27711APOLICANT TA FII 1 IN IMPnOMAYInki unruw ten --es . — —.. __..._ __.. _... _. I
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
--- BurrIC •
PLUM -MECHANICAL
PERMITNO.
BUILDING ADURESg: /• or \t� /D
O ERS NAME; (/• �PHON/H:: �•
L.r MJl- pc�. alj
RCIIITECT/IiNGI ER: LIC NO:
PROJECT
BUILDING PROJECTIUENTIFIC.AR'ION
UNffp LOTH
CO CTO'S NA E: LIC NO:
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M LI tat
27711
SANITARY NO. 'i'LICKHONSUBMITTALDATE
N/C CONTROL
bNTACf: PHONE:
__' V, " — `
QTY. ELECTRIC PERMIT FEE
BUILDING PERM�I,�TfgIN,EO
✓ �7 —
PERMIT ISSUANCE
BO �O PLj�/ MEC
[J
LICENSED CONTRACTOR'S DECLARATION
tlhmby
Zffirm tharlarnlicensed u,Maprovisiom.fChapmr9(commencingwiN
f Division 3 of the Business and Profession, Code, and my license is in
f Rt gyp, 2
,m LiccnseC ass Lic.g V /� L
iN Dmecanunctor
r Z ARCHITECTS DECLARATION-[3�Lt�fO
in 1 understand my plans shall be used o; public words.
APpL1ANCBS-RESIDENTIAL
NELS
UP TO 200 AMPS
TOB DESCRIPDON
`
201-1000AMPS
OVER 1000 AMPS
SQ. F1'. FLOOR AREA
5/SQ. Fl,.
SIGNS ELECTRICAL
�, Lmcnsed Prnfessmnel
jU OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Canwcmr's License Law for Ne
no •E following reason. (Section 7031.5. Business and Professions Cade: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any swcate
priunoits issuance, also requites the applicant far such pewitmflleeaignW statement
that he is IicensM pursuenno the provision of me C.nmecuals Liame Law (Chapter
fs, 9(commeneing with Sedion]OOp)of Divisian3of Ne Business and Professions Cade)
m onhns he ie exempt Werefmm and the bn,ieforNmlleged exemption. Any violationof
Q Section 7031.5 by nny applicant forepewit subj«lithe epplicenno ecivil penally.(
O not mart then five hundreJ dollars (3500).
❑ I,mawnerofNepmpeny,.rmyemploy<eswith wagesmtheirsolec.mpemarea,
willJo the work,and the svunure isnot intended.roffercdforsale (Sec.70g4, Business
end Professions CMe: TTe Commdor'a License Law Jces not apply to an owner of
property who bui Ids or i mprovcs therton,and who d«a such wort hiwel fm ughhis
awnemployeu,providcd metauchimpmvemenBart not imm�dW oroffertd (.'sale. If.
haweveq the building or improvement is wld within ane year ofcompletion. the awner-
b e.). uose will have the burden of proving mm he did not huild or improve for pryof
ealeJ.
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE INS'
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
VALUATION
/„^7CJtx
l�J LL..�L��
NEW RESIDENTIAL ELECTR _SQ. FT.
STORIES
OCC. GROUP
'TYPE CONSTRUCTION
RES. UNITS
TO AL
QTY. PLUMBING PERMIT FEE
❑ I,uownerofinepr.peny, est exduxivelywnwning wiNlicemNconwnorsm
comwd the project (Sec. oani Business and Professions Cade;) The Contracmr's
LicenseLaw metsf not spiny toanown conformers)whosed Vamimpro me Commend
whoconwds fm such projeete within conuvcmKs) licensed pursumun Ne Conuactofs
License Law.
❑ I um cxnmpt under Sec. B @ P C fm Nis reason
FLOODZONE
APN
PERMIT ISSUANCE
ALTER - GRAIN @VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
SfD F
Owner Data
SANT Y V _N
RECT:Ipfg
WORKMAN COMPENSATION DECLARATION
❑ IherebyaRwtbu l havea«rtifam afcorso". self-insure,«e«rfificmea
Wmkm'Cmnpenm0an lymurvyn{pmemu«ni0ed wpy them.( (Sx.Jg00, Lab C.)which
Pot cy M lJY f- +.2�hu / �[
DRAINS - FLOOR, ROOF. AREA, CONp.
SCHOOL TAX Y_N
ftECIiIPTa
FlXTURES - PER TRAP
PARK FEE yRECFIPf g ry
GAS - PA. SYSTEM.I INC. 4 OUTLETS
Company IA
GAS - EA. SYSTEM -OVER 4(EA)
BUILDING DIVISION FEES
❑ Cenifiedcopyishertbyfamished. IF
G— crified copy is filed with the city inspection division.
PIANCHECK FEE
GREASFJTNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
(lids section need not be completed if the permit is for one hundred dollars(s Him
ore
I certify that in thepadawamen afthe work for which this permit is issued, I shall
not employ any person in any maturer an u in become subject to the wml
Compensation Lawes of Celifamia Data
Applicant
SEWER-SANITARY-STORM EA. 200FT.
ENERGY EB
A
PAID
WATERHEATERW/VENT/ELECTR
WATER SYSTEM/TREATING
Date eeipt
• a ,
NOTICETO APPLICANT;m
If. after aking this CeriGam of Exemption, you should
baomesubject to Ne Warkefe Compened. pmvishnsofthe Labor Code,you must
forthwith comply with such provisions on, this pemdt shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby ufftrm that Nem is a construction lending agency bathe permu
fance of
the work fm which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
NEW RESIDENTIAL. FUME. SQ. FT.
BUILDINGFEE I Vr LUNC u r'N
X11
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Leader's Address
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
y
I «nify that I have mad this application and smut that the above infm ulmn is
wet. legmemcomply with alltlry and county oNinenca and ante lewa mla0ngm
building construction. and hereby auNonrereprcsenuuves of,, city menterupon the
above-mentioned property for inspersion purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilitics,judgments,costs and a ses wI, b areyia anyway accme against said City
seance o granting of pewit. (g Q
PERMITISSUANCE
MECHANICALFER
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigolume of AppurnerVConwcta Date
EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant as future building occupant store or handle hazardous material
PAID
HEATING UNIT (TO IO ." BTU)
Date Receipt g
TOTAL:
as defined by the Cupertino Municipal Code, Chapter 9. 12, and Ne Health and Safety
Code, S«tion 25532(a)] veey,,�'
❑Yes y,No
HEATING UNIT (OVER 100, l BTU)
VENTILATION FAN (SINGLE RFSID)
Will the application, future buildingmcupemuseequipmemordevices whichemil
hmallous air contaminents in defined by the Bay Area Air Quality Management
Distinct?
❑Yrs
BOILER- COMP UIHP OR IO0,01g) BTU)
BOILER - COMP OVER 100,0110 BTU)
ISSUANCE DATE
NEW RESIDENTIAL. MECH. SQ. FT.
T have read me hot mammals requimmeals under Chapter 6.95 of the
California Health @ Safety Code, Sections 25505, 25533 and 25534. 1 understand that
ifthebuildingd«anmem Bh ea mmnL,ma n.,',my responsibility to notify me
«cu f the rcqu ant. w he
must be met prior to isscan�ficum of
BY:
wn or auth.naadagent Data
TOTAL: ISSUED
11COVxO