25036 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERM IT NO. arms ^(
APPLICATION/PERMIT PING PROJECT IDENTICAL 2503E
0 3 E
BUILDING DIVISION �:- BUILDING PROJECT IDENTIFICATION.
BUILDING ADDRESS: p �p'ax SANITARY NO. APPLIC�ATyIONN S
aU
.BMITTAL DATA
or 6 1 DF 411 /7LVYl UNIT# LOT# �..� `�
OW 'ERS NAME: PHONE: — • t n GU/�A!C7 E L NAME
/T9EL H .1 ¢oNO:
-7 C
! PR/NTlN b 55 Qi V NIC COMBGLa
ARCHITECTIENGINHEW LIC NO: ADDRESS: D
!v 2l, L,4r r- Wh
CONTACT: PHONE: 4 't t BUDDING PERMIT INFO =C
�S-Z- It33S QTY.;yak '�EtiEclwcPEwiri, ;� FEe ' "
wL 1 67� /�/Ec A/ s,tT L- w PERMIT ISSUANCE BLDG ELECT PLUMB MECfI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
yZ Ihercby af0nnthatlamlianmd underpmviaionxofChapmr9(commencing with
O Section7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
KU full force and �1
<ZI31 Liccnsx.Clas a' L(t Lic.# �f"!�0 / 0 UPT020OAMPS
oo j i4 Doc Comm c... N 201-IOW AMPS SQ.FT.FLOOR AREA S/SQ.Ff.
�ONZ ARCHITECTS DECLARATION OVER IOW AMPS R 1
Z_G 1 understand my plans shall be used as public record.
_yFul SIGNS ELECTRICAL "
�J Licensed Professional : j I. I f p'�
_,M< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. j l` ,[�[{�
I hereby affirm that 1 am exempt from the Co cions C's c:Any Law for the y� -
a 0< following fires. (Semon 703L9.Business and Professions Cade:Any city or allmy TEMP.MEIER OR POLFJINST. —
< which requires a permit m emswcl,mar,improve,demolish,m repair any swnure
on_1 prior to its issuance,alsorequires the applicant!orsuch Permit to file asigned statement POWER DEVICES
JC
CC) that he is licensed purman,to the provisions of the Convectors License Law(Chapter
SWIMMING POOL ELECTRIC VALUATION
9(commancing`s'ith Section 7")ofDivision 3 ofthe Business and Professions Code)
(,o .,that he fs exempt therefrom and the basis for Ne alleged exemption.My Amitianaf OUTLETS-SWITCHES-M(TURES
,_Z Y Section 7031.5 by any applicant for a permit subjects the applicants n °a civil penalty of
not more than five hundred dollars($500). NEWRESIDENMALELEM _SQ.FT. STORIES TYPECONSTRUCTIOI
�Fpre ❑ Las eroftheproperty.ormYempioyces withwegesastheirsolecompenmtion.
a3— will dothewons Code:
he Contractor's
License
La does
apply 70#4.Business
end Rofosions Code:The Convenor's License Lew does not apply in no owner of
properry who build or improves Barren,and who does such work himself.r thrmgh his
OCC.GROUP RES.UNITS
°w°employees,provided Nsrsuchimpmv sold
within
it arenm Amendedmoffered forrole.IL
however.Neavete burden
of ememis Dat
id not build of completion,theownerf TOTAL:
builder will have the burden of proving Net he did not build m improve for purpose of
sale.). "-Yit " FLOOD ZONE APN
❑ I,asownerofNe propmY.amexclustvelY conwcung with lrcenxd contract t 9M f�yy["Lt d PLUMBING PERM1Ty,yti taw .-y FEE '.
camwet the project(Sec.7044,Business and Professions Cont The Contravener x
Licros Lawdmsnotapplytoomow rofpropevywhobuildsorimMvesthercan,and PERMIT ISSUANCE
who contracts far Such pmjmts with a contractors)licensed pursuant to Ne Convectors ALTER-DRAIN&VENT-WATER(EA) x£:;`•� '.n3 fti'_;F SUMMARYe,`1'
ion
Licenexl
❑ 1 em exempt undtt Sec. .B&P C for Nis rtasmBACK FLOW PROTECT.DEVICE A O FE S
SANITARY Y N_
Owner Date RECEIPI'p
M
WORKMAN COMPENSATION DECLARATION DRAS-FLOOR,ROOF.AREA.COND. SCHOOL TAX YN
• ❑ Ihembyaff=Natlheveacenificateofmnwntt°self.insm,oracefi Leaf FU(IlIRES-PER TRAP RECEIPT#
, Workeri Compensation Insurance or a cenifiad copy moof(Sec.3800,Lab C.)which
- - ll employee's under this permit. GAS-EA.SYSTEM- INC.4 OUTLETS PARK FEE RECEIPI'N
covers aN
I}
Policy# BUILDING DIVISION FEES
° an>' GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby famished.
❑ died copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEMR P SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed BOO,permit s forom hundred dollars(SI00) SEWER-SANITARY-STORM EA.2WFT, ENERGY FEE
or less.)
I cenify than in the perortnanceaflae work far which Nis permit is i.xmd.]Shelf WATER HEATER WNENT/ELECTR
not employ any Person in any marmer S.M to become Sadat c the WorkersPAID
Compenumion Lewsof Califomia. Date WATER SYSTEMfrREATING Date Receipt
Q z Applicant
z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should NEW RESIDENTIAL FUME. SQ.FT. TOTAL:
r q became subject to the Workers Compensation provisions of the labor Code,you must BUILDING FEE
> forthwith comply with such provisions or this permit shall be deemed revoked.
C [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
U
I hereby affirm thin there is a comwction lending agency for the performance of z :
U O Le the work for which this permit is issued(Sec.309],Civ.CJ ELECTRIC FEE
TOTAL
Lenders Name ° PLUMBING FEE�! Lenders Address QTY.2 .,MECHANICAL PERMIT rx, FEE"�`t4:
V 1 cenify Nat I have read this application and am¢that Nc eMve infawetian is MECHANICAL FEE
aa
crt.Iagree to with ell city and county ordinances and smm laws relating to PERMIT ISSUANCE
building construction,sndbereby atubmiae rtpresemetives ofthis city center upon the CONSTRUCTION TAX
U Z above-mentioned property for Outsmart.purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilittes,judgments,c°stsand expenses whichmay in arty way accomandasr said City AIR HANDLING UNIT(TO 10.000 CFMI
in conxquence of tre grartin g of this ,mit.
IIJJ11( a _ - AIR HANDLING UNIT(OVER 10,000 CFM)
Sipmaturt of ApplicantManvan.r Data EXHAUST HOOD(WIDUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt#
Will the applicum Or future building peculiar,Sere or handle bitmahus mavnal HEATING UNIT(OVER 100.000 BTU) A
Com,es defined by the Contra..Municipal Co ,Chirac,9.12,and the Health and Safety ^w
Code,Section 25532(a)?
❑Yes 11 No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will flamplicintrefumre buildingmcupamuseequipmen,ordevices which emit BOILER-COMP(3HP OR 100,000 BTU)
• brummus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) `
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. M E D
I have read the haardous mmedals requirements under Chapter 6.95 of the {p�
Cslifomia Health&Safety Code.Sections 25505:25533 and 25534.I understand that ?99
if the building does not currently have a annual,that it is my responsibility to notify the
occupant of the requirements which must be,mea Prior,o issuance of a Certificate of
Occupancy. G/I Y j•
Owner.rauthoGud a gent Dam TOTAL: ISSUED BY: �— - 'y
OFFICE