21277s+rre.evr.amr ave• am nmev - .. ..�.
Building Project Identification ' " -
BuWbg Addrter.I
PE3IMIT NO.
o�oo Gw� �UsE awl
_ 21277
• am: .a;
CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
HUII.DINC-dECnUCALPLUMBINGMECHAMCAL
cantndm`sLN,s� Lic.Na
CATEGORY
CONTROL e
Ilea/Engive m•. Llc. Na:
22
;,-�;:;Z,4IIUILDtNC,PERMIT-INFO'. '. fir'%'
c:
Address
( PFAAETISSUANCE OO
17--1-
t/f 7
LICENSED CONTRACTORS DECLARATION
Ihercby'llumthal l am Emend under pmbimaafChapter 9 (commanc,
Ingwith 7000) ofDivisionWent. the Busima•and Prokulonafade,and
Iimnss b e full fate and elect.
APPUANCMIMNDENTIAL
O
�1.(,�
Pis
License CInss Lk.S
Data Ccorrector
ARCHRECrS DECLARATION
I understand my plan hall be used an pubilemno s.
Limned Profession.[
201'
OVERIODDAMPS
SQ. Fr. FLOa.OSR, AREA
111
SM. Fr.
I
+ 7
SR;NSELBCIAICAL
SPECIALCBtCNT/MISC
OWNER -BUILDER DECLARATION
exempt fromtheCorac eaLkense Lawfmthe
1 hembydOrm'hat I am nt
TEMP. METER OR POLE INST.
following mmon.(Sedlon 70315, Bwlness and Profanation Cade: Any city or
county which require a permit to mnalruct, alter, Improve, demolish,., repair
any stmcture prior to In lwam, sial requlreathe applicant for Much permit to
file a signed statement that he b Iicenaed pursuant W lir provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OUiI.E785LVI7CF(ESFLXNRFS
Commove. LlceneeIA. (Chapter 9(Commencing with Section 7000) of Devi-
Won 3 dthe Business and Profession Code) orthat he In exempt therefromand
the basis for the alleged exemption. Any viola on of Section 703)5 by myd
sppBunt(.,a permit mb)eetathe applkant los civil peruity d not iron than
VALUATION
ILA ISix,
fWund,ed ddbrs MW.
1, a owner of the property, or my employ. with wages a their Bole
NEW RESIDENTIAL E.LECiR SQ.PT.
STORIES
TYPE CONSfRUCT1ON
mm. flor, will do the work and the Wructum In nal frustrated or offered for
ale (Sec. 70K Bushmen and Profession Code. The Contractor, Liam, Law
dm norapply to an owner of property, who bulls, or lmprme theme, and
whodoessuch work himself orthrmgh Marmot. ploytes, pmhied [hal wch
impmemmnu m rad Intended oroffamd faaale. rL however,thebulMing a
TOTA4• Z�
SCC.GROUP
RES. UNITS
ImpmvementbaddwllhinarmyurofcmmpldbrytheavnerbuWerwRlhave
nofpravingueM hedhi rad buOd or rove fa purposs olssle.).
a owner of 0r< property, am axchrs aontrMbg with Ikenaed
tm a to mmlru s the project (Se, 701A. Bwbea and Prdessbro Cade:
,E r
yT'4: * r4LwBIIVavikMl�t,'+, �'Y
FLOOD ZONE
APN
PERMIT ISSUANCE 'L
CantrsdorY Ltoeme taw dao rad apply to m owner d pmopety who
build, or Improve, therms, and who contracts fee rod with a
orb) Borued pursuant he the Contactdion
a LLaw.
Lam exempt undo Sc B k P C (or thio mason
ALM -DRAIN kVFM- WATER Q!/U CZ)
BACK PIAW PROTECT DEVICE
�,: •. 4;':
ti $ft.I'I FEE SUMI1'�IIRY, .yrh;°e •I1!�.da
DRAINS. FLOOR ROOF, AREA, GOND.
pD(•Ngg PER TRAP a�
SANITARY RECEIPT 1
SCHOOL TAX Y_ N_
RECEPT S
Owner Date
WORKMAN COMPENSATION DECLARATION
1 herebbyy affirm that I have a adl0rate d consent forelf-Inwro, a a
C111fiateofworkerec.pemdlm Lmranaaaoxalfiedaopytb.f6ec.
3500, Lab Q
-)INCA OUS
I GAS. FA. SYSITAI ILLR
PARK FEE Y N_
RECEFr I
Policy
Co�mp+ray
S
CAS. EA. SYSTEM -OVER! (EA)
BUILDING DIVISION TEES
1 IC.WIBedmpylahereyhumid".
B CerlNed copy b filed with the city InspMbn dMWm.
CREASE/INDUSTRLWASTE ENTFRCFPiOR
PLANCHECK FEE
GREASE IF" ��
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION COMPENSATION INSURANCH
(rhlsmdlon need nen becomplded Hthe permit Informer hundred dollen
(f10D)aless.)WATER
I adlfytha Inthe peaormanodthe weak for which this perms la band,
PAID -
Date Recei lB 'LQo
SETA'ER-SANRARY-STORM P.A. 100.7
HEATER w/vExr/o.ECTR
ENERGY FEE Y_ N_
WATER SYS /TRTING
EM EA
1 shall nen employ any perwn In any manner M, a W become wbjed to the
Waken' Compmatiun[Awad California.nia. Dab
Appllant
PAID ;%Dk ws�
Date Re I IN -a'�fw
NEW RESIDENTIAL PLM¢. _SQFr.
NOTICE TO APPLICANT. U, after m.ngthis Certificate of ExemplION you
M
shmid become mb) d to the Watkemi Compemalbn pmbbn of Ihr Labor
Cod, you must forthwith comply with such provision ar this pemdl dhallhe
TOTAL:
BUILDING FEE 40 ZCP
dmnmd revoked.
CONSTRUCFION LENDING AGENCY
I hereby afOrmthat them Is a mrmwdlm lending agency for the pedorm�TOTAL:
.nm mftha work far which this pe¢ In InOIL,ed OIL, C1v.c.)
rm
Lender: Nana
lender,Addrea
SEISMIC FEE a
~
ELECTRIC FEE t�
PLUMBING FEE CfJ•
y yy�y� yp
, ^ e - icAl1�L�KM1l� '.:Si
MECHANICAL FEE <- O CXJ
IcrAltythat l have ad this application and MablhdlFaabove b(omutlm
Inmrnat.Iagreeto comply with 60 city and countyardlanm and Wale lawn
PERMIT ISSUANCE Q7
FEES PAID:
ALTERORADDLOMECH.
minting to building comlrodfor, and hereby,uthor� mpmseniativet ca m.
city to enter upon the above-mentioneddy for lropectbn pumpmers
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
agalnt llab0lln, jrdgmenes, mWaand expense which may In anywayacctue
Date Recei t(1
AIR HANDLING UNIT (M 10,000 CFM)
SUBTOTAL:
agalnt In caasmtl.mp p{f gnnlhyd his prank. I
YIN a/4/ �aT��y1
AIRTfANDUNcuNrtrovERl0.roBephn
CONSTRUCTION TAX
Slgnturc AppOont Cont Data
EXHAU517HOOD(W/DUCT) q a)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheI PHard or future building occupant Mom or Handle hmrdon
material as ddlnd by the CupeMlro Municipal Code, Chapter 9.17, and the
I lealth and Safety CodeSection155334)7
r(1���--rr No
Will rhe ipplicam Rome building oaupnl use equlpmem ver devices
Rill
which emit hourdm, air omtamntnnta n defined by the Bay Area Ab
Quality Management Dietrlatr
Yn Na
nalf.0 hehva ws Cod.,brequlmmM,2553erChap M.I of
aCalllomIn HedthASafetyCode, 9ectbm 25.505, 755)3 and 75531.1
understand that if the building don mel currently have a tenant, that III$ my
Date Recel til
HEATING UNIT (W 10D,000 BTU) ''
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RIMD)
ISSUANCE DATE
RAW p R/�
F'/��
ev
MAR s�i9y1
MA
BORER -COMP OHP OR 10UM BTU)
BOILER -COMP 1110,001) BTU)
NEW RESIDENTIAL MECH SQFr
ropomlblllly to not ify the occupant d the requirement, which =at be met
Pdor to nua cox d a Certificate of Omp ray.
rjty p� rnnMw' e�nn� � tr..
ISSUE gY..�JrL [�J�'�'AC/�1-+`•'gym
Owner or mlhorieed agent Date
70TAL:
OFFICE COPY----'
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