25312 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RICA]. PERMIT NO.
BUILDING,DIVISION APPLICATION/PERMIT PLUMBING CT IDEANIFIC 25312
BUILDING I'RrSJFF'T IISPN'flFlf-ATION
BUILDING ADDRESS:7W / Tyr _ .4 SANITARY NO. A'PPPLICATIONSUBMITTALDATE
OWNP NAM A '
�'Y'P
4 - 4 COITN R'S NAME: L LIC NO: a •_��
NIC CONTROL#
•ARCHITELT/EN INFER: �O� CNO-
N99 D ADDRESS:
LC -
CONTAC'�CCa.t m • o061^04 PHONE: QTY. ELECTRIC PERMIT FEE
/'N{ BUILDING PERMIT INFO
OB — PERMIT ISSUANCEBHLDG ELECT PLUMB MECH
7/�„ ❑ ❑ ❑
LICENSED CONTRACTOR'S DP. RATION APPLIANCES-RESIDENTIAL. JOB DUSCRIPTIO
O0Z Ihere(o.1'mshal 3 Of the
Business
and rofesions Codc9nd(commencing with
010P02 Sectionhereby of Division aofcensed inessmd Profession Caars)(c my Beeneis inwith PANELS
a on.anderre y 9S'So/ r
FZIv1 License Class Lia# _ UP TO 2W AMPS
y6y Da Contmaor 201-I"AMPS
ZDyz ARCHITECTS DECLARATION OVER 1000 AMPS
SQ.pT.FLOOR AREA $/SQ.FT.
O Z 1 undersand my plans shall be used o public mcm u s. Q
ern(= SIGNS ELE ICA o
QSd$ Licensed Professional
L y W OWNER-BUILDER DECLARATION SP[ /MISC.
xaOyF 1 hereby aRNat at 1 nn exempt from the C«waola License Law for Ne
tzla4va following...a(Section]031.5,Businessand Pmfeasions Code:Any city or cuu TP 'R OR POLE INST.
k t='Oy which requires a permit to comma",alter.improve,demolish,«repuv any sw
>V pn... issuance,nlxa rtyuiresthe applicant for such permit to fileaeign m WER DEVICES
W that he is licensed pursuant m the provisions of the C«mcmis License Lew(Chaps
o. a 9(cnmmencing with ScdionlWO)of DivisionJof the Business and Profeasiona Cad SWIMMI POO E VALUATION _#
Mot or hal he is exemptthemfmm and the basis for the alleged exemption.Any violati':1 UTL XILRES
Section 7031.5 by any applicant for a permitsobjects the applicant to u civil penalty of
net more than five hundred dollars($50(1). NEW FSI AL ELECRtS FT.
❑ I,asownerofthepro any,ormyemployeeswithwagesntheirsolecompensaVon, Q' STORI TYPECONSTRUCIION
a will do Ne work,and the lonammisnot intended oroffcred forsale(Ser.'/0, ,Business
and Professions Code:The Contractors License Law does not apply to an owner of
Property whobt iIdsmimproves thereon and whod«e such workhimselforthrough his
ownemployces,providedthat such improvements am not intendedorofrered forsale.IL OCC.GROUP RFS.UNITS
however,the building«improvement is sold within one yearofcompletion,tneowner-
builder will have the burden of proving this he did not build or improve for purpose of
sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
❑ I,ct the Project
property, ,Business
C beans he Contractor's
icconensetsheproject(Ser.oaro nerm7arand Professions Crimpone Conre.ar'e PERMIT ISSUANCE
License Law d«snot apply to un owner of property who bu i Ids«improves Nctean.and
who crammer,for such projectswitha conuactoKa)licensed pumuemrothe Contractor's
License Law. gLTER-DRAIN&VENT-WATER(PA) PEE SUMMARY
❑ I am exempt under Sca. ,B&P C for this reason BACK ROW PROTECT.DEVICE .IDF. ES
SANITARY Y N
Owner Data RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,BOOP,AREA.CONI. SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofcmmm to self-insure,ora cenifeumof RECEIPT#
Workers'Cam FIXTURES-PER TRAP ��
pensuti«Inumnce«ecenificd copy thereof(Sx.3B00.Lab C.)which PARK FP.E Y N
rs till employees under this permit. GAS-HA.SYSTEM-1 INC.4 OIITL.ETS RECEIPT N
Policy# '1 BUILDING DIVISION S
Cmmpany GAS-EA.SYS E LANCHECK FEE
❑ Cenified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFIINDD O RADING ME
CERTIFICATEOFEXEMPTION FROM WORKERS' GREASE TNAP SOILIFEE �a
COMPENSATION INSURANCE
(This aechonneednot be completed the permit is foronc hundred dollars($11) SEWER-JANITARbATWos, E YME Ia
or Iew)
I certify that in the performance offle work(«which this permit is issued,l shall WATER W/VENT/F.LECI'R
not employ any person to any manner ao n m become subject to the Workers PAID L02f {wt�
Compensation Lowsof California. Date WATER SYSTEMf[REATING Date n p
O z Applicant
z0 NOTICE TO APPLICANT If,after making this Certificate of Eaemption,you should NEW RESIDENTIAL PLMIL SQ,FT, TOTAL:
FIA become subject o the Workers Compensation provisions ofthe Labor Code,you must
a ; forthwith comply with such provisiom or this permit shall be,deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
V z 1 hereby affirm that hem is a construction lending agency for the performance of ELECTRIC FEE
T
O the work for which this permit is issued(Sec.3097,Civ.C.) rb e
Lender's Name
Lattice.anPLUMBING FEE
del.Address QTY. MECHANICAL PERMIT FEE �•
I certify that I have read this application and state that the eMva information it
comet.l agree to comply with all city and county ordinances and nate laws relating to PERMIT ISSUANCE MECHANICAL FEE
V, building construction,and hereby authorize representatives ofthis city menterupoothe
U 7 above-mennoned property for inspection purposes. ALTfiRORADDTOMECH. CONSTRUCTION TAX
r� (We)agree to save,indemnify and keep hasmlesa the City of Cupenino oilman
liabilities,judgments.exerssndexpernsea whish may in y wayincrueagaiot said City AIR HANDLING UNIT(TO 10,MCFM)
in conseyue o he ruining of this permit.
7 AIR HANDLING UNIT(OVER 10,00 CFM)
Ir-
Signewm of Applicent/Conuactor Data EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building mccupant atom or handle hazardous material BEATING UNIT(OVER 100,000 BTU) TOTAL:
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE R[SID)
❑Yes ❑No 11
_ ISSUANCE DATE
Will the applicant mfuture building«cupant use equipment ordevices whichemit
BOILER-COMP(3HP OR 110,W BTU)
I zazdnms air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1011.000 BTU)
Tisvia?611- ❑ 13ECR1 pP'G ' D
Yes Na NEW RESIDENTIAL MH. SQ.FT. 1'�
1 have mad the hazardous materials requirements under Chapter 6.95 of she
Jul(�/
ifomia I lealth&Safety Code.Sections 25505,25533 and 25534. I urrsm
ulcnd that
if the building does not currently have a tenant,that it is my responsibility to notify the
Occupant of the requireme as which must be met prior to issuance of a Certificate of
Occupancy. �//Y (. r
tnIINU
Owner or authonuJ agent Date d i I A ISSUEDBY:
Q