24960 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY( CAL
CLPERTINO BUILDIN i-ELEI;'1'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PRO ECT ID IANIFICA n /I 9 C 0
BUILDING PNU,IF.O'1'IDI;N'1'IhTCA"PION L f•� J v
BUILDING ADDRESS: SANITARY SANITARY NO. APPLICATION SUBMITTAL DATE
:� W .IE I � UNITa LOT — 3
'OWNERS NAME: PIIONI3 -257.- CONTRAMOR'SNAME: LIC NO:
/IJ -`iNJ,YnTLLC✓Za�oY7 ,tJ� N/C CUKDOLts
ItC111'IYCI'/INGINI'eL'R: LIC NO: ADDRESS: ❑ .-y /
nNrncr: PHONE: a BUILDING PERMIT INFO
r/69-70f6�� QTY. ELF.CI'RIC PI.RMIT FEE
W� ss. L ELECT PLUMB M'
,- PERMIT ISSUANCE: a17�
LICE>NSBDCONTRAMOR's DECLARATION hGH! pPPL1ANCf•S-R ID L IrJ
IQ
Iheub ffimrthatlam lieenud under fiche t 9(rommcncin th OB DESCRIPTION
rmazOO Ye pmvisintlai per gwi
8400 Section a and of Division 3 of the Business and Proftssiom Code,and my licrnu is in PANELS f /VY
KI4 fall License
Class effete, UPT02MA
Q VZ pt License Class Lic.X
y Q d Dem Conroe 201-1INUVANW
ZOy� ARCHITECTS DECLARATION OWE at PS SQ.FT.FLOOR AREA $/SQ.FT.
I understand my plana shall be used m public retards. / TY—f
'vrope SI LECITICAL , 1I78Licensed Ihofessionul OWNER-exempt;R DECORATION .CIAI RCUI ISOyF 1 heuby e(frm that 1 um exempt from the Contmcmre License Law far the
t43wm following rtarm.(Secsinn 70315,Bueineasamd Prefeasinns Cale:Any city or county TEMP.ME R U:INS .
�0� which te,im,a Femtit o eimmmeh n0er.improve,demolish,m uplr any sham... �a
N� pour to its issuance,also raluires the applicant for such permino file a signed statement POWER DEVI .S
W qp thntbeis licensed parsmntmthe provisions or the Contractoes License Law(Chapter gWIMMING I' OL FLECIRIC VALUATION
W i 9(nommaming Mill Section 7000)mf Dri,jim 34the Buslnessand Professions Coda)
y� T F
1-. ¢ ,,that hcma.cmpuherermomWth,loans forrhedllegedexcmption.Any violmion of OUTLCTS�SWITCHPS FIX Q QU
seetinn'loil Sny mty npplioam rnrulnrmit xanjcna me apvecannoncivilperdlyof
^� not more than five hundred dollars($5M).
❑ I,esownoroftheprop rly,onnyemplmyeaawithwogesostheirsolecompensation, NLW RCSIDL'NTIAL EL' R —SQ,Ff. STVRIRS TYPECONS'IRUCI'ION
L 20 will do the work,amd the surname is not imendedorofremd forsale(Sec.71144,Business I e
and ProfessV 'ions Code:The Contrectoes License Law does not apply to an owner of I N
mv,Mymcnem who
yees.pdsnrimpaweschercngmdwho amnotchwmrk himulfonhrough his or,rr aufeffe ;Syyyl,IS
nempinye buillh rmliprmsuch impr,and he doessuhwrokdurselrcdfor umle.If, _1[[{/(Ij-EP,J K
however.the bulldingm improvement is sold within one yearofcumpletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
as owner of the property,am exclusively contracting with licensedconlrecoss to
QTY. PLUMBING PERMIT FEP. .DOD ZO
m 0mct the paxil(Sec.7044,Business and Professions Code:)The Contrumrs
Li ane Lawdoes not apply rove ownerofpropeay whobuildsorimproves thereon,and PERMIT ISSUANCE
wholnumaixformch pmjmts with aconwcmrpl licensed pvrsuanuothe Contmctofs ALTER EA
Ucmtse law. 1 ) a FEESUMMARY
❑ I am exempt under Sec. ,B&P C for this rtaxon OUTSIDE FEES
BACK FLOW PROTECT.DEVICE. SANITARY Y N
Owner Dam RECF.IPTN
WORKMAN COMPENSATION DECUBATION DRAINS-FLOOR ROOF.AREA,COND. SCHOOLTAX YN
❑ I hereby affirm that l have acertificate ofeweenuoal insum.oraurdficateof FIRECEIPT
XTURES-PER TRAP
orkeri Compcnmtion Insurance uracenified<opy thertof(See.3800,1ab C.)which PARK FEE YN
ovonatill employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'a
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4IEA) PUNCHECK FEE O'1;-.SD
❑ Ceriried copy is hereby famished.
❑ Cenitied copy is filed with the city inspection division, GREASEANDUS3'RL WASTI7 INTERCEPTOR GRADING FEE n.01
CERTIFICA'T'E OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE pS:V/
COMPENSATION INSURANCE
(This section need not be consplered i f the permit is for one hundred dollars($I00) SEWER-SANITARY-STORM FA.200M. ENERGY FEE
or less.) 7 7
�l
I awry that in the perfnonnnceofthe work for which this permit is is sued,l shall WATER DEALER W/VENT/81.ECIH p
not employ any person in any manner so as to be:ome subject m the Worked PAID, -3L
Cnmpenxmion Utwsnf Cnlil'mmia. Duro WATER SYSTEMRRHATING Data Reeeipta
Q z Applicant u�
O
NO]ICL TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL: eS
become subject m the Worker's Compensation provisions of the labor Code,you most
fff�^^^ , fannwith comply withvmh prnvixions or this permit shall be deemed revoked. BUILDING FEE (b+�s Ut7
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that there is u construction lending agency for the performance of lass
Q the walk far which this permit is issued(See.3197,Civ.C.) ELECTRIC FEE
Lks E Lembn'e Name PLUMBING FEE
Q U Landers Address QTY. MECHANICAL PERMIT FEE
I certify that I have=ad this application and rude that Be above mfummaw is
>' Ia.I caprin.I agree to comply with all city and county ordinances and state laws echoing o PERMIT ISSUANCG MECHAMCALFEE
ybuilding ronstmction,and hereby nationu mpuunetivcsmf thiaciry to enter upon the CONSTRUCTIONTAX
U z Wovo-mentinnW property,for inspection purports. ALTER OR ADD TO MECIL
(We)ague to eve,indemnify and kap hanalae the City of Cupertino agaimt
liabiliuits,judgmrne,coxtswdexpenus which mayin any wayurneagaill City AIR HANDLING UNIT(TO 10,000 CFM)
in cmwe� f the min rhia perm
` m /��� AIR HANDLING UNIT(OVER 10,000 CEM)
SI nctmem'Applice V odor � EXHAUST HOOD(W/DUMO
o PAID
o AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipta
Will the applicant or future building occupant some or handle hazardous material
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOq"BTU) TOTAL:
Code,Section 25532(a)'!
❑Yes El No VENTILATION PAN(SINGLE RPSID)
Will thedpplicunt or fwurc bu « m
ildingcupauseequipment ordevices whichemBOILER.COMP(3ll'OR100,
it 0MBTII) 13Sl NCE DATE
�py,
,handom air emmanninunts as defined by Ne Bay Arca Air Quality Management BOILER-COMP(OVER 100,0D0 BTU) 6Y
ixrnrt7 ��
1:1 ye. ❑No NEW RESIDENTIAL MECII. sQ.F'f. 1
Sys
1 have read the hazardous materials mgnircments under Chapter 6.95 of the ch y Q
,
,r ��9�
Gulirmmin l health&Safety Caly have nn darn, rm it is3 and responsibility
1 undersond that V
if die nuilding Ann nm currently hove a tenant,Omt it ix my rexponsinility m notify the h l jI PV
uccupnnt of tlm reyuirenreob which must he mm prior m issuance of a Cenificme of
Occupancy. �''�'��(��/�/�
Owner or umhnrizeJ agent Data OT ISSUED BY: �a \/'� I'
OFFICE