26140 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINOB II.DI .
.- ..CTR CA RM
PEITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26140
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO, AP PLICATION SUBMITALDATE
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adIMM U 'RSNA7te is �/P�IIONE: C Ii'S#Ne V,& n// LIC NCO„V7� N/C CONTROLp
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ONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG E,L�EyCT PLUMB hfEFH
PERMIT ISSUANCE � iTr 1
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �yL DESCRIPTION
nyz Ih7")ofDi Natl 3 of
fThnsedinss add isionaofns Code,and
mmencise with ^'1'1_drSy-
00 Section 700117 of Division3of The Business and Prodcasiom Code,and my license is in PANELS
To full force and If _/ 9!422—
Lie.
201-I"AMPB
<Z f ilf d LiaN
y6 Dam Lie.N ter 201-IIIW AMPS
Z FO y,Eoa ARCHITECTS DECLARATION OVER IlX10 AMPS SQ.Ff.FLOOR AREA $/SQ.IT.
O Z,—W 1 understand my plans shall b,used as public records.
SIGNS ELECTRICAL Q 2
70
Q5d,7, Licemsd Professional
�yadd< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�O0.0 1 hereby affirm that 1 am exempt from the Conaacrrs License law for The
W 3 LL y following mason.(Section]031.5,Business vW Professions Code:Any city or county TEMP.METER OR POLP.INST.
N0¢, which requires a permit'.conswct,alar,improve,demolish,Tom*,any dour art,
_
K�Q� prior 1.its Issuance,also requires Ne applicant for such permit to file emineeminentswmmcm POWER DEVICES
C qW
O That he is licensed Pursuum TO the provisions of the Canwemrs License Law(Chapter
Lca 9(commencing with Section 70100)of Division 3 of The Business and Pmfessium Code) SWIMMING POOL ELECTRIC VALUATION
ifor that he is exempt therefrom and the basis for the alleged exemption.Any violation of UTLETS-SWITCHES-FIXTURES
I:4r Section 7031.5hyanyapplic.t fare permitsabj.,.the. pcnahy of /
$ nm team Than five hundred dollus(5500). NEW RLSIDENTIAI.FLECfR SQFT
aCQxe ❑ 1.mownnofthepmKny.mmyemplDymswiNwagesusThcirsolecompemetion, —SQ,FT. SOR'
R T`yPICWUTON
will dathewmk,undthemactare isnot imendedmuffered fortme(Sec.7044,Basins C�sA
and Profasians Code:The Cnnuacmr's License Law does not apply to an owner of
properly whobuildsnrimpravaihertan,andwhodoeasuchworkhimsel(artlwughhist IPS
employees,providedthmsuchimpmvemcnmamnot intmdedmoffered fm We.If.
however,the building an improvement is sold within oneyear ofcomplaion,The owner- O
builder /
will have the burden of proving Nhdid build i
at e not uor improve far purpose of
ale.
DA
s0)Leaownetrofthe properly.amexdusively contnetingwith licensed contocmrsm QTY. PLUMBING PERMIT E _ A
oemnict the project(Sec.7044,Business and Profusions Cade:)The Conumemra
License Law does not applym an ownerofproteny whabuildsorimproves Thereon,and PERMIT ISSUANCE
whocammasforsuch projects with aconuacurds)licemed pursuant to the Communes
License law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I am amampt under Sec. .B&P C fm this rtuon OUTSIDE
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,GOND. RF.CF.IPfp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby short that l have a certificate ofcunacnt to self-insum,an a comifica,of FTXTVRES PER MAP RECEIPT#
Workers'Compensation Insurance ora testified copy thereaf(Sau.380,Lab C.)which PARK FEE N
overs all employee's under This Penni. GAS-EA.SYSTEM-I INC.4 OUTLETS #
Policy# BU ISION FEES
Company
copy 0,4dified co GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK b
is hereby fumiaheJ.
Certified copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FL
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE MAP SOILS Ff
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is Forane hundred dollars Stop) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfnrmanroaf Ne work for which Thispermilisissued,lshall WATER HEATER W/VENVELECI'R
not employson t py'�a t m r the Workers' PAID
CompenanIi r1WATERSYSTEM/IRFATING Date Receipt
Q z APPlicwt r
z 0 NOTICE TO APPLICANT:If.after nuking this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
� rA become subject the Worker's Compensation provisions of the Labor Code,you mum s
a , forthwith comply with such provisions or this permit shall be deemed evoked. BUILDING FEE /#
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE L
z 1 hereby affirm that there is a construction lending agency for the performance of ELECTRIC FEE
O the work for which this permit is issued(See 3097,Civ.C.) -�
Lenders Name
OF Leaders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 teddy Net I have read this application and state that the above information is MECHANICAL FEE
>" 4 correct.Iugrcemcamply with Wl city and county ordinances and smmlaws mlanng to PERMIT ISSUANCE
�! N building construction,and hereby authonce representatives ofthis city to enter upon the CONSTRUCTION TAX
U Z above-memmood property for inspection purposes. ALTER OR ADD TO MF.CI I.
We)agree to save,indemnify and keep harmless the City of Cupertino against
liab1 'uJ ex, res whichm 'n any way accrue agvnstmid City AIR HANDLING UNIT(TO 1,000CFM)
in cmuryue of s period.
AIR HANDLING UNIT(OVER IO,OW CFM)
Signature of Applicant/Commenor Date EXHAUST HOOD(W/)UCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO 100,000 BT1f) hate Receipt#
Will the applicant or fume building de.C a p erre m handle hH a Health
as material HEATING UNIT(OVER 100,000 BTU) TOTAL:
r defined by the Cupertino Municipal Cale.Chapter 9.12.and the Heahh and Safety
CWt,ScOmh25532(a)? VENTILATION FAN(SINGLE RESID)
❑y. M4/1
ISSUANCE DATE
Will the appllcanwr future building occupant use equipment or devices which emit BOILER-COMP QHP OR IO,000 BTU)
hazardous air contaminants u fined by the Bay Area A.Quality Management BOILER-COMP(OVER I WIM BTU) qq
District? / r A 1 1)
C3 Yea LTJ NEW RESIDENTIAL.MECH. SQ.FT.
oifthebmddinMy�atcnw,
read the hazardous materials requirements under Chapter 6.95 of the 410 7 1
ealth&SafetCode,Sections 25505,25533 and 25534. 1 understand that 1 199
nt, titis ytesponsibilitymnatify the etPrim t isswnuSf tfgat oft AAA Ijourimalagem Date T ISSUED BY:
OFFICE
q /! t = �//�A\C - //a P an -:' '•g•'qI�//E \\\\� /l.ALM
' : _
lia = :dam,
r „e r• i
No. 916 f
AT
%Lkatif tratt of orrupaury
ii
(pity of CtluVrr#inu O �
15•eliar#mett# of 39ttilMug �ns�px#ion
A. This certificate issued pursuant to the requirements of Section 307 of the
Uniform Building Code certifying that at the time of issuance this structure was
�411j.
in compliance with the various ordinances of the city regulating building
F construction or use. For the following: t
ra Use Classification Tntarior Improvement Bldg. Permit No. 261:40
Croup B-2 Type Construction V-N Use Zone _Planned Development `s
Ownerof Building Appl a Crunplltpr Address 10240 Bubb Road ut
/
�`� Building Address tn940 nnhb Roan Locality Cupertino, California
I
Date: fM1a., 9p igoa \
Building Official
- \: POST IN A CONSPICUOUS PLACC
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