25607 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ".I'. 'NTRI.RCFRTCAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUM ROJECTECHANIFIC 25607
BUILDING PNDAN(:T TUI?N'fINV,A'1'ION
BUILDING ADDRESS: SANITARY NO. APPPPL`ICA111O-NSUBMITLALDATE
r �F UNIT# LOTH
OW BRSNAME: C NH:� COM'' R'SNAM': e 5 J LIC NO NIC CONRO
TROLk
j IiITECT/FNGINEIi LIC NO: ADDRESS:
RCOSe� ��/� �✓z_ O�
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMTT INFO
86 ELECT PLUMB MACH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL '
I hereby affi.,hat l am licensed under ns of Cha ter 9(commencin with TOB DESCRIPTIO
�+] Section of Division Boniness and Professions Code,and my licemeis in PANELS
y full force unJ effect. Q
FZZ, Sow CI Lic.p 3 Z 9 UP T0200AMPS
may Dat[ s _ Contrwmr s 201-15M AMPS
ZON2 ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR ARBA $/SQ.PT.
O Z- I understand my plans shall be used us public rew,ds. f
�� j SIGNS ELECTRICAL A . - r1 A , rr ;
Y J Licensed Professional t oV
y.CG OWNER-BUILDER DECLARATION SPECIAL CMCUTT/MISC.
KO y1- 1 hereby affirm the,1 am exempt from the Contractors License Law far NY p"1
Ia13Om , or count TEMP.METER OR POLE MR
ST. y ��� 0 IYI It—� which requires a permittoconstruct,alter.improve,demolish,or repair my structure
following reason. 7031.5Business and Professions Code:Any city
;!(}2 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
y4_Oyp that he is licensed pursuant to The Provisions of the Contractors License Law(Chapter Is
L o�' 9(co anstrang with Section]0007 of Division 3 of the Business and Potassium Code) SWIMMING POOL ELECTRICy ATION
p '^y
or that he is exempttherefrom and the bums for the alleged exemption.Any violadmaif OUTLETS-SWITCHES-PIXTURP.S
CSectio,RU 1.5 by my applicant for a permit subjw,s the applicant to civil Penalty of
no, not than Five hundred dollars($SM).
W 22EDI,vownerofthepropM,ormyemployeeswithwagomNeirwlecempewdon . NEW RFSIDENTIALELECIR _SQ,Ff. STORIES TYPECONTIRUCDON
Wa322 willdmhework,endrhe...Imm is not inrendedoroffered far We(See 7044,Business
and I'mfcsaions Came:no Crewman's License law does not apply to an owner of
prnpmy who builds or improves thereon,and who does such work himselfor through his OCC.GROUT' RES.UNITS
ownemployees,provide lthat such imMovememsarenot intendedoroffered f wale.IL
however,the building or improvement is sold within one ytarof completion,theowner. TOTAL:
builder will have Ne burden of proving dua he did out build an,improve for purpose of
sale.).
❑ I,uvswnerofthepnpeny,amexclusivelycontmvtingwiNlicenudcun.ctomm QTY, PLUMBING 11I3RMIT FEE FLOOD ZONE APN
construcl the project(Sec.RWQ Business and Professions Code:)'Ilse Con[rector's
License Lawdaes not apply to an owncrofproperty who builds or improves thereon,end PERMIT ISSUANCE
whocontracts for such pmjams with aconbacauds)licensed pursuant o the Connectors
License Law. ALTER-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this revon BACK FLOW PROTI3L7f.DEVICE SIDE FHFS
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,ARTS,COND.
WORKMAN COMPFNSATIONDECLARATION SCHOOL TAX YN
fli❑ Th'Camperimtlual mInstaveacmifieamed[cope ntrevdf(Secs38,m acert.)chid MOPURES-PERMAP RECEIPI'p
Worker�Cnmpensetionlnsu,wceor.cenifiedcopy thereof(Sec,Jg00,Lab CJ which PARK FF.E YN
covers all employey_suWcr UBs gs,rYy6 _ �j GAS-PA.SYSTEM-I INC.400TLP,TS RECEITN
PolicyM 11 UU S O - BUILDING DIVISION FEES
CompanyGAS-EA.SYSTEM-OVER4(IA) PLANCHF.CK FEE
❑ Caddied copy is hereby famished.
Certified copy is fled withthe city imepection division. GREASETNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This section need oat becomplerdl ifhe prand is forone hundred dollan(SIN) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or lay.)
I certify that in the performance of he work for which,hispe.I,is issued.Ie hull WATER TER W/VHNT/ELHCDF
out employ any person in any manner so as to become subject m,he WorkerPAID
Z Compensation Lawsof Califomia. Date ATER SY .M/1'RFATING Date Receipt#
O O Applicant
rZZ NOTICP.TOAPPLICANT:ILaliermaking this Ceriicateaf Exemptlomyouahould ESIDFNI'IAI.PIMB. SQ. TOTAL:
C"t fn become subject ro,he Workers Compensation provisions ofthelabm Came,yau must
tai . forthwith comply with such provisions or his pe.it ball be deemed revoked. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z Ihereby affirm that ohm is a construction lending agency for the performance of ELECTRICFEE U O the work for which this pennit is issued(Sec.3119],Civ.CJ
Lia Lcndcr'a Name
O Lender's Address QTY, MECHANICAL PERMIT' FEE PLUMBING FEE
1 certify that 1 have read this application and stare that Ne above information is
0o. correct.I agree to comply with all city and county ordinances and state laws mlming to PERMITISSUANCE MECHANICAL FEE
buildingcous.clion,and hereby authoriu,epresen,alives ofthis city to cater upon the CONSTRUCTION TAX
U y above-mentioned Property for inspection pnpwas. ALTERORADDTOMECH.
L7 (We)agree to cave,indemnify and keep harmless the City of Cu an
inet
liabilittes,judgments,c swhi maymanywaywemea insts hat
AIR HANDLING UNIT(TO 10,000CFM)
inc quem no is
AIR HANDLING UNIT(OVER 10.000 CFM)
Sign cofA p,cmd/ mmmor V 7 Dan, EXHAUST HOOD(W/DUC1)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UND'(10 FTE030 BTU) Dam Receipt#
Will the applicant or future building occupant stare or handle hazardous material (EATING UNIT(OVER I W,(Np(ITU)
v defined by me Cupertino Municipal Cale,asp cr 9.12,and the I lwhh and Safety
Cole,Scainn 25932(e)]
1:1 Yes ID No VENTILATION FAN(SINGLE fdfSID)
Willthenpplicanmrfmure buildingoccupant usr cyuimnen,nrdcvica whichemit BOILER-COMPLIHPOR 100,0011 BTU) Rj, AISeSIJNCEJIM
hazardous it cnarsou mms as defined by the Bay Area Air Quality Management BOILER-COMP(OVFR 100,000 BTU) V- 1 u
'ardor]
❑ OCT - 51993
,J Yee ❑No NCW RCSIDENI'IAL MF.CH. SQ.IT.
1 have read the hazardous materials reyuimmems under Chapter 6.95 of the g
California l health&Safely Came,Sections 25505.25533 and 25534.1 understand that CITY Ur GUrtnulvv
if the building does not currently have a tenant,that i,is my responsibiluy to notify,he
occupant of the requirements which mux,be met Thor to issuance of a Certificate of /
Occupancy.
Owner or nmhudzed agent Date TOTAL: ISSUED RA