 of the APR 30 1993
Califami.Health&Safety Code,Sections 25505.25533 and 25534. 1 m derstand Nat
if the building does not currently have a tenant,that it is my responsibility in notify the
Ovnererapant.f mho regmrementa which mmol IN rot prior I.issuance if a Cenificnm of Cf IY-Ur G (IVU
orr. ��Y1ti-T
Owner or amhunud agent Dam TOTAL: ISSUED BY: �`C/