26900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B MBI. .- .L. RIICA PERMI"f NO.
APPLICATION/PERMIT PING PROG-MFIDENTIFIC 26900
BUILDING DIVISION BUILDING PR(IJECI'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPIACKIION SUBMITTAL DAT.
IDDLer B11,04D. UNIT# LOT H
I— CC//
IWNIiRSass.2�val
k ME: at)V PHONE: 4� CONT CTO 'S MAdIIIII E J NO NIC CONTROLp
CJ I
ARCI ILCf GINEER: LIC NO: RES$: /_ A ) ❑
� G O
CONTACT: PHONE: v BUILDING PERMIT INFO
QTY. ELECI'�IC PERMIT FEE
LI 12C PLUMB MliCll
PERMI"I'ISSUANCE. 0;37k�.Q(�'',
LICENSED Lou CONTRACTOR'SDECLARATION APPLIANCES-RESIDENI'IAl. JOB DISCRETION
pyZ Ihereby)(Hol' mthm l 3 ofthnudunes and
Professions
Coter9(commecense with
uF100❑ 8eainn]1X10)of Divia on3of the Business and Pndessions Cock,and my license is in PANELS 4
tY UU full force are effete. i
IQ.,ZW LicenseClass Lic.p 69Iii UPT02MAMPS 1�IFrV7
m6y Date Cmuma r _ 201.Had AMPS
2�OyZ-4 ARCI IITECT'S DECLARATION OVER TWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
undersmne my pluas shun be used as public records.
SIGNS ELECTRICAL
QnLicensed Professional q� (.�
KKyW< OWNER-BUILDER DEC[ tAT10N SPECIAL CIRCUIT/MISC.
xOyF 1 hereby affirm that I urn exempt it Il1�Commcmrs Lice Law for the
F��gfollowing reason.(Section 7031.5,Busine d Professions Code:Any yor county TE MP.METES OR POLE INST.
W.
which requires v permit m eo°sons c impose,demolish,or repair EE wmum
N:F primmnai—suse,alxn rtqulresme liemufor mchpermhmfilea gncdirumem POWER DEVICES
W <O 0arheis0censedpursuannotlm ovisionsofthe Contractors Licen aw(Chisper
my �' 9boneramei "N'SeeiomT )of Dlvision3ofthe Business I, Code) SWIMMING POOL F.LEC'1'RIC VALUATION
W�m mth°theisexempnherel, amdtsclus,sfor callegede.e it t [.tion of t��
rya Section 7031.5 by any a licaotforapermitau stheapplic t gi ri penalty of OUThCfS-SWITCHES-FIXTURES Q�
C$ ern mom than Eve h red dollars(u
Fp ❑ I......n eproperty,mrmyemp ithw lets ecompemamon, NEWRESIDENTIALELEM —SQ.FT. SPORIESi TYPECONSTRUCf10N
a3=° will do thew ,end thaatrvaure isnot1 dor°ff IW4
l e J ,11miness
.rather, cions Code:The C.mrtc nu La t pply to an owner of
proper hobuildscrimprn sther n, dwhmd.4ahimulforthroughhie OCC.GROUP RES.UNITS
wnomp ycea,prosided that ch rovemepl)tt��arz��robot dedcrofforedformle.IL
however, ebuiltling nr in rn tis sol 14IIhi0Jmey rofcrmpletion,the owner- L:
hudderwill vemeh., not .1 at h dd or improve for purpose of
sale).
1 ❑ Lmowrer thepropery, v clusivelycon t[ng with licensed contractors to QTY. _ PLUMBINGPERMIT FEE MOOD ZONF. APN
construed the prone (Sec.70as Business and °fessicn,Code:)The Comoubsu'a
LicenseWwdcesnot ly tovnrwneroflropc who buildsmimprovexthereon.and PERMIT ISSUANCE
whomntractsforsuchpm tswiNacomnn s)licensed pursuannothe Cnntr dols ALTER-DRAIN&VENT-WATER(EA)
License Law. FEE SUMMARY
•❑ I am exempt under Sec. ,B&P C for this reason O T'. );•I•
BACK PLOW PROTECT.DEVICE. SANI'T'ARY YN
Owner Date RECBIPTO
GOND
AREA
ROOF, , .
WORKMAN COMPENSATION DECLARATION DRAINS.FLOOR, SCHOOL TAX Lys N
❑ I hereby effrm that l have a certificate ofconsenno self-insure,ora ocrifteutenf .%TURES-PER TRAP R.CF.IPPM
Wmke,i Compenution lnsumnee or a cenificd copy thereof(Sec.38W,Lab C.)which PARK Ili'
covers all employer's under this p.if GAS-EA.SYSTEM-1 INC.4 OUTLETS IiCEII
Polk,# ILDING 1 .ION FEES
Company GAS-EA.SYSTEM-OVER4 MA) PLA KFEE
❑ Cerifiod copy is herchy famished.
❑ Cenifed copy is lilcA with the city inspection division GRIIASIVINDUSTRLWASTIi IN'I'F.RCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASP,TRAP 50 PEE
COMPENSATION INSURANCE
(Thissectmis neednmbeeompletedifthepemrit is foronehondredd.11.($I00) SEWER-SANITARY-STORM 1A.203FT. ERGV FF.Ii
or less) IC
I cenifythat in the performance ofthe work for which this permit is issued.(shall WATER BEATER W/VENT/ELECTR
not employ any person in any manner so as m become subject m the Workers' Pp XPL
O Z Aorlicowitmnl.awsof CalifrmieT
. Date WAER SYSTEM/fRP.ATING vine 11
ant
z � NOTICE TO APPLICANI11L after makingthis Cerificate of Exemption, no should NEW RESIDENTIAL PLMB. SQ.PL TAL:
F' .�. become subjcono the Worker's Compensation provisions of the Labor Code,you must
� , forthwith comply with such provisions or this Permit shall be deemed revoked. UILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z Ibemby M.that here is aconsmadness lending agency for the perf°mmnea of C•LECIRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.) �-
,r Lenders Namey
W hrnems AAarws QTY, �t ,MECHANICAf II,RNIIT`' {{ Fl)E,`j' PLUMBING
aa
U I cenrfy that I have rend this application ane state that the.lave information is St
F correct. [agree to comply with all city and county orlinmces and state laws relining to PERMITISSUANCE ME C L E
qL it-
y building construction,and hereby authorize representatives ofthis city to enter uponthe
U z above-mentioned property for inspection purpous. ALTERORADDTOMF.CH. ' CO Q IGN TAX
(We)agree,to ve,indem' Jrespkernless the Ciryof Copeninu against
liuhilitie"'no' cost dexpe which may in any way eccmeagainn said City AIR HANDLING UNIT(TO 10.(100 CFM)
canseyuen t cgr tgn omit.
8 (
epro L AIR HANDLING UNIT(OVER 10.000 CFM)
gnat o pplicam/Cmtmctor ate EXHAUSTHOOD(W/DUC ,
PAID
HAZARDOUW&T!'J*S DISCLOSURE HEATING ONR(TO 100,01X)BTU) Data Rmeiptg
Will the applicant or future build�ycpupa
nt store or handle hazardous material
as defined by the Cupertino ManiGarzsl1Ccl halite,9.12,and the Health and Safety HEATING UNIT(OVER 100,010 BTU) TOTAL:
Code,Section 25532(e)] - VENTILATION FAN(SINGLE RESID)
❑Yes ❑Nu
BOILER-COMP(314P OR I00JHI0 BTU) "ISS ANCE DATE
Will the applicam nr futurt building occupant use dsryipmenmr devima which emit
hazardous air contaminants as defined by the Hay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) UG 3 0 19
Dia ct g4
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hamudom materials rryuirtmcros under Chapter 6.93 of the all y Vr LV
California Health&Safety Code.Sections 25505,25533 and 25534. l understand thin //�u
if the building does mol currently have a mount,thin it is my responsibility to ratify the
mupam of the soqulrements which muni he met prior to issuance of a Ceti Berne of
(xenNmcy.
Owner or authirizee agem Dam L. ISSUED BY: �►
4
OFICE
ADDITIONAL PERMIT FEESy
/Pka 21,RGD
BUILDING PROJECT IDENTIFICATION VALUATION
q
ADORT.
fool SaN(C R?L A.
owxsR s
NAME
pi/_L1{S {{oJCSD�� vxoNE 8bS` FEE SUMMARY
CONTRACTORS
NAME BUILDING �� op
NAME �>
-X'?FALL-56ALVleU"t la�o G7t45 PLAN CHECK
cox.R ACTON
AooRess FEE
T,
i_ /G7 Jn�w,iuC '"`" •oh cS'wYZSZ7rG S�
SEISMIC FEE t
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ,CD ELECTRIC
LIGHTING FIXTURES I'
PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL II//y/
SIGNS TOTAL !�% 1 00
SIGNS TRANS. Y
SPECIAL CIRCUIT �pO
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH. L7O
I' O SERVICE CHANGE �Dn4
ZZ
1- T TOTAL S .o
LU > QTY. PLUMBING PERMIT FEE ISSUANCE DATE
LU _ BLDG, ELEOL 0CT, PLG. MECN.
Z ALTER-DRAIN&VENT-WATER(EA.) ,� ti-I• ❑K` ❑
V O BACK FLOW PROTECT.DEVICE rtrt11 [n1 I!
O w DRAINS-FLOOR,ROOF,AREA,COND. ^„Q IJ” l:•! 9
>_ h FIXTURES-PER TRAP
Fz GAS.EA.SYSTEM-IINC.4OUTLETS SEP 29 199
(„) GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER, ill ( Vr VUrrm ou
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2001t/
WATER HEATER W/VENT
WATER SYSTEM
�. WATER TREATING EQUIP.
TOTAL 2L>.V
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE '
AIR HANDLING UNIT(TO 10,00D C.F.M.)
AIR HANDLING UNIT(OVER 10,000C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT IO V ER 100,0000.T.U3
VENTILATION FAN (SINGLET
BOILER-COMP(3 H.P,or 100,000 B.T.U.)
BOI LER-COMP IT)—100,000 BTU)SEE FEE SCL.
TOTAL