24533 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING T T'RI A• -- PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 533
BUILDING PROJECT'IDKNTIFICXD()N
HUILDINGADD/,RIiSS- - SANITARY NO. ATI
APPLICONSIIBMITAI.DATE
/ W « UNIT LOT#
OWN NAM _ PHONE: �/ CONTRA R'S NAMIi: LIC NO: (��S
G/'lS Z 'J `--�Fd75 NIC CONTROI.q
AR TECT/ENGINEER: LIC NO: A DRESS: , �d` .$)L/ ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMI'I'ISSUANCE
BLDG ELECT PLUMB MECH
❑ ❑ •q ❑
LICENSE.DCON TRrderan SOECLARATION APPLIANCES-RESIDENTIAL �J
Matz Iheathy offrnvnm1 amlivens u under and
P000nsofCColle, (commencing is will, 109 DESCRIPTION
f�00 InIf 70(q)af Division3 fthe Business end Professions Cala and my license is in PANELS
In V� full force and cjfp t._ o_ �r y
_zW License Class Lia# UP TO 200 AMPS
Fly Data e!—6'�- Convacmr 201-IIgOAMPS
mZ 7 shall
be TS DECLARATION 2 St FLOOR A - $/SQ.IT.
ZO-0 OVER I(q0 AMPS
OZ—0 q I understand my plans shall be used as puM1lic records.
FayFtn SIGNS ELECTRICAL
I.ncenseJ l'rofessnonal _
y�Q
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°�OaU 1 hereby uffmn that I am nxclnPt from the Qmtmmor'v Llcensc Law[or the
W40`n following reason.lSation703 L5.Business and Professions Cade:Any city or county TEMP.METER OR POLI?INST.
y 5 which requires a permit m constma,alter,improve,demolish,or cepa r any 9lmetuee
a� prior In its issuance,also requires the applicant for sacs Pcmninnfleesignalsmmmem POWER DEVICES DATE
qp That he is licensed pursuant mthc provislons of the Contractor's License Law(Chapter
dXo�' 9(commencing with Section 0000)of Division 3 of Ne Businessland Professions Code) SWIMMING POOL ELECTRIC
or 0but he is excmm for,dearafmand the basis alleged exemption.Any violation of VALUATION
^
kzG
Section 7031.5 by any applicant for o permit subjects the uPplimen to a civil penalty of OUTLETS-SWITCHES-FIXTURIiS LID-�0
E=q t mom than five hundred Jollus(E5W).
w m n❑ 1,asownerofthepropcny,ormyeniployeeswithwagesastheirsel¢compensation, NEW RESIDENTIALELECIR __SQ.Er. STORIES 'I'YPF.CONSTRUCTION
a _ willAo the work,unJ the atrucwrolsnrn imendnl nrofferoJ for sma(See 9044,Busincry
and Professions Code:The Contmemr's License Low does not apply m sn owner of
property whobuildsorimprovesthemon,and whod«ssuch work himselfor through his
oweemplayeas,provided shut such improvementsare not lntendedorofferell forsule.ll', OCC.CROUP RES.UNITS
however,the building orimprovement is sold within one yemofcompletion,thenvo er-
builder will have the burden of pmsing that he did not build or improve for Puryou of TOTAL:
sale.).
❑ Las numeral'ihepromity,amexclusively convening with licensed ennlracrors as QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cantonal the project(Sec.7044,Business and Professions Code:)The Commences
License Lawdoes not apply to awevarrodproperty,who builds or improves themnn,and PERMIT ISSUANCE s�
omeomrucis for such pnrjects with o amens tis)Incensed pollution the Contractors
License Law. ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
C31 am exempt under S<c. B&P C far this reason
SACK FLOW PROTECT.DEVICE U_M_-1DE_MR
Owner DamSANITARY V N_
WORKMAN COMPENSATION DECLATI
RAON URAINS-FLOOR,RUDE.AREA.GOND. RECF.II'1'p
Ihereby affnrm that lhave a urance to
retecal copentto icitf(imsure,0,acerb.)which SCHOOLTAX Y N__
okem'Com lion Insurance arvcmifiW ropy thereof(Sec.3g00,Loh CJ which MIXTURES TRAP RI?CEIPI'q
poensu PARK PL'E V__N
overs elle y 's nQ1 h' noir^ EA. INC.40UTLEI'S
Pom,ml 43 GAS-h RECEBT#
BUILDING DIVISION FEES
Company—p 6 -6 -� GAS-EA.SYS'1'IiM-OVER 4(EA)
11CertifiW ropy is hereby umished. PLANCI IIiCK IsLC
KCenifieJ copy is filed with the city inspection division. GREASIyINDUS-IRL WASTE IMIF.RCEPI'OR
GRADING PPB
CERTIFICATE PENS TJONINN PROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE SOILS FIST?
('this section need not he completed ifthe permit is forone hundreddallure(SIM) SEWER-SANITARY-STG.
'ORM2WF1'.
or less.) ENERGY FEE
I candy that in the perfommnce ofthc work for which this permit is fistad•I shall WATER HEe TIiR W/VENT/ELECI'R
not employ any Person in any manner so as to become subject to the Workers' PAID
z Comnt an Lows of Culilismia. Doty WATER SYSTEM/TREA•1'ING Date Receipt#
O Applicant
z 0 NOTICE TO APPLICANT.-If,atter making this Certificate of Exemption,you should NEW RESIDENT'IAL PLMB. SQ.FT.
FV) become subjecrto the Worker's Compensation previsions of the Labor Code,you muse TOTAL:
�
forthwith comply with such provisions or this Permit shall be deemed revoked.�_ BUILDING FEF.
IJ-) Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iwmby affirm that there is a construction lending agency for the performance of
U O the work fell which this permit is issued(Sec.31097.Ci,C.) TOTAL: .S-0 ELECTRIC FEE
Lender's Name
U Lender's Address QTY. MECI IANICAL PERMIT - FET? PLUMBING FEE
W 1 cenify that 1 have mad this application mad state that rte above information is
� L1s correct I agree to comply with all city and county ordinances and state laws belatingto PERMITISSUANCF MECHANICAL FEE
-' building construction,and hereby amhonic representatives admit city to voice uponthe
U above-mentioned p.N"y for inepeninn purposes. ALTER OR ADD TO MECI L CONST'RUCT'ION TAX
(we)agree to save,indemnify and kap harmless the City of Cupertino against
ishilities,judgmenrs,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT IT 0 I0,0110 CFM)
/Wp coca¢of'th gomh foes Pa.".
o AIR HANDLING UNIT(OVER 10,0W CFM)
�gnulr ur—col AIfila t/Comraetor Dole EXHAUST HOOD fW/DUC9)
PAID
HAZARDOUS MATERIALS DISCLOSURE, T IFATING UNIT-(TO 100.000 BTU) Date Receipt#
Will the applicant or Mala¢building occupant stere or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING ON]]'(OVER I WpW B'I'U) TOTAL
Cade,Section 25532(a)?
❑Yes 0 N VENTILATION FAN(SINGLE RE.SID)
BOILER-COMP(311P OR 100,0%10 BTU ISSUANCE DATE
WilM1heepplicamorfmumbuilJing occupant uuequipmem ordevi«s whichcmit ) -
h'aard'us air emi ami�ou as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,000 BTU)
J ❑Ya ❑No NEW RESIDENTIAL MECIL SQ.FT. PAID
1 have road rho felt'Code,
materials 5505.255 nts under Cnnptsr understand
of the �O
if he wint lding lth des Safely currently
ttle,Seeinns 25500.t it I. end 25534.1 ily u,f and that Q�01
ifthebuildingd«ssatonam, yich ¢vnL thatitis my reuanceof a to notify Ne
occupant of the rc:ryircmenl..which must be mw prior m issuance of a Certificate of n Y
Occupancy. V Cur LVY
Owner or authorized agent Date TOTPAL: ISSUED BY '
OFFICE