26422 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILLUI .-N. TRI.AL PERMIT NO. /y�� /A1 /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBIND-MF.CHANIC'AI. 2 6 4 2 2
BUILDING PROJECTIDENTIFICA'FION -
BGILDI G RO - SANITARY NO. API9.ICA'1'IONSUBMG7AL.DATE
JJJJJJ Iv LOT N r2�\
OWNf: NAME: PHONE: C CTORaD� ^ LIC NO:
yy�/T/�� ` ' P�x/c4 11.. , 1�y1 ��fl' /��pay N/C CONTROLN
fi ARC I'[ /iNC 1/ IlF/{�/�+ICN� / 1�J45W/J K// �rI'v (/(�✓G s"i( rJ/�
CONTACT: I PHONE:
1 QTY. ELECTRIC PERMIT P8E BU1I,DING PCRMIT INFO
,rk�,if -- 1 -� rz rj BLDG .ECT PLUMB MECH
(�VI[�QII�J V�V'v[/ PERMIT ISSUANCE 75
X A4
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DP RIPTION
pocZ Iherehyaffrm Oiallamlicenudunderpmvisiomof Chapter9(co meingwith
Poo Secllonl690lof Divlslon30flhe Businessund N4 rf,lionx C«l,andmyli«nuisin PANELS
full force and effect /�.
C�y UPT02 AMPS rp\ '1-C
rF<Z Licen Cmum I )`tis
« Dale Convenor 201.1 AM
F-y{_ ARCIi1TECT'S DECLARATION n SQ.FL FLOOR AREA Q. '
z'O m 1 understand m I shelf he used n public records. OVER I A PS
OZ�O ypanss a
Xtra Fn1 SIGNS LEC ICAh -� r- �- _
'� Lid lhofeona
nil
��6 censeOWNER-BUILD ER DECLARATION SPECT CIR TMISC, vC
KO�V 1 hereby n.(Se tint 1 am exempt from she Contmno a License Lew for she
m30yQ following reamn.(Seaimn1111 L5,Business and Professions Cede:Any city nrcounty TEMP. E'ILH OoAQ�I145T. ` q,
<L' yJ whichrequiresneemmil rewms theplate.improve,demolish,«repair any Hmnufe
K�Qn prit he itsliwouniccensed pursuant
to the
theapplicantofor u ontramm's file LicaseLadsmcmrnr POWERDEVILFES-
W pK that herr licensed porsuam m the ofDi ons of the Comrecmis Lime bow(Chapter
a' e4 9that he is exempt Seefom,and)of Division 3o the Businessand Professions Code) SWIMMING POOL ELECTRIC VALUATIOy�/�
WZy onhut 7031. by yapplimanfor a d the bermitss for bjealleged caemantto civiny l
of UTLLTS-SWITCHES-
FZa Section than by myapplicantdollrs($50mmit subjects applicant acivil pendD of F1 RES
not mom than five hundred ny,DT (SS(IO). NEW RESIDENTIAL EI.ECTR S .FT.
W m ❑ othe wrk,muleprmpertur,is empindedouilhwed forslhe(Sce.compenmtian, Q STORIES TYPE CONSTRUCTION
L _ will do theworsCore; sso Cradmnmimended orowdoes mituec.1614,Business
and professions Code:The Convector's Line Lew does not apply lf an owner of
property wyees,ptlnnrimphasucheuon,andwhod«emehwnedorofentAthmughhis OCC.GROUP RES.UNITS
ownemployem,prnvided provehent iss sold
thin not iamcfe oroffered frown.B,
however ill have
lding au improvement is sold within one year or improve
for theowner. To .
builder will hav<the burden of proving that he did not build or improve for purpose of
sale.).
❑ hmowncndthe property.emexclusivdy convactingwith tic<mN<onuecmrnn QTPLUMBING PERMIT FEE FLOOD ZONE APN
Y.
onswct the project(Sec.10,14,Business and Professions Cade:)The Committees
License Lew does not applylo anownerofpropersy,who builds or improves thereon,and PERMIT ISSUANCE
who comrade for such projects with a conmocmds)licensed pursuantto she Commctoes
Licence Law. ALM-GRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason S .
BACK FLOW PROTECT.DEVICE: SANITARY YN
Owner Date RFCE.IPT M
DRAINS-FLOOR.ROOP,AREA,COND.
WORKMAN COMPENSATION DIiC1.ARATION SCHOOL.TAX YN
❑ Iherehy affirm thutlhaveaccdifimm of consrnno selFinsoue,ma«rtificne of FIXTURES-PER TRAP RECEIPI'N
Workers'Compensationlnsumncaoracenificdmpythereof(See.3g00,lab CJ whleh PARK FEE Y N
covers all employee',under this permit. GAS-EA.SYSTEM-1 INCA OUTLIES RECEIPT N
PolicyN DI VI ION FEES
Company GAS-FA.SYSTEM-OVER4(EA) PLANCH
❑ Canified copy is hereby Unnishod.
❑ Certified copy is filed with the city inspection division. GREASHANDUSTRL WASTE INTERCEPTOR .FC
CERTIFICATE OF 17XEMMON FROM WORKERS' GREASHTRAP OI
COMPENSATION INSURANCE
Ina secticatmodmot hecnmplemd ifthe permit is borons humdreddollarxISM) SEWER-SANITARY-STORM EA.200FT. GNLR 'E
or less)
I«nify that in the performance of Roe work for which this Permit is issued,lshall WATER HEATER W/VPNI'/CLECTR
not employ any person in any manner u m to become subject to she Workers' PAID
.� Compens:Nnn Lawsof California. Date WATER SYSTEFVTREATING Date RamiptN
Applicant
zQ NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FI'. TOTAL:
rp become subject to the Worker's Compensation provisions of the Labor Code,you must
5' forthwith comply with such provision or this permit shall be doemed BUILDING PEE revoked. �a
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE.
I hereby affirm that then I,.cnmmuctlom lending agency for the performance of
V O the work for which this permit is issued(Sec.300,Civ.C.) ELECTRIC FEE
hendoes Nue
0 U mLender's Address QTY. MECHANICAL P17RMIT FEE PLUMBING FEE
1 certify that I have reuJ this application and stem that the above ofmmodam is MECHANICAL.FEE
>1 0. correct.Ingres mcomply with ell city end cnumy oNinances end nom laws refiingn PERMIT ISSUANCE.
�1 M1uilding construction,anJ hereby amhorim reprtsenmtivm of Nis city learner upon Ne CONSTRUCTION TAX
L) 2 move-memmuld property for impcnimt purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabillties,judgments,emus and expenses whichmay in anyway seemeagainstmid City AIR HANDLING UNIT(T010.00)CFM)
in asequence of the granting of ' it.
S AIR HANDLING UNIT(OVER 10,000 CFM)
amreof Applidr0Conmrror Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data ReceiptN
Will the applicant or future building occupant mre or handle hcturat material
es defined by the Cupertino M unicipal Code,Chapter 9.12,and the Health and Safety I MATING UNIT(OVER I Of0fad BTU) A
Code,Section 23532(a)l
El Ya 11 No VENTILATION PAN(SINGLE REBID)
Will the applicant or(uwre but Iding occupant uu equipmrnt ordevicea which emit
BOILER-COMP 13HP OR 100,6p BTU) ISSUANCE DATE
havuNoua air contaminants n defined by the Bay Area Air Quality Management
District! BOILER-COMP(OVFA IQ1,000 BTU)
IQI p
❑Yes ❑No NEW RESIDENTIAL MECtI. SQ.FT. W
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that Y 19g
if the building d«sn«currently haven¢nant,thatit is my mapnnsibility mnotify the ^ L 4
Oc upant of the raTirememn which mot be met prim m issuan«of a Certificate
ificate of I uh s
Occupancy.
Owner or emhorizW agent Data T ISSUED BY:
OFFICE