26537 4PPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I I _
CITY OF CUPERTINO BUILDING-F.LEC'I RICAL - PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. I 26537
I HVILUING PROJECT UIENI'B'ICATTO,Y
9UILDIN1++1GA55ppRFSS a{I`y-f I , i SANITARY NO APPLICATION SUBMITTAL DATE
O ):kS NAM �/^D' o/� IONI:' 'I ~ oe—COM RACPOR'S E. 1.0'1'M LIC NO
0 IIf - - N/C I CONTROL.#
n RCDIIEC I/ENGINEER: LIC NO'. A iy:S: ❑
tti Ado
t TATA-Cf: PHONE
QTY. ELERIC PERMIT FEE CT BUILDING PERMIT INFO
PERMIT ISSUANCE Z_� I BLD ELECT PLU MECH
LICENSHE CONTRACTOR'S DECLARATION TILL 11 APPLIANCES-RESIDENTIAL. _7 Oy-O_QB'6'CS�CRIPTION
yy Iherebyaffmi that l am licensed underpmvoronsof Chapmr9(commmcingwllh I
00 Section 70W)ofDmsion 3 of the Busincoirml probations Code.and my Incom is in PANELS
ull lnngandeffed _ ''ll,, I . /
FZ, laccn•c a... Lic.N Z W - ,r4 Z ` UP TO II MPS ' I �L✓ ! �n �p0 1
m=y Date Cnmrucmr 1201-I MPS 1
ZOy A CHITF.CTS UEC RA N I V 1 AMPS - SQ Pf.PLfN1R AREA $/SQ Irl'.--
OZ�O de of my Ian Ilbe apublj/tecords. I L
QY�Q 1 -used Profeaiona NS EIP
K� OWNER-BUILDER DECLARATION IAL S/
1 hereby affirm that 1 inn exempt Boothe Connncmis License Law far the
R13Ov�i following reason (Section]031.5,Bruness and Prefessmus Code:Any city or worry MP. OR!'LSLE MST. / yI
Fk which requires u permit to conxtram,aher,improve,demolish or repair any structure _"v. ,,WER DEVICES I Y t-
W oionn.tsu...me,also ruryirex deapphcanl for such pmort m his.signed amtemcnt rV
C p hat hen lmeneedp oumd tribe pownuonsitf the Contmmth License Law(Chapter
SWIMMUSOPOOLELECIRIC c) �at
9(cnmmenang wrtli Section]0110)nl Orvrsinn3of the Busmen end Professions Code) I / aL{d I VALUATION
tA..m or that he is exempt metefrnm and the bans for the alleged exemption.Any vtolatimn ar OUTLEfS-SWITCHES-FIXTURES'
FZQ Section 7 031.5 by any applicant for a permit subjects the applicant to civil pantry of {[JJ a 1
O t more than rive hundred dollars(5500) v �19
Ir o nLl I,aowneroFlheprol'crty,ormyemployeeswith wagauthevsolecomp,manard, I NEW RESIDEMDALELECM —SQ.FT. I STORIES TYPECONSTRUMION
a3= wtlldothe work,and the souaumisnoumendelinoffered for sale(See 70J4,Business -
and professions Code The Cormar or s License Law does non apply to an owner of I
propcnywhobuildsonmprnveethemon,mdwhodoessuceh workhorselfortluoughli s
own employers,am,rdeddrou such improvements are nmuntcndcJ UrofPorcd forsale IL I I OCC GROUT' RES.UNHS
hawevcntho bulldingor improvement is sold within one ymrofeompletion,downer- I T(7AL
bmldcr,will have the btormifpnwmg that he did not hurt,]to improve for purpose of -
sure)
❑ I,anwneronhe propenY•amexclarvelycunnaningwith hcansedconoadmsto IQI'Y. PLUMBING PERMIT FEE I FLOODZOND AIN- -
nense the project(Sec osuro Business and Profeaiom or imp The Cannector's - w
,vorane Law dceenot(See 70,1,4,
mownerness and tom who ImiLda or improves; , PERMIT ISSUANCE Yl apply
whoconimcm forsuch projects with a vomracmr(s)licensed pursuant m the Contrectora -
l.mense Law AI:IER-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ 1 am exempt under Sm. - B&P C for this tea on I RACK FLOW PROTL•CT DEVICE SANITARY sit Y Do_l N
Owner rsim DRAINS-FLOOR,ROOF,AREA,COND. _RECFIO,g
WORKMAN COMPENSATION DECLARATION ____ _ __ IcCHOOLTAX gGCIi1PTN N
_❑ Iherchy affrm thmlhuvcucenifate of consenuo scl f-mmm.mricemficmeof IIXT'URFS-PER TRAP
i Wnrkrrs'Campensmlon lnwnmea nru oeniFUl copy thoroof(Sec.3gfSl,LUb CJwhwh _ PARK FEE Y ,k_,kN
covers all employee'v under this pamil. I `I GAS-FA.S TEM-IINCA'6tn'LETS I BUILDING OC PON FEES Pfir
Policy M
❑ rCemfiedcopyealit.byfumished. GAS SYS M-OVER4(FA) I p1ANCHECK Ff?Fi
Ceinficd copy is flml-uh the city iinpeouon divtsmm I CRIiASFN Rh WASTE IWERCEPI'OR (GRADING FEE s• I`a Y%�/
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS TR SOILS FEE
COMPENSATION INSURANCE I ��/ �q�� I'
Cum l ecrufytth�WSth Ceffomtmoofthwork mm which one hundred dollars(Alpl SEWER HA.200111' ENERGY FI?F: r1
('Ian section need oat he co kfi ThjL( -
to,,
Y pc ma manner nor torwcours,n subject tsuu Workers( I WA'f1iIt HGTER W/V P. L.Ii
not employ tiny pervon in any manner eo ss to become suhjem m the Workers' - ---- rAID
Z pease n. pm- I WATERS TEM/M TING �) Date Rcceiptg
O O Applicant '
NOTICE TO APPLICANT:If,after making this Cm+Bcam of Exemption,you should NF.. LPLMB. TOTAL
Z V_1 becismesubjmttothe Wodcr's CompenUtLMpmvisionsofthe Labor Cade,youmust \�\err
a > forthwith comply with such provunmel or this permit shall be dearned revoked. I f (BUILDING FEE a�►�
aQ CONSTRUCDON LENDING AGENCY I �^ SEISMIC FEE
UZ 1 hereby affirm thin there is u construction lending agency for the(ierfonnana of
O the work for wha.h this poor is issued(Sec.3097,Cis C) I ELECTRIC P1114
lender's Nom• / q -
I'Z& Addy-•• ll/ YI- _ QTY. MECHANICAL PERMIT hlil? PLUMBING FBI?
U 1 eerily that 1 have mad this application and state that the above mfoimar rs
0. mead,(agree to comply with dl city antl compy oMmancesandxtatelowsrelanngm I J PERMIT ISSUANCE r �� I M[CIIANICAI.PEIi
F' pj bulWingconsnucton,and hereby authnrmc repmaentaovo mums city mente upon the
U Z above-mentioned property for inspection putpram, ALTERORADDTOMECH. CONSTRUCf10NTAX
(We)agree m save,indemnify and keep journalists the City of Cupatmo against
hadshlos,judgments,costs andexpenseswhmh may in any way accmeagmnst said 01y I AIR HANDLING UNITOO 10,000 CITd)
in cimseyuence of the granting of this peril.
IAIR HANDLING UNIT(OVER IgdnB GFM) I_ _
`i ro
PAID
of Apphc,rVCinractor fXIIAUST HOOD(W/DUCT)
HAZARUOl15 MATERIALS DISCLOSURE I IIfiATING UNIT(TO IIXI,IXIII NTI1) I pule receipt
W,]I the applicant or forum building occupant store nr bundle huzurdnus mammal Hf?ATING UNIT(OVER IW.(k)11 BTU) " j
C defined by the Cupertino Municipal Cade,Chapter 9,12' the Health and Safety _/ I t __ OTA
Cw1e.Seri❑Ya32(a)p ❑No' VId`TILATION FAN(SINGLE RESTED
BOILER-COMPORPOR IU0,fN10 RTUj I I IS DATE
Will theeppbcantorf uwre hmWingoccupant useeyuipmenmrdcv ices which etmt I 1
hamrdaus air conmmmnnts ur del nail by the Bay Area Air Quality Mmagement I B011,13R-COMP(OVER I(IO,IXXI BTU) I PAID
Astrin'1 11 _
❑Yes W No NEW RESIDENTIAL MI?CIE. SQ ET AUG 1 haw read the Safety Co e,Sarnia reyuirementa osier Chapter a eod of she I A 3 0' 1994
California Health&Safety Cotly have ate 25505,25533 and spons 1 understand that
U the building does not currently heveemnanL that it is my responsibility to notify the I
�` ymrerrrenn which L27"`,77,Ccrtifxam of G�/)'
O rrtr nr our �. .g� Y! •i/II —_ _ b �JY I �Il AU
OsL ...... da ant �-= 5,, sC I55UEDBY
OFFICE - ` -