24017APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identif{utio%
Building Address: -
PERMIT NO
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CITY OP CUPERTINO-BUILDING DIVISION�_1Y
APPLICATION / PERMITG7«
BUILDING-ELFSPRICATPLMBING-MECHANICAL
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N•rm:
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CATEGORY
CONTROL N
AmhRect/Engineer. Llc No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO '
Address: 0 led 3- q5la
PFRMITISAIANCE
�I ❑ PLUMB mmi
t� 1:1 ❑ .
LICENSED CONTRACTOR'S DECLARATION`
I hereby affbm that l am licensed under pmWons&Chapter 9(commmc
ingwlth Sectbn]000)of DlvlNon3ofthe Bualmaand Pmfe wiCodga dnV
nse
Mais In full ru and effect.-
Lkensc am ClLk.a 3�d
Date Comrator
APPUANCESRESIDENIAL
—
B RII•TION
ieP
I
PANELS
I'1000'U`fr5
_Y�/7/�
ARCHITECTS ECLARATION
OVERIWIOAMPS
SQ. FT. FLOOR AREA
L. E D IN
S/SQ.FT.
I underMaM my pbnselnB be used upubkcmords.
Limned Profmlonai
SIGNS E[IS"fACAL
I hereby affirm that f exempt from the C
Otfam -BUILDERe. mptfro the or'• License Law for the
la U
SPECIAL CIRCUIT/MISC
TE R
TEMP, METER OR POLE INST.
I[riVQt DEVICES
n 7
Following rth mcluietiaor it toslnm sMPmfmlms Codr.Myttyor
Prune
countyrime, rtprkm a permit to construct,uireattm, applicant prove, demoLLsh, or mit to
anystactedstameMthat prior to its he]alieorequbmsuetothe forachpermite
we a signed statement that he b Bmmed pursuant it the proWbns of the
w�
7'G
SWIMMING POOL ELECTRIC
(commencing Semonherefof Divi-
h4-
Contactors Ekins law Cdesedohapter 9(mmmentlng he is
sonof the Budnmand Ndemlon. Code) or that hob exempt and
VALUATION
the b My violation of Section nolo b/ any
7MI-5 by
the licela for the alleged jeemthe applicant
applicator for a pemdt subjects the applkant to • tldl penalty d not morttlun
OUTLEISSWITC}QSFD(TVRES
/�OD y O �l
V
'
NEW RF9DFN7IA1'ELECI'R SQ'F7'
flee hundred rcmotionhe pr)m.per<yh wages sok
❑i,nowrd the , or my employ. with u
STORIES
Tl'rECONSiRULTiON
comproadben, wBl do the wmi,, and the structure is not Intended or offered for
sTk (Sec. 7D44, Bwlrsas and Pmfmbns Code: The Contractors License Taw
'
does not apply to an owrcr, of property who builds or (mprrno thereon, and
who dm such work himself or through hie own employees, pm,,Wed that such
OCC. GROUP
RFS. IN115
improvements are not Intended oroffered fmsale. If, howeser, the building re
Improv mem baold within oneyearofcunpletbntheownerbullderwlll have
TOTAL
t4�1?u rden of poring that tie du not bib! or lmprewe for purpoae ofw.).
owner of the property, am eacheaNely commuting wXh Ilmneecl
LJ L as ismtr
contractus to construct the project (See, 7044, BualnemaM Pudmlons Code:
QTY. PLUMBING PERMIT FEE
PERMDF ISSUANCE'
FIDOD ZONE
ASN
I -
The Contractor's License Taw don out apply to an owner d Property who
bullds or lmprwe therem, and who contracts fee such p�ajets with a
o9aEfector(Oi1cans<d pursuant to the Contractor's License Law.
LJ I am exempt under Sec B & P C for this moon
ALTEIR-DRAIN& VENT-WATER(EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINSF1Z<)R ROOF,ARFA,COND.
FWTUME$ PER Bea
SANITARY Y_ N_
RE= 4
Owner Date
WORK MAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a utlXute 0( consent to rlf-iwm, or •
10,Fahc.) rken'Campenutlovinsuranmmamrtlfkd ropythereof (Sec.
ago, IAb C.)
SCHOOL TA% Y - N_
RECEIPT al
GAS EA.SYSTEhF.i INC40ITILEIS
PARKFEE Y N
rollry I
a
GAS EA. SYSTEM -OVER 4 (EA)
Com anvhereby
DING DIEIFrr
BUILDING DIVISION FEES
L_JCerci edcopy (umecity
NM ropy b filed with the mY inspection divbion.
GREASE/INDUSIRI, WASTE INTERCFi TOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXFMPFION FROM WORKERS
COMPENSATIONer,ANCE
Rhb stttbn need not be completed Bthak ppermit blmone hundred dollen
PAID
Date. Recti t#
SEWERSANITARY-STORM FA XpFT
wnrER l->FATTR w/vrxr/F�.ecrn
ENERGYFEE Y N
.
PAID
cs'm)nlm-)
I mmlythat b the performan a of the work forwhich this permit is blued,
I slug not employ any Penn In any manner w as to become subject to the
Wmken' Compensation lawn of California. Date
WATER SYSIk r!RFA.RNC
Applicant
NOTICE TO AIaPLICAM:R, aXer making thisCertBkate of Eaemptlon,you
should become subjet to the Workeri Compensaulan pmvbbns of the Labor
Code, you mice fothwlth mnply with ouch provbbns orthb P°•nnB Mall be
duos& revalud.
Date Reoei t#
NEW RESIDENTIAL PLMB. T.
'�F
TOTAL
B '
SEISMIC FE
CONSTKUCEION LENDING AGENCY
I herebysfBrmehat there Is amnstnuctlm lending agency for the perfortry
antt of the work for which thio permk b Lssued (Sec 3097, CN. C.)
TOTAL
ELECTRIC FEE
IcMera Name
Underi Address
certify thatl have read TZ appButbnandi state that the •hove Informrtm
i
hornet. lagmetoemplywkh•IlcXyaMcountyordinancussndmatelaws
QTY. MECHANICAL PERMIT FEE'
PLUMBING FEE
MECHANICAL II
PERMrr ISSUANCE
FEES PAID:
relatingtor athmfu
ponteabo,ctlan,anthereby
purposes.
urposcity (Wenterupon Ue•hove-mentioned property(mss the Cit of 0p pert
(We) agree to save, Ise and keep who the City of Cupedbn
agokM WbWtln, judgmerds,mtlasM sperm whkh mayb any way a¢ae
against saidC b erimo granting dth mut.
ALTER ORADD TOMECH
AIR HANDLING UNIT (TO 70,000 CFAU -
Data Raeeipt#
.SUBTOTAL:
AIR HANDLING UNIT (OVER 10,o0CFM)
CONSTRUCTION TAX'
Bunt/cont is
EXHAUs HOOD(w/DUCT)
CONSTRUCTION TAX PAID:
HAZIRDOUSMATERIALS SCLOSURE
HEATING UNIT (TO 103,000 BM '
WBlthe applicant or fmm, bruildingo¢upant port or handle havrdcus
material as defined by the Cupertino Munuipal Cede, Chapter 9.12 and the
Date RCCei t#
HEATING UbTT(OVER 100,000 BTU)
TOTA .
}leahhaM Safety Cade Section 75S37W7
❑ Ym No
VENTILATIONFAN(SINGIFRESID)
ISSUANCE DATE
WWthe appBunt ar tum bulldingoavpantuu equlpmen�mdevkn
whkheMt M1av wsdremlamkumsactdeBadbythe Bay Arc•Ab
Quality Mamgcment Dblrkt7
Yes ❑No
have read the h arardcve materials requirements under Chzper 695 of
the Californiaalifornia Health& SafrtyCode, Sections 25505,75573 and 25534. 1
E� E'f AD
BOILER-ODMP O}N OR tOQO(IO BTU)
BOILFRNMP(OVER I Kate BM
NEW RESIDENTIAL MECH.—SOFT
understand that illhebuildingdoea not camently hamamrant, that it bmy
respons(blllty to notify the occupant d the requirements whkh moat be met
prior to Issuance d a CediflcateofOmupancy.
AU , 92
IhbT]EDB {/`
Owncrorauthoromd agent Date
TOTAL
OFFICE COPY