25770 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO B I DINU-hLECI KICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL n C 7 O
BUILDING U/VISION BUILDING PROJECT IDF.NTIFICATRIN L J /
DING ADDRESS: SANITARY NO. APPLICA'DON SUBMITTAL DATE
_
LTM LOT#
O S NAME: ONE: O ACTOR'S NAME: LIC NO:
. " NIC CONTROL.#
X ix 329—• ARCHITF.Cf/FNG HER: LIC NO ADDRESS: ❑
CONTACT: PHONE: a BUILDING PERMIT INFO
QTY. ELECFIi1C PERMIT PEE
BLDG ,F.CI' PLUMB ME❑CII
PERMIT ISSUANCE � II�LJ,
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-RESIDENTIAL
nmz Ihcrchy affirm thatlmm license)underpmviaione of Ompmr9(commencingwith JOB DESCRIP'l[ON
IAO_O S«difall varemB)ofect. on7nf 0e Bminess and Profession Coda and my license is in PANELS ��
Fy 02 Section 7000 effect.
Fzw License Class Lic.Is UPT02MAMNset
Fjy Dote Connote 201-IWO AMPS SQ.PI'.FLOOR ARCA $/SQ.FT.
ZOyZ ARCHITECTS DECLARATION OVER IOW AMPS
CZ-0 1 understand my plana shall be used as public records.
P4 ; SIGNS ELECTRICAL /'� f�1 !)
QWeea License)l'rofessionml P OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �, ��, / \ �, t:-'✓
Ywu I hereby affirm that 1 um exempt from the Contractor's License Law for the
O
Sit following reason,(Section 7031.5,Business and Professions Code:Any cayor county I TEMP.METERORPOLEINS'll
C IL N JQ which requires a permit to construct,aper,improve,demolish,or repair any structure u
!!( � prior to its issuance,also requires the applicant for such Permit file a signed POWER DEVICES
at
O that he is licensed purmout,o Oe provisions ofilm Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL HLEC'IAIC D
(y_rn tithed he is exempuherefmmandthe basis for the alleged exemption.Any violtniowl' OIITLEfS-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
Lr WtR n cwwraivehnndred Jollare(ESIq). NEW RESIDENTIAL ELECI'R _SQ.PI'. STORIES TYPECONSTRUCTION
��$ I.uo ernfNepropeny,ormyemployeeswitM1 wagesntheirsolecompensai«,
a3-- ill work,and the structure is not intended or offered for sale(Sec.7044.Business
and Pm cs ns Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his OCC.GROUP RES.UNITS
awn emp l oyes,provided Out such improvements are not intended«offered for tele.If.
however.the building or improvement is sold within one yearofcompletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owncrofthe property,amexclusively contacting with licensed ctntrecdorsm QTY. PLUMBING PERMIT - FEE FLOOD ZONE APN
amstma the#,oil(Sce.7044,Business and Professions Code:)The Contractor's
License law does not apply munownerofpropeny whobuildsorimpmves dhereov,and PERMIT ISSUANCE
whocortams for such Projects with acontractor(s)licensed pursuant to Comractmh
License Law. ALTER A) FEE
SUMMARY
❑ 1 am exempt under Sec. ,B$P C for thin reason O fSIDI ;ES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,CONO, RECEIPT#
WORKMAN COMPENSADON DECLARATION SCHOOLTAX Y N
• ❑ (hemhyafrr.thetlhavee«nificateofconunitoulf-insum.nramnificateof ITXTl/RES-PER TRAP RECEIPI'M
Workers'Compenvnion Instruments candied copy thereod(Ste.3800,Lab C.)which PARK FEE Y N
covets all empltyce's order his pemtlt. GAS-IA.SYSTEM.I INC. OU.RTS RECEIPT#
Policy 0 DBUILDING DIVISION FEES
Company GAS-E.A.SYSTEM-OVER J(EA) PLANCHECK FEE
❑ Cerdifiede.,isla,mbyfumimhed.
❑ Certified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('I'hiss«tion need not M completed iflbe permit is furore hundred do]).($100) SEWER-SANITARY-S9'ORM EA.MET. ENERGY FEE
ar less)
I terify that in the performance or the work for which this penult is issued,l shall WATER((CATER W/VENT/ELECTR
not employ any person in any m as m become subject m the Workers PAID
z Campensaion Lawatf Califomia. Dude so WATER SYSTEM/1'REATING Dam Receipt#
Applicant
OQ NOTICI7'1'0 APPLICANT:Ir.after nuking this Certificwcof Exemption, va,hould NEW RESIDEMPIAL PLM. SQ.FT. TOTAL:
ybecomemubjcettothe Workers Compvnnationpmvisionsofthe"s rCode,ynumufl
FFFa^^^ , forthwith comply with such provisions or this permit shall be deemed rcvnkeA. BUILDING FEE
4 �] CONST RUCTION LENDING AGENCY SEISMIC FEE
7 z I hereby affirm Nat there is a construction lending agency for the performance of I^#
U O the work for which this or i is issued(Sce.3097,Civ.C.) TOTAL: ELECTRIC FISH
LS. p--t Lenders Name PLUMBING FEE
t-' LeadersAddressQTY. MECHANICAL PERMI'P hLFEEU I certifyfythat I have read this application and state thin the above information is MECHANICAL FEE
0.W) cors et. Iagreemm,am with
rebyancity and
acrepr county miruset fandsmm lawsr upon gm PERMIT ISSUANCE
H Cl)z atho n cut mall ioofsrt berinspecbodu representative. dthiscity to enter upon
U ,2 ebo -n cntionvem,cwrthfor inspection It seta. ALTER OR ADD TO MEC((. CONSTRUCTION TAX
( c)agreemsave,itodusif enJ is harmles aCity
co Cupenino against
.fill ,jnicofilhegaisundex mics hich moyin way ecermugeinsdseid City AIR HANDLING UNIT('1'O I(I,FW CFM)
nuque reo(the gaming this it.
AIR HANDLING UNIT(OVER I0,000 CFM)
rcof Applicant/ mtactor Dam EXHAUST HOOD(W/DUC'o
PAID
AYABOGUS MATERIALS DISCLOSURE HEATING UMT(TO I03,000 BTU) Date Receipt#
Will theapplicamor furore building«cupunt store or handle Ismadous material ❑EATING UNIT(OVER 100,000 BTU) TAE:
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)?
13 Yea 0 N VENT ILATION FAN(SINGLE RESHE
Will tair conicsnt Inds ire building«cupantoy Amp Air Quality
es which Management BOILER-COMP UHP OR 100,OW BIG) ISSUANCE DATE
• hasarJonx air eonwminanls as definuJ by the Bay Arca Air Qunlily Management
Distrlm? BOILER-COMP(OVER I W,000 BTIO
P p
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.F1'. Po
have reth the haardou.materials 5505. 533 under Chapter first of the VO1. 1
California building
dos Safety Code.Section 25505,25531 and 25534.I understand that Jtl V
if the building d«a not currently have a tenant,that it is my responsibility to notify the
Ocupunt of the requiremm�tx which must be mm prior m issuance of a CeniOcam of /+//I
Occupancy.
Owner orthA ag
uunmcent Dec TOTAL: ISSUED BY:
OFFICE