25328 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLECTN AI- PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL, f� [ a] n O
BUILDING DIVISION BUILDING PROJECT']DEN i'IF'ICAY'ION G J J L o
"'I
TD$ S: v / SANITARY NO, APPLICATION SUBMI'TT'AL DATE
ko&ndoll UNIT It LAzot;:0
OWNERS NAME:1y
..+ CONT N'S NA ?� �� N/C CON'1'ROLY
•ARCIU'1'ECT/I'N IN?ER: NO: ADDRES
CONTACT: PHONE:
Q'I'Y. ELECTRIC PERMIT FEE Q BUILDING PERMIT INFO
ELECT PLUMB MECH
" P17RMHISSUANCE 1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p00 Iherehy nfErtn malam licensed under PrnvisiO"I.dMylimusekin
nsofChnpter9(commencing with LOB D�R1
IA00 Section]OW)tf Div'iw3 the Busin51E
on ppNEIS CV fulforcdeffec Z, UP TO 200 AMPS
6Dae Cm201-IfglO AMPSmD SQ. I'.FLOOR ABPA ' $/ FT.a
I underxland y plans slndl he use rec ds. OVER IIgX1 AMPS
FEa�a SIGNS I?L1iCTHICAL
a Licensed Pmfexsional
g OWNER-BUILDER DECLARATION 51'1?CIAL CIRCUIT/MISC. 1
iF 1 beach,a!f Nal I ran exempt from the Contractor,License law for the
,n3D-m following reason,(Section 7031.5,Business and Professions Cork:Any city or county TEMP.MITER OR POLE INST.
which lequhcs a permit tt construct.alter,improve,demolish,or repair any sanclure
�,<7 gnat,its issuance,.6o mgmres Neepphca,for such pemdut fileasigned statement
RPOWER UEVICI'S v
N�'p O m that he is licensed moment the Provisions of the Contractor's License Law(Chapter
O� 9(commencing with Section]W0)nf Division 3 of the Businessend Professions Code) SWIMMING POOL,ELECTRIC VALUA'T'ION
y{_y or he is exempt herefrom and the basis forth,alleged exemption.Any violation of QV11EI'S-SWITCHES-fIXTURtS ft
5 K 4 Section 7031.5 by any applicant for a Permit subjects the Rift icanno a civil penalty of • d{/
not morep than Eve hundred dollars(S50(). NEW RESIDENTIAL FLf:CTR SQ.FT.
❑ oche work,andeestrucy,trmy<mtendeeawimwed forsaleisale(Sec.70mpensiness STOMP TYP:CONS'IRUCTION
will drnhewons andthehe CommOmture is not inLicenseed Law does not apply
an Business /
and Proerty who
Code:The Gmtmrerm.License Law does not apply f rt owner of ` r.
progeny whoas,provi i d thovesch impr add who doasuch
tendo oroff red hrmbb ssle.I s
owneer.do,cu,pingor improvement
impmvld within
neyearo comphfered then nor. OCC.GROUP R' NITS
htwevcwmeavet a burimprovement issoldwithinoneyear o Improvef for
r-
builJer .will have the harden of that he did not build or Improve for f TOTAL:
proving p purpmseo
seta.). - -
❑ 1,asowncruOhe progeny,amexclusivelynm0aaing wim licensW cnno-acmrstn QTY' PLUMBING PERMIT., FEE FLOOD DONE qPN
construct the projcet(Sec.](194,Business and Professions Code)The Contrnemrs PERMIT ISSUANCE
License Law does not apply co an twnerofpropenywho builds or improves thereon,and
whocontrsns forsuch projects with a convaclor(s)licensed pursuant collie Contractor's ALTER (FA)
License law. FEE SUMMARY
❑ I nm exnnPt under Sec. ,R&P C for,M1is reason BACK PLOW PROTECT.DEVICE OU DF, ;
SANITARY Y N
Owner Dae RECEIPT#
WORKMAN COMP17NSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, SCHOOLTAX Y_N
❑ I hereby affirm that l have a certificate ofemsenno self-Insurt,or a certificate of RECF,IPI'p
FIXTURES-PER TRAP
covel
Wmkcra'Com T/�)a�BeT�tfr9i{c.ertified cop hertoffSa.3S00,IabCJ which PARK FEE YN
mall e-:PoL � , GAS-FA.SYS'I'IiM-I INC.4 OU'I LETS RECEIPTN
Pnli<yM I /�Iu BUILDING DIVISION FEES
Company— I n GAS-EA.SYSTEM-OVER 4(EA) PLANCH17CK FEE
❑ Certified c py r, mi'shu��
❑ Cenifed copy is Elul with the city inepectiondivision. GREASHINDUS'ME WASTE INTERCEPTOR GRADING FEE
CER'11FICATE01'EXHMPTIONFROM WORKERS' GREASE TRAP SOILS FEL?
COMPENSATION INSURANCE
(Ibis section need not bectmpleted ifine permit is force hundred dollars($100) SEWER-SANITARY-STORM HA.200fT. ENERGY FEE
or less.)
Iciamay ha it tl per( soca of the work for which mi pe nisi cd,IsM1al1 WATER IIFATFR W/VP-NT/ELECTR
not employ any r n NV
manna so m to b c nb Workers' PAID
Z Compensatin 1. �I'C } ! WATER SYSTEM/1'RFATING Dam Recei'lN
APPlicant
z� 0 NOTICE TO PPLIC :ilia ranking this Certificates(Exemption,youshould NEW RESIDENTIAL PLMB. SQ.FT. '1'O'rAl.:
beconm subject mthe kers r pit... nPmvieitns of the Labor Code,you muss
••"�" > forthwith comply wim suer proPermitr, ons or this Permit shall be deemed revoked. BUILDING FEE �r
WQ CONSTRUCTION LENDING AGENCY SEISMIC ITH
7 z I hemby affirm that mere is s construction lending agency for me perforamnce of
V O
the work for which this permit is lamed(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
Lenders Name
O F Lenders Address QTY. MECHANICAL PERMIT _ FEE
PIAMBING FEE I certify law 1 have read this application and state that the above inftrnat int is
correct l agree to comply with all city and county ordinances and state laws relating to PFRMITISSUANCE M IiC1 IAN[CAI,FIAT
building construction,and hereby sultanas repmsenmtives of this city to enter upon the CONSTRUCTION TAX
L) z ab�ve-mentioned p,.,ny for inspection purposes. A LTER OR ADD TO MECII.
(We)agree I eav indemnify and ka less the City of Cupertino against
Iiabilitics,judgme ,4,vJJqq,'/;;/'',�.'' dexpertuswh'I a yinanywayaocrueagaist td Ciry AIR HANDLING UNIT(TO 10,"CFM)
in umeoqumcr tM1 Is �nfng f1 isp 1.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature App leant/ ontnmmr at EXHAUST HOOD OVIDUCT) PAID
IIAZARDOUS ERI S DISCLOSURE HEATING UNIT(TO 101,11010 BTU) Date Receip,k
Will me applies.,or(mare but gacaamt anre or hand to hazardous material HEATING UNIT(OVER 100,0[1013TU) 'TOTAL:
as defined rti
by the Cupertino Municipal Code,Chapter A 12.and me Health and Safety
Coda Sarson 25532(u)P
❑Yes ❑No VENTILATION PAN(SINGLE RISID)
Will lair conicanmut as building by the Bay Area Air Quality Managemch ent
Doubt,
BOILER-COMP QHP OR 100.00D BUD) ISSUANCE DATE
haturdaus air contuntinmts as defined by the pay Area Air Quality Management BOILER-COMP(OVER 11X1,000 BTU)
"Diatncn pp
CIYes ❑No NEW RESIDENTIAL MECH. SQ.Mpp A'. T 1 D
1 have and the hazardous mmenals armacomms under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand thin DEC - 1 1993
if the building does no,currently have u tenant.[hut it is my responsibility to notify the
aupam of the requirements which must be met pnm to issuance of a Certificate of
Occupancy. _
Cllr .r.
Owner nr au,hon dagmt Dine TOTAL: ISSUED OY:
OFFICE