26618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1 II.DING-ELF. TRI AL PERMIT NO.
APPLICATION/PERMIT PING PROJECT ID
IANIFIC 2 6 6 1 E
BUILDING DIVISION BUILDING PROJECT IURN'PIFICAT'BOX
BUILDING ADDRESS: T SANITARY NO. APPLICA'DON SUBMITTAL DATE
Z0009 S UNIT# LOT# / —�
OW ERS NAME: PI{pN& CONTR 'OR'SN E: LIC NO: V
(r tv,Adco
NIC �/s CCONTROL#
•`RING /F.NGINE:R: Co �I_7 ADDRESS: Ell �V
MAA
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUM M/ CH
PERMIT ISSUANCE �
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I--V JOB DESCRIPTION
WOO I M1crcby of i Nott am lice Bu i n ss and rotes i ons Code Ind mmend.g with
WOO Sertion]000)mf Division3of No Business and Professions Code.and myliccnse is in PANELS
yU— full force and offer,.
FZW License Class Limb UPT02MAMPS Aoo
Njh Date Central 201.1000 AMPS
z0„Z ARCHITECTS DECLARATION OVER PONT AMPS SQFT.FLOOR AREA g/SQ' T'
OZ—O 1 understand my plans shall bo uud u public records. �� 0 �Z
F_+F”V SIGNS ELECTRICAL
2 �J LimnsW Professional
erz�a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaU I hereby affirm,bat I am exempt from,he Conwc,or's License law for,he
F�wFi following reciam.(Section 9031.5,Business and Professions Code:Any city or county TMMP.METER ORPOLEINST.
w which requires a Permit,o conswn,alter,improve,demolish,m repair any sweturt
SWY:E prior to its issuance.also mquiresthe applicant for such Perot to file a signed statement POWER DEVICES
m C<O that he is licensed pursuam to the provisions of the Commences License Law(Chapter
d XMA 9f commencing with Section 7")ofDivision 3 of,he Business and professions Cade) SWIMMING POOL ELECTRIC � VAL,,,U���AT///I rrrO��aIS
py_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of wU'Tf E-fS-SWITCHES- 1 1eb
I•Z¢ Section 7031.5 by any spheral for a permit subjects No applicam,oa civil penalty of FIXTURES - —` `
E s r than five nonmed dollars(E500).
Kh-eandties five bond,dd <m to ms with wa pass N`axdecom NEW RESIDENTIAL ELECIR _SQ.FT.
Son
y.osmy p y g pBusiness STORIES TYPE CONSTRUCTION
o, 22 e work,and@c nmcmmisnot imm�dcdomffertdfm salt(Ser.9044,Business
taCadeCommctorsLicense tawdas not apply,o an ownerofwhobuilda oripmvesthereon,endwhod«such workNmmlforNmugh M1isoyee,providedthasucM1 improvcmcrosare no.imm�dedoroffered Tarsale.IL OCC.GROUP RFS.UNITS
however,the building m improvement is sold within one yerrovionple,ion.the owner- T A
builder will have the burden of proving that he did net build or improve for purpose of
sale.). TY. PLUMBING PERMIT
❑ Lu the project
(Sm.70oW, exdusis and nmassions C licensed Contactew Q FEE FLOOD ZONE APN
License the project sec.]044,Baaineea and Professions Code:)ove Contractor's I
License Law dcesnm apply nowncrofpropeny who
sed pursuant
to the thereon,and PERMIT ISSUANCE
who contracts for such projects with aconuaaor(s)licensed pursuam,.the Contractors
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am pump,under Sec. ,fl&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
Owner Date SANITARY YN
WORKMAN COMPENSATION DECLARATION DRAINS-FLUOR,ROOF,AREA,CONE. RECEIPT#
❑ 1 hereby affirm that l have a cenifcue ofconsent,osel8insum.oracedifcam of SCHOOL TAX Y N
FIXTURES-PER TRAP ^ RECEI N
orkers'Cmmpensmion Insurance orncenifW copy thereof(S ea 3X00.Lab C.)which ` PARK FEE Y N
covess all employee's under this pertni,. GAS-EA.SYSTMM-1 INC.4 OUTLETS RECF UP#
Policy p BUILDING DI SION FEES
Company GAS-EA.SYSTEM-OVER PLANCHECK FEE � II 1.
❑ CenifieJ copy is hereby famished. �C
❑ Certified copy is fled with the city inspection division. GREASE7INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICA'IM OF EXEMPTION FROM WORKERS' GREA TRAP SOILS FEE 4� I�
COMPENSATION INSURANCE
phis section need no,be completedBNe Penni,is formic hundred JollasfEl W) S E -SANI'T'ARY-STORM EA.200EG'. ENERGY
or less) V
I sonify that in the performance ofthe work for which this pcmnit is issued,Id, 1 WA . 117 ;RW/VFNT/ELECfR
amt employ any person in any manner ,,as m berome subject to otM\Workn PAID
Coorpenvullmnlawsf California. Date WAT'I?R
Q Appficunt— r SY, li /TREATING Dere Recta of
Z O NOTICE TO APPLICANT:ILaftermaking this CcmEcmcof Exemption, to ould NEW DE Al.PLMB. OTAL:
V) hecom,Subject In the Worker',Compensation pruvislons of the labor Cale,you mus,
a > forthwith comply with.such provisions or this permitshall be deemed revoked. BUILDING FEE
I�
y Q
CONSTRUCTION LENDING AGENCY SEISMIC PEE
Z I hereby affirm Nat there is a construction lending agency for Be performance of
C) O the work for which this permit is issued(Sol.3097,Civ.CJ U ELF,CTRIC
Lenders Name
ULender's Address QTY. MECHANICAL PERMIT FEE PLUMB I E
I codify that 1 have read this application and state that the above infnsmmio.is ^�
0. correct.l agree 10 comply with all city and county ordinances and state laws elating to PERMIT ISSUANCE MEC I Al.FEE
building construction,and hereby uabodae representatives ofthis city to enter upon the
f,) Z above-mentioned properly forinspeoion purposes. ALTER OR ADD TO MF.CI I. CONSTRUCTION
(We)agree m.se,i emnify d ke codes.Ne City of Cupertino against
habilities,judgmeal co
of
w c oyimanyw y accrue Nat City AIR HANDLING UNIT(TO 10,000 CFM)
m rsamsequem of a got 4l C
AIR HANDLING UNIT(OVER 10.000 CFM)
Sig sof Appli,do/Co mct. Dam EXHAUST HOOD(WNUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,1100 BTU) Date Re<eiptN
Will Ne applicant or future building accuser,same or handle harardou,materiol
as defined by the Cupertino Municipal Coda Chapter 9.12,and the health and Safety HEATING UNIT(OVER 100,000 B'ITT)
Code,Section 25532fa)?
EI yet El No VENTILATION FAN(SINGLE RESID)
Will,air contaminants
deli d by the ay Amu Air Quality Management
BOILER-COMPL3HPOR 100,000 RTU) ISS NCE DATE
�iheous air cmnwninans u defined by Nc Bay Area Air Quality Management
her, BOILER-COMP(OVER 100.000 BTU)
❑ ^
Yes ❑No NEW RFSIDENTDd_IxECIL SQ.FT. P q
1 have read,he haandous materials«yuimments under Chapter 6.95 of,he e'9
California Health&Safety Code,Sooner 25505,25533 and 255J4. 1 understand that /�
if the building dore
s no,currently have a ean
mt.the m
d is y responsibility 1..,try No V
occupant of the"comments which mus,be me,poor to issuance of a Cmifam of
Occupancy, c/ r 271994
—se....uthommd engem Dae r h
ISSUED BY: :.ri,
OFFICE