24875 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B111,11tNl.-hLoA J lr.Al I PERM)I NO.
BUILDING DIVISION APPLICATION/PERMIT I PLUM BING-MECIIANICAL 24875
BUILDING PROJECT IDENTIFICATION
OUILDzzs 4�6 d�co.�d,q /7 a'11 UNIT# LOT# gAN19'ARY N4 APPLICA'I'IONSUOMrI'1'A�3A'1'li
OW' RS NAME S PHON13i X CONTRACTgppgggSNAML �k I.ICNO
5 � ��AST• rK q 1 I 1�+// / /� N/C CONTROL:#
-� ]fiTECT'//I:NGIN4ER Lf`-• LIICC NOS Tr�T^,TA^ ?.z:I4,id 4/JCQ//„CLL!•• Itoa
CONTACT NHONIi. BUILDING PERMIT INI°O
1 1 QTY. ELECTRIC PERMIT Plili *� .,.(� ``��BLDAC.Y LJfR,SrEi2 SG Ca �y60 1 ` ,i P/�/ v
1 PERMIT ISSUANCE
LIC NSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
X00 (herehy nf0oth:nl a of Lire Business and wmnsiCCode, ndmy enensewnh ��
X00 $eaiont,AndefDrviaon3of the Business end Professions Code,and my hams ism PANELS 1 �` O
Jet full(urce and<f&m UP'f0200AMPS s/1r'
<- License Clns\ Lisp
wcy Date Ciouni 201-INS)AMPS
Fyp ARCHITECTS DECLARATION SQ IT FLOORAREA $/SQ Fr
$Oq0p l understand my finds shall be used as public recordv. OVER I(XIOAMPS P
FrnCW, SIGNS ELECTRICAL 2 00 r lq
Lacreed Rnfcssional OWNLRBUILDER DECLARATION I SPIiCIAL CIRCUI'I'/MISC. -J �
.I hereby Affio that 1 am exempt from the Com actors License Law for 0.
W 3 U. foil es ing reason (Section 70315,Husmess and Professions Cale:Any city or county I TEMP.METER OR POLE INST
whatreymrnneer is rereclaims teafar,mipmve,d PAmsM1.nrmpavnaytatemerc
pno hoe licensed pursuant prvisionof the Commnc TOLicese Lit statement POWER DEVICES
0.oJ'C p that here licensed purxuem to the provisions of the Comracmfs License r"a s coder
L alt 9(cunimencuig with Section](1110)of Donsionlofthe Basinessand Pniingans C+nle) SWIMMING POOL ELECTRIC /Q/'tea VALUATION
At_rn orded he is exempttherefrom and the basis far them exemption.Any moh"am of I OUTLETS.SWU'CUPS-FIXTURES �-
.F. 6Section]031.5 by any applicant for a permit arblects the applicant to a civil Penalty f
not ninre(ban Eve handed dnllnn($500,
_p ❑ I,asowneroftM1epmperry,nrmyemplo)ttvwilhwegesas lhmrsolecompensminv, NEWRFSIDEN'IIALELUCTR SQ IT S'I ORIE TYPE CONS]RUCTION
y'3m will Jothework,andilias rt.o imyemteddedoia wAdforsale(solecom Banl,on /
And Ihofonons Code.The C inaidara Licence Law does not Apply ,,an or of II n II /S n ,.. I
owns ywhnbmlJsonmpmvesthcmprove emearr hat en through his I II +I OC'C\.GROUP_
employees,pr�videdthat such impmvememsare notimend eJornffertAforsale.ID
however,the bw lding of improvement'n.ald wahm one ycoot vampletinn,thr owner-
builder will have the banden of proving that he did not hold on...... ti,
sale.).
❑ I,ASOwnerof Wapropeny,amexdusivdynimrectingwnh b.ense.l um labor....to (QTY. PLUMBING PERMIT EE EE FLO9 U /� APN
consvum the proton(Sec.701 Business And Pmfessmre Code)The Contmclar's f, ATE /o`v
License La wdoesnotA pplytor nownerofpropcnywhobuildsonmproveslhei eon,and PERMIT ISSUANCE
who contacts harmer such prolectx with a cnnvaca rl sl licensed pursuant to the Conlraclor's -
Lieea.law ALTER-DRAIN&VENT-WATER(EA) TEE SUMMARY
❑ I am exempt under Sec. B&P C for this medcan _ OUTSIDE FEES
BACK ROW PROTECT.DEVICE SANITARY Y N
WORKMAN COMPENSATION DECLARATION I DRAINS-FLOOR,ROOF.AREA,COND ISCIIOOL TAX Y N
❑ herehy.Affirm fhmlhuvicecemticate of eansentn.self-insure,oru wreficme Of RIi'TF1'#
Weaken'Cnmpensauon lnsumncemecenified copy Thereof(Sec 3gW,LebC)wh]ch .� FDtTUR13-PER'1'RAP � �� (PARK FEE Y �
re all employee's under period GAS-EA.SYSTEM-I INC.4OUfLETS f RECEIPT'# JJ
Policy ' #�. �� BUILDING DIVISIOONNFFTs
-6,e. . copy is hereby fumubeA.---- -_ GAS-EA.SYSTEAI.OVFR 4(G) PLANCHECK FEE
❑ Certified copy is fled with the alymspecome division. GRUASIJINDUS'I RL WAS 2 IN I ERCEPfOR (GRADING FEE. aw L�1fJ
CER1'IFI COMPENSATION INS ROM WORKERS' GREASE TRAP SOILS FEE
('Dos sectionnttdnot becompleledifthe peimn isfaronehandrM dollar($100) SEWER-SANITARY-STORM RA.2001 (ENERGY FEE
or le. I
Icr i fy Walm the performance of lire work for which this permius ienued,Ish,ill WATER I IFATER W/VEN'I'/F.LECIR
not employ any person in any.amen so To to become subject to the Workers PAID
Compensation Lawsuf Califrrom D++• WATER SYSTEM/IREATING Date Receipt#
0 '7-' APPlil, NEW RESIDENTIAL PLMB S FT.
NO'1'ICh FOAPPLICANTIf,aRo makmgthrs Cemficme of Gxempunn,you should Q TOTAL:(
pJ became subject to the Worker's Compenwaan provision of the[.AN,,Crde,you must h
a ; fonhwnh comply with such provisions or this pconshe l be deemed mv.i BUILDING FEE /V �1
a Q SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a contraction lending agency for The perfnrmun.e of '
U O I ELECTRIC FEE -
The wad for which the perms is issued(Sec.309].Civ.C 1
lenders Nam-
OH Lender's Arkie== Q'Ii MECIIANICAI,PERMIT FEP. PI-umewG FEE ##' /�
U I cah y the,1 have read This application and omc That The Above information is ` MECIIANICAL HE D-F correct,i agreemnunply enhall city andro unty oMmances And sate hews mlatingm P17RMIT ISSUANCE �� si
building construction,and hereby ambonze rcp ssenotives of this city to i n ccupon the CONSTRUC'T'ION TAX
lai)U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save indemnify and keep harmins the City of Cupertino against
huhdmes,lud enn,co s expense hash mayor any way twermagaint said City
in Co.". the n AIR IIANI3LING UNI'1'll'O 10,000 CFMI
an AIR HANDLING UNIT(OVER I B"CFM) I
I
ignal of Appltean Contractor EXI IAUSI'HOOD GV/DUCD I PAID
p IIAZARDOUSMA'rER1ALSDISCLOSURE ' T 1117ATINGUNI'I'('T01M.11pB'1T0 Cf Ii' Date Receipt# /�or
Asde
Will Thy fhepCutmotn ntm'm building l excellent
store anJdIhe lleelth end Sdety TRATING UNIT(OVER 100,000 BTU) I TOTAL:
Cale.Seetian 25532607 VENTILATION PAN(SINGH BE.SID)
❑Yes ❑No
ISSUANCE DATE
WtllthenPplicent orfumrcbwldingnccupwmseeyummenmrdev tees what eon BOILER-COM1fi'1311P OR 100,(NIO HTIJI I
haceral Air comeminants as defined by The Bay Arta Air Quality Management I BOILER-COME(OVER IO
#Dis fi.(NIII NTUI
trict° ,ate
❑Yes ❑No I NEW RESIDENTIAL MECH SQ., P
ITT.
1 have read the hazardnus materials reymremems under Chapter 6.95 of The ���
California IIca1Th&Safety Cale,Serum.255(]5,25533 and 25534.I understand t]an se,
if the budding Jces not currently have a tenant,that is my responsibility to notify the
occuryml of The reymomare s whmh muss be stet pnnr m icon ev at a Certificate at
Occupancy.
it
J
Owacrorawhoondagent Date ! r (ISSUED BY
OFFICE