26002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIBI-IJB�LFCIIB A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT vING PRNQ-MFCEAN'ICAL 26002 0 0 2
INILULU PANNE M IUENI'IFICA]CAL 'ION L U G
BUILDING ADDRESS: �,_1^ ��}\ (/�����'''�''/����� SANITARY NO. APPLICATTONSUHMOTALDATH
O2-7 O BJ �+ NIT# LOT# I-kN-q,
OW 'NAME: ^/� P ONI'R C� �N/3MF— �On 1 LIC NO,
{/ )1_q 1l. 'V i NIC CONTROLp
RCIII'TE' .iR: LIC NO'. D SS:4. .tea � ,a �' ❑ Lea
(CONTACT: PHONE: <V t[CP BUILDING PERMIT INFO
QTY. ELF,CTRIC PERMIT PEE
/I�.. BLUE I:LP.CI% PLUMB ECII
L—JVl PERMIT ISSUANCE �� Il}—yl�`
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DISCRIFI'ION
nKZ I herebyaffirnthm l em liecnsedunder provisiumofCTapter9(commencing with
u100❑ Swsri 70f1(Onf Division 3ofma Busineasand Professions Codgand my license L.Sin PANELS
I zw Licnse Clad dfc UPT02MAMPS • W�
QZW License Class Lic.M c-�
t~itQ6 Dore Com '1 201-IOTA AMPS
�hSQ.Ff.11.0 RAREA JQ
Z OONg ARCHITECTS DECLARATION ]"AMPSOVER IAMP5
1 undersand my plans shall be axed us public rccoNs. ��
0 h F W SIGNS ELECTRICAL
QY2j Licensed Pratcssimul
Lc, < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
oX` aU I hereby affirm Thal 1 am`tang,from the Conmacmrs License Law for the InIl
J3p-tFii following reason.(Section 7031.5.Business and Pmfesaionv Cade:Any city or county TEMP.METER OR POLE INST.
0
¢'5 which requires.permit m comma,aloe,improve,demolish.c r repair any structure
prior to it issuance.also requires he applicanlfar such Permit to file a signed statement POWER DEVICES
KKthat he is licensed pirorom1.the provisions of the Cono-actor's License Law(Chapter a./`
aX,ao� 9EomVAhUATIONmencing with Section 7o0H of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC CJC
^_y ormm Misexnnpnherefrote and the basis for the ullegedt,nemptian.Any violation of UTI F'f5-SWITCHES-FIXTURES
OZaSection 7031.5 by any applicant for apemit subjects The applicant a civil Penally of Oa
not more than Eve hundred dollars(5580).
SSG NEW RESIVENTIALF:LECIR _SQ.FT. STORIES TYPF:CONSTRUCHON
Cf-p ❑ I,usownendTheprogcny,ormyt,mployees winhwageaaztheiesolecomperuatiom,
a3 will domework,and the structure is not intended or offered for sale(Sec.7044.Business
and Professions Code:The Cam rcuo's Liunse law does not apply to ma owner of
progeny who build.mrimgroveanhereon,andwhndmssuch work himxlformrough his
umploycca.provided that suchimpmvemcros urcnnt imm�dedonffBrcdtmsele.IL
OCC.GROUP HES.UNIR
however,the building or improvement is sold within one year of completion,the owner If
-
builder .will have the burden eoproving that he did not build or improve for purpose of
sa1C'). P
TY. LUMBING PERMIT FEE
[3I.asownerofnhepmpny,mnemlativelyconinctingwithlicensedcontnetorsto QFLOODZONE ANN
construct the pmject(Sec.7(44,Business and Professions Code:)The Contractor's
License law dcesnnt apply to an ownerol'property whobsolds or improves Tbercomund PERMIT ISSUANCE
whornturxts forsuchpmjmuwiNacontnctm(s)licenced Pursuvtt Tonle Contrecnrs ALTER-DRAIN&VENT-WATER TAO FEE SUMMARY
License Law.
❑ 1 an exempt under Sec. .B&P C fat this reasongpCK PLOW PRO MCI.DEVICE OUTSIDE I
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF'.AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCIOOL.'1'AX Y N
❑ I herebynffirm lhatl haveacenificmeofconsents,self-insun.oraanificateuf FIXTURES-PF.R TRAP RECEIPTN
Wmken'Camperuatna
iom lmunccorcenifiedeopythenof(Sce.31100,Lab C.)which PARK HE Y N
covers all employee's under this pcmil. GAS-EA.SYSTEM.I I NC.4 OUTLET S '—w RECEIPT#
Policy# BUILDING DIVISION FEES
Com GAS.EA.SYSTEM-OVER4 THAT PLANCHECK FEE
Certified copy is hereby famished.
Certified copy is fled winhnhc city inspection division. GREASUINDUSTRL W TE INTERCEPTOR GRA 1 -Eis_ /�
CERTIFICATI3 OF EXEMPTION FROM WORKERS' GREASETRAP (I ti Iia' Cu SOIL,
OIL 1114
COMPENSATION INSURANCE
(This Sectionneed not be completed ifthe permit is forest,hundred dollars(S IIID) SEWER-SANITARY- TO 1 IIOPT.I�� I o F rH
or leas.)
I cenifythalin the performance of he work for which Nis permit is issued.lsball WATER HEATER WIVWIELECTR
of employ any person in any marine so as to become Subject To the Workrn' AfD
Cron,amion l.aweof Califomia. Date WATER SYSTENUTRP TING Receipt#
Q Z Applicant
NOTICE.TO APPLICANT:If,after making This Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.IT. l'OTt
ZY, becmmesubjmuo the Worker's Compensation provisions of me Labor Code.you most
I--' 7 forthwith comply with such previsions or this permit shall he dimmed revoked. BUILDINGFEF
04
(� CONSTRUCHON LENDING AGENCY SEISMIC IEE
7 z I hereby affirm that mem is a construction lending agency for the performance of
U O me work for which this permit is issued(See.3097.Civ.C.) ELGCfRIC FEE
Lenders Name
u' F Lenders Address Q'PY. MECHANICAL PERMIT' FEE PLUMBING HE
O U I ccnify that 1 have read this application and state that the above information is MECHANICAL H-C
>" W comet. lags``us comply winM1 all city unJ county ordinances end Slate laws relating to PERMIT ISSUANCE,
I--' building constructor.and hembyamhmixerepresentaniveaafmis cily locales uponfam CONSTRUCTION TAX
(� ,Z aboe.romomed property for inspection pury,S. ALTER OR ADD TO MECH,
(We)agree m nave,indsmnify and keep hartnlc3S the City of Cupertino against
limb' os',jmllpnen¢,mase expenses which may in any way accrue agninsn said City AIR HANDLING ON]r(TO 10,000 CFM)
in uence of the grand his permit.
�� AIR HANDLING UNIT(OVER 10,D)n CFM)
Si cure of Applicata trrm Conr Date q EXHAUST HOOD(W/DUC
PAID
1 AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM.000 BTU) Dam Receipt IT
Will The ap,fcam or future building occupant Store or hardle herardous material
as defined by the Cupcnino Municipal Cole.Chapter 9.12,and The Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(x)'! VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(31111 OR I0p,000 HTB) � A ISSUANCE DATE
bmm=Will thwpplicam orfuwrebuilJingoccupam uueyuipmem nrdevices which`mil 1 `/
x air contaminants as defined by rhe Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
LIAR ! 8 1994
❑Yes ❑No NEW RESNIiNTIAf.#ECII. SQ.IT.
I have read the h:reardous materials"itinmerts under aspire 6.95 of the ell y Ur- L ul-
Califomiahealth&Safety Code.Sections 2550.1.25533 and 25534. I understand that L Iavu
if the building does not commonly have a tenant,that it is my responsibility a notify,the
cecupant of the requirements which must Is,met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE