26899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD;Nt. LLLCt B"', PERMIT NO
APPLICATION/PERMIT PLUMB NG-MECHANICAL 26899
BUILDING DIYJXlUN I BUILDING PROJEMADENI'IF'ICA'I ION
BUILDING ADDD� 1 SANITARY NO, APPLICATION SUBBBbUTAL DATE
LO� V� .• 1 �� UNIT LOTH _ I (_,Igyq�
OWNERS NAME: PHONE' CONI'RACI'OR'SNAME' LIC NO: NfC CL.JJ COII//NTIt-OLp`
�=P ,AA Q�f_n uia l4 k,
ARCHITECT/ENGINEER: LIC NO ADDkES ❑
"NIl--�A#1 ROUIIJ �`'�'/��
coNTAC': pxoxE: QTy ELECTRIC PERh11T pEG ' BUILDING PERMIT INTO
BLDG fiLL—q, PLUM1 - 'C
I PERMITISSUANCE (
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RPSIDENTIAL + JOB DPSCRIPI'ION
0IX 2 1 hereby affirm that 1 tun licensed underpmvisionsofCha pmr9(cotmnmcing with
1+100 Scsvmn e mid of Divisors l ottne Business and POfessons Code,tail my license ism PANELS
�U full force[.aelse
ZUt Li lass Lic.p LIP TO 200 AMPS
wQ m Comrmtm
a ppv��w.f
FyZ_ ARCHITECTS DECIARA'1']ON �3A3 T1100 AMPS t SQ.PI'PLOOR AREA $(SQ.IT.
20 rn I understand my plans shall b,used as public records. I DYER 1000 AMPS
OZ
<�r F"
SIGNS ELECTRICAL
Qy�, Licensed i'mft>wonel
V OWNER-BUILDER DECLARATION (SPECIAL GIRGUIT/MI$G. v
s�0a 1 hereby i lllom that 1 am exempt'feom the Comment's Uranro Low for the
W 3 a Ire rnllowmg reason(Section 703L5,Business and Professions Code Any city m county I TEMP MITIER OR POLE INST.
at,�A; wnicM1 rnlmres a permit m constmcp eheq improve,demolish,or repair tiny structure pnonoita osounce,also agmrc>theapplicant forsuch pemnnofleasigned smtemem (POWER DEVICES
(aU'C,p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
ta. O(colmnencmg will)Section 7000)of Division 3orthe Bmura,aand Professions Code) I ♦ SWIMMING POOL ELECTRIC VALUATIO
W_m nnhatbeiseaempOherefmmand the beasfonheatlege appempuoo. Civil of
FZa or that he is e5 M1Y any apphcantfor te petmM1rthemegial aploanlm a anvil penalty of 1/f�dI OUTLETS-SWITCHES-FIXTURES
F t more than five hundred Jolla..($500) NEW RESIDENTIAL ELECTR _SQ FT.
CO ❑ I.asownerofihepmpen)tormyemplayecswiNwegesaathetrsolecompe naabmn, S9'ORI& TYPE CONSTRUCT ION
2 322 will do the work,end the structure is not intended crofferad forsele(See.]0ai Business
and Prom,noms Code The Cmulacmr's License Law does not apply Ire w owner of
property whobmldsocormoo es thisman,end whndoes such work It maelforlhmughhis _
hoempoyee......deJ lhnl such Improvements me nm inrendeJ Onif fcred for le If, I OZC.GROUP RES.UNITS
wever,the building onmpowement is sold within one year ofcc plan. e nu.
builder will have the burden ofprovmg that he did not build ot prov rpuryo of
sale)
❑ I,azhwnerofthe pmpeny,amexclusively contacting tail)l I immetata QTY.( PLUMBING PERMIT PEE I FLOOD ZONE APN
tiatooto the prole.ISa,THY,Bootie,and Professions e0 The Contract 's 1
License Lawdas not a pplytoannwnerofpmpeny whobu or'[p INercon,an ' PERMIT ISSUANCE
whocontmsofnauchprolects wrhacontractm(s)lmen punuen oCont pL'fF.R-DRAIN&VENT-
LmerwL.w. WATER(EA) f 'FEE SUMMARY
❑ Iamexemplonder Sec. "his BACK FLOW PROTECT.DEVICE 011'I:SIDEFPEb
_I SANITARY Y N
Own— a 's -- RECEIPT#__—
WORKMAN COMPENS IONDE ION DRAINS-FLOOR,ROOF.AREA,CONU (SCHOOL TAX Y N
❑ Iherchyaffrmthmlhmc.cvmfc of, sent s -intone rx ifcm f r7 I I - - RFCEIPT#
` , FIX'1'URGS-PER'I'RAP ��
:'m kers'CLmpsnedurs.lnsuanceorac of(Sec 7$NI�Lab CJw cIt _ SPARK PEE Y N
r.all employee's under this perm \\ GAS-FA.SYSTI3M-I INC.40UTLEfS RECFIPT# _
Policy p BUILDING DIVISION 193'5`
Co.,._ GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished TirT/p�p
❑ Cendied ropyrs filrA wish the city mspechon division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WOR S' GREASETRAP SOILS IFP
COMPENSATION INSURANCE
_—
This section need not becomplemdif the Permit is forone hundred d011arslElfgD SEWER-SANITARY-S'T'ORM F.A.301 ENERGY FEE,
or less)
I certify that the peroomance ofthe work for which this permit is issued,Ishall (WATER WATER WIVP.NTryLECIR
nut employ any person In any manner so as to become subject in the Workers' .AID
Compensation Lawsof Culifomte. Dar WA TER SYS'IEMUREATNG � — -- - Dam Receipt#
zZ Appllcan• _
0— NOTICE'1'OAPPLICANT If,after making this Certificate of Exemption,yoosbould NEWRESIDENTIALPLMB. SQ.FT TOTAL:
V) become subject to the Worker's Compensation,provisions of the Isbor Code,you must
� � fnnhwnh comply with suchpmvisiona onha perms shell be deemed revoked. _ BUIIAINGFEE
� Z CONSTRUCTION LENDING AGENCY (SEISMIC FEE
1 hereby affirm that(hero Is it construction lending agency for the performance of yt�
U O the work for which thu pctmn is issued(gee 3119'/Crv.CJ AL. ��— 13LECIRIC FEE
Lenders Adm• __ _
Lenders tify that _ QTY. MECUANICAI,PERMIT pFE PLUMBING FEE f
L) I c<ndy Nat 1 have read this application and state that the above information IS 7
rent. lugtee.comply with ell nsy and county ordinances and smmlaws rclming to r PERMIT ISSUANCE �� MECI IANICAL FEE
�' V) building constmetion,and hereby authonee mpresenmtives Old isntymrnmr upon the _
U above-mentioned property for inspection purposes. AIATR OR ADD TO MECH I I CONSTRUCTIONTAX
(Wm agree ,,save,Indenmify and keep harmless the Cny of Cupemao ugmnd hold.linespardiptimmar,emis anJexpamms which may inanyxeyalxru .,purat said City AIR HANDLING UNIT(TO 10.000 Crm)
,It CgV4.arec of the grt L9 QW It.
AIR HANDLING UNIT(OVER I L.CM)
vu ma o Inr D e I EXHAUST DOW(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE. I HEATING UNIT(TO 100,000)BTU) Dam Receipt p
Will the applicant Or Note budding occupant store or bandle huraof mmerial -
as defined by the Cipenom Municipal Code,Chapter 9.13,and the Ileallh and Safety HEATING UNIT(OVER 100,000 BTU, _ { TOTAL
Code.Seaton 25512(e1P 1 VENTILATION FAN(SING LE RESID) �Sv
❑Yet Cl NO
Will the xppbcanmrNUture hulldmgixcupunmsenllllpment nrdevices whshemu
BOILER-COMP(3HP OR IN."BTU) I ISSUANCE DATE
haardois an conmminants m defined by the Bay Area Air Quality Management I I BOILER-COMP(OVER IN,"BTU)
D"ame"Doe" P A
❑Ycs 11 I I Nn NEW RESIUEN' AL M13CH. SQ,PT.
I Itave mad'he Ilnardons ammonia¢9irements under Chapter 605 of the
Callfomm Heallh&Safety Code,Sections 25505,25533 and 25534.I understand that /l V
if the building dies not currently have a tenant,that it is my rtaponsbtnty to notify she
rupdnl of the aymrenenis which must be met prior to n+aance of a Certficate of
Occupancy I CII Y r
I -
Owneroraulbnnaedspnt D � �I � ISSUE] tt IYV
OFFICE