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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY '
CITY OF CUPERTINO 11.111111t, - aile.11 KICAL-
APPLICATION/PERMIT BUILDING DIVISION PLUMUING- MECHANICAL
P,,t44ukWCl BUILDING PROJECT IDENTIFICATION;,TjKd.-- C!rs,>.'
PERMIT NO,
f� C q /.1
G513
SJU1LDING ADDRESS:
jo13o st�,,ud
swJ�,z DTB-z�
SANITARY NO.
APPLICATION SUBMITTAL. DATE
3
DWNE�NAME: PITO'
��L\/VM'n f`r r
CTOk'S 1E: N
25 6•
VL
N/C
❑
CONTROL is
gCIII /ENGIN LICNO:
DRESS:
ONTA PHONE:
73$•
QTY �+7a�tY`�7yrELECTRIC PER 3 )x K�FEEt,'
. a r.-. - - wd+'T"' -
• BUILDING PERMIT INFO
D EL PLUMB
M4
PERMIT ISSUAN /�
LICENSED CONTRACTOR'S ,.CLARATION
1 hereby effimt that l am hrenxd under provisions of Chapter9 (commencing wi(h
Section 704) of Division 3 of the Business and Professions Code, end my license is in
APPLIAN ,S- ID AL
ELS
1011DESCRIPTION
full fora and effect.
1.
License Class Lic.p
4AMP5
Da¢ Contactor
1-1(MMIA
ARCHITECT'S DECLARATION
I understood my plans shall bo used as public records.
SQ. FT. FLOOR AREA
`
$/SQ. M.
OVER I"A 'S
SIGNS ELE ICAL
\L � � L D"�'�
/DIY`
Licrnsed 14ofessional
OWNER -BUILDER DECLARATION
SPECIAL CIRCU41MI C ��
License Law for the
1 hereby ell Nat 1 am ex<mpt from the Cosions
TEMP LE IN
Cs
followhich Ngrcawitpmna(Sart iom7031triel,Business„,and Profession Code: Any city ry
which requires •permit Wer, improve, demolish, err repair any smict
miwnewn,
cas
primwiaeomxe.Jwinum Nromisicantfor such permiHofilen signed
PD F ICTS
the
Net he is ncenaed pursuannti the) my ivisi of the Contractors License Law (Chapter
RP:
9 that he is exempwith heefrom andthe Division Dofthe Business and Professions Codd
or Net he is exempt Ncmfrnm and the basis for all<Bed exemption. Myviolation of
See i.70315 by any applicnmt fore permit eubjec4 Ne epplicam to. civil Penally of
5 TNG PObL ELECTRIC
VALUATION
333, 0
.SWITCHES-FDT`URJi 3
at more than five hundred dollars (3501
❑ I,nownerofthepmNm.ormyemployeeswithwegesntheirsolecompensotion,
j�EWRESIDENTIALELECfR _SQ.FT.
STORIES
T4PECONSTRUCTION
will do the work. end the structure is a m i ncended or offered for sale (Sm.1046, Business
and Profcssiom Cade: The Conmawrr Lima. Law does not apply a an owner of
isill -1
propcnywhabuildsorimpmvei(hereon,anal whodoeasuch workhimxlfarNmugh his
ownemplaym,. vided Nmsuchimprovementsercnotintendedorofferedfmmle
OCC. GROUP
RES. UNITS
`
however,NebuildingatimprovemcmiswldwiNinaneyeacofcompiniion.theo net::
builder will have the burden of proving that he did not build or improve for p of
1pvlyjNaav-wr'A.aeus..w..,i/ a ..
yy PLUMBING PE
� :Also !. M.�MPa4YM�h•f+ANMbYhAtRIs'1 a� ^� Y S��NL�L
role.).
❑ I,uownertifthe property.emexdmsivelyconmectingwiNlicen nmwtoam
CmL(Wer the Frei (Sm. 7016, Businessand Professions COde: a ConOaelaf6
FLOODZON
APN
Liame Lew dasrwt apply toanownmofproperty wlwbuilds orimproviesthereon,and
PERMIT ISSUANCE
who convects fwsuch pinjeeu with ewnvectar(s)lic sed pursuant to she Communities
License Law.
ALTER. DRAINk VENT -WATER (EAI
� - .offs.:.:-a•r:+.-
_ y �-f�
- ;p�;tPEH SUMMARY ., x ¢ - >.
u''f 'fXi'--. t if.ftlYFt44
❑ 1 em exempt under Sec. B &. P C for Ws reason
BACK FLOW PROTECT. DEVICE
S
SANITARY Y N
RECEIPT-
RECEIPT -
Owner —Dan—DRAINS
- R, ROOF, AREA, CONO.
WORKMAN COMPENSATION DECLARATION
SCH LTAX Y N_
J.":3Ihereby eft that l have a cerifiman tifconsem w self-imare,m a amficaaof
Workeri Compansaion Insurance araanifiedmpythmmf(Sec. 3800, Lab C.) which
FTXIlfR .P 'v a
RECEIPT#
PAR FEE Y N
coven W employee's under this peanut.
Policy p
BEti g
GAS - G. SYS -I BgC.6
BUILDING DIVISION FEES—
antimony
GAS - EA. SYS -0VLR4(F'A
PL ECR FEE
t0
❑ CemifirdcopyisherebyfumiNed.
GREAS UST0. INTE
GRA NG FEE
❑ Certified cagy is Bled wird Ne miry inspersion &vision.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE*AP
SOILS FEE
assail
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 24FT.
ENERGY FEE Lio
(This section need not be completed ifthe permit is for onehundred dollars 15100)
or less.
WATER HEATER W/VFNT/ELECIA
PAIDO
I
I certify Nes in the performance of the work for which Nis permit is issued, labell
not employ any person to any mower so is to become subject to the Worker%
WATER SYSfEM/IRFATING
usonlawsof Califomie. Date
Compcmi
—Lill
Data {,
Applieant
NOTICETO APPLICANT:H, after making Nis Certificneof Eaemptim, youshould
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
becomesubject to the Wahees Campensarion pwvisionsofthe Labor Cade, you must
forN com
hwiply with such provisions tie this permit shall be domed mvokM.
BUILDING FEE `
SEISMIC FEE sisal
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is s ennsmuctitin lending agency for Ne Perfomana of
the work fm which NIS Permit Is Issued (Sm. 3097, Ci, C.)
LenderaNa
L:
-F
ELECTRIC FEE `
a
Lenders Address
LI.. t 44+ -iso i :.Y' .'Ya"1 :4
QTY,' MECHANICAL PERMIi'�y-�r ��FEE ;,.
PLUMBING FEe
I amfy that 1 have read this application and ante Net Nc above imforrnatian is
correct. l agree w comply with all city said county ordinances and state laws rtlatin6m
- �a
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives of thin city w caner upon the
above-mentioned propcny for inspection purposes.
CONSTItUCI'ION TAX
ALTER OR ADD TO MECIL
(We) .gree w save, indemnify and kap hardens the City of Cupertino against
is
ubilnti,v,jt^dgmenu. coasand cxpenseswhichmayin any way accrue against said City
Io
AIR HANDLING UNIT (TO I Dal" CFMl
egrvming of t e
✓o 2
VA
AIR HANDLING UNIT (OVER I m,M) CFU
EXHAUST HOOD(W/DUCT)
1'NIJ
as
Signature of Appicarl/Contraelti Date
HEA UNG UNIT (1014dMM) BTL4
HAZARDOUS MATERIALS DISCLOSURE
Hoc kcaima
Will the applicant or future building occupant stare or handle hazardous material
ma defined by the Cupertino hEirwiPnl Cade, Chapter 9.12, and the Health said Safe,,
HEATING UNIT (OVER 14.000 BTU)
'TOTAL:
Cada Sec6025SJ2p)? ”
❑ Ya ❑ No '
VENTILATION FAN RESID)
Will the applicant or future building occupant use equipment or devices which mail
BOILER- COMP QHP OR 14.000 BTU)
ISSUANCE DATE.
Itizardous air conuminenu ss defined by the Bey Area Air Quality Manegemem
)IntriniT
k
BOILER-COMP(OVER 14,40BTU)
13 yes ElN.No
�a /[
r M I D
Ni RESIDENTIAL N1ECf1. SQ. FT.
1 have read the haurdous materiels requircroenu under Chapter 6.95 of in,
California Health & Safety Code, Sections 25505, 25533 end M531. 1 undersand that
if the building does but currently have a cannot. Nrt it is my responsibility to notify the
e
µ
-
occupant of the rtquimmcnu which must be met prior to iuuance of a Certificate of
Occupancy.
ISSUED B , ItIINV
Owneror euthorissd ager Dace
OFFICE