26205 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO riun, ;Ncr., ,,,TR PERMITNO.
APPLICATION/PERMIT .rING PROJECT
IDENNICAL
FICA 26205
BUILDING DIVISION BUILDING PRO.IFCT'IDI:N'fIFICA'1'ION
JILDIN1G ADDRESS c .{1�. �- SANITARY NO. A^PPLI41VG NfSUUaBMITTALDATH
11Z` t+ 1 K V �/�./ UNIT# LOT#
WN�$ryA'LME;tp ��.A.INaE;� C NTRACI����OIVS NAME LIC NO: N/C J CONTTRROOL#
ARCHITECTCCT/kNGINVER: LIC NO: ADDRESS ❑
CONTACT: PHONE: 5 d b ¢ t m y
TY d �FL.fl(3 C PERMIF,. '�„ s{, . FEE, BUILDING PERMIT INFO
PLUMB MUCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRII'flOfy _ �� a
Met I hereby affirm that l oro licensed underprovisions of Chopmr9(commencing with `�`G111�1�i
ts100_ Section 700)of Division 3 of the Business and Professions Code,add my license is in PANELS
C fall frace.nd effect
QLicenve Cbns Lic.If UPT02NAMPS
yZ,
Qy Date Contractor 201-]Bud AMPS
z ONZ ARCHITECT'S DECLARATION OVER 1000AMP5 SQ.FT.FLOOR AREA $/SQ.Ff.
0 z-,G I i ndersmnd my plans shall be used as public records.
K=�; SIGNS ELECTRICAL
KQ , Licensed Professional
Q that
I mor
BUILDER from the Co DECLARATION SPECIAL CIRCUIT/MISC.
0.xQ�Oy F 1 hereby affirm that I urn,ramie from the Contractor's License Law for the
LLlau.y following reuwn(Section]03 L5,Business and Professions Code:Any city or,army TEMP.METER OR POLE INST. n' -
°� which requires o penult m construct,elty,improve,demolish,or mpeir my awmwe
M�7 prior m its issuance,also mixtures the applicant for such)con rite.signed statement POWER DEVICES
00 that he is licensed pursuant to the provisions°fthe Contractors License Law(Chapterto
dy C 9th Section 7000 ) SWIMMING POOL BLia't Ssti�
x 0. (commencing with )nf DivixinnJofthe Business and Professions Code VALOATIO4,
y_y or that he is exempt and the basis for the alleged exemption.Any violation of OVfLEI'3-SWITCHES-FIXTURES O wwil • 'V
QSection 7031.5 by y applicant for a Permit subjects the applicant a civil Penalty of C.rV
not more than Eve hundred dollars($500). NGW RESIDENTIAL ELECTRf
Prof Y Ys P Y 6 pens Q �NI I 'TYPE CONSTRUCTION
m ❑ I,esuwnemOhe rt,arm m la eeswit wn esesteirsolecom etion, F
y _ will do the work,and the swcmrc is not intendedoroffncd beside(Sm.7014,Business ( �: \ 1 z• '' L'�^s
and Professions Cale:The Cahoot License Law does not apply to an owner of 1'ss
property who buildsor Improves lhereor,andwhodcessom work himselforthrough his S/ 1RP RES.UNITSownemplryecs,providedthatsuehimpmvementsarenotimmndedoroffemdforsale.lf. n � / 'V' U
however.the buildingor improvement is sold within one yearn(completion.teowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of 17 1
,
❑ I,asownemDhepropeny..muelusivel wetin tliceneedconwconm Q�'Y'� "x"s L BIND MIT ' FLOOD ZONEcommuAI'N
Y°° 8w F .
Licemsm the project )ply]Of o Business and Pwhohmss ICode:)The Convector's r
LicenseLaw dcesnot uchps lyra within rand ry who huildsorimproves tereogmd PERM
who mLawsforeuch pmjmts wllh.cnmmchrr(e)licensed pumu.mto We Conrunrr'e
I License law. ER- VC -w (BA) PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far tis moon BACK OW 1' .DE C SANITARY DO Y DL N
Owner DateRGCEIPf p
DRAINS-FI. OR. EA, U.
WORKMANCOMPENSA'1'IONDECLARATION SCHOOLTAX YN
❑ Ihembyaffirmtm l have acenificam ofconsenttoself-insum,orarenificateof FIXTURES PER P RECEIPT#
Workm'Cnmlrensatism lnsumnceorareni0cdcopy thereof(SecJ80p,Lab C.)which - PARK FEE YN
covers all employee's under this lwrnit. GAS-fi.SYSTEM-11 4 OVI'l.. RECEIPT#
Policy It BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4( PLANCHECK PBC
El Certified copy is hereby famished.
❑ CaniliW copy is Eled with to city insp,cirn division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING L=EE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPI3NSATION INSURANCE
(Thissectionneed units,completed ifthe permit is(.,arm hundred dod.($100) SEWER-SAN]TARY-S"I ORM EA,200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this Pewit is issued,l shall WATER HE,TER W/VPNE/ELECfR
not employ any pemon in any mariner so as to become subject to the WorkersPAID
z Compcnsationlswsof Califxern. Date WATER SYST /T
EMREA'TING Date Receipt#
Applicant
z0 NOTICE TO APPLICANT:If,aftermelon,tis Certificate ofRuarption.you should NEW RESIDENTIAL Ful SQ.FT. TOTAL.
r•+ VI hecome subject to the Wmkeex Compensation provisions of the Lahr Coda,you most
a > forthwith comply wit such provisions ,,his pet bull be deemed revoked. BUILDING FEE �•
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is it conswetion lending.gene,fomhe perforrommof I L-10
TOTAL: ELECT RIC FEE
O the work for which his p,mtit is issued(Sec.309],Civ.C.)
Lenders Name PLUMBING ME:U" F Landers Address QT'Yt ..MECHANICAL PERMIT FEE
U 1 certify that 1 have read this application and state that the above information it " 3 " '
correct.Ingtra,to comply with all city card county ordinances and state laws relating to PERMIT ISSUANCE MSCI IANICAL FRE
building construction,and hereby authorize representatives of this city to enter upon me CONSTRUCTION TAX
U 7 above-mentioned pmpcny for inspection purposes. ALTER OR ADD TO MECH.
C
(We)agree m save,indemnify and keep Imwless the City of Cupenino.,.fast
liabi
,lities,judgmen anam�pmsesw l[h ma inmyweyace •ago, stsoid City, AIR IfANDLINGUNIT(TO 10,000CFM)
i nose oft ratio hiss �'/II/171L{/// R HANDLING UNIT(OVER 10,000 CFM)
Signature of Applic onwctor Data 'XHAUSTHOOD(W/DUCq
PAID
I IAYARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I W,ost B'ru) Date Receipt#
Will the applicam or future building rampant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I w,"BTT) TOTAL:
Code,Second25532(.)7
0Yee 13 No VENTILATION FAN(SINGLE REST[)) �—
BOILP.R-COMP(3HP OR 1 W,oaT NTU) ISSUANCE DATE
Will theapplicmmrmure buildingamupmmseeq.ipmentordevices whichemit gy, r
mrdous air contaminan s as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 RTU) V' Y
striet7
y
11 Yes 0 N NEWRESIDCNTIALMECH. SQ.FT. AI� 291994
a
I I have mad the hazaNm m
oro mills requirementsN
under Chapter 6.95 of the - nK 29 1994
Cnlifomlo Health&Safety Code.Sections 25505,25533 and 25534. 1 undmstund that fs//
if the building docs not currently have a tenant,that it is my responsibility to V notify me y
cupmt of to requirements which must ed met prior to issuance of a C<nificete of tar uuf-rh,'Ir(yjy
Occupancy.
Owner or mtorized agent Dam TOTAL: ISSUED BY:
OFFICE