26221 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •- " ' PERMITNO.
Buaowc DIVISION APPLICATION/PERMIT PING PRNa CT IDENNI IC 26221
+ BUILDING PROJECTIDENTIPICATION`d. ',v.
BUILDING ADppDRE//SS: /� SANITARY NO. UFPRJGTIONSUBMT'ALDATI
OJ�V C[� �� UNIT# LOTH
OWNERS NAME: PHO E: CO A OR'S NAM LIC NO:
2++0 ✓ 407/"- t� cs, e^/S S/y1o9 NC CONTROL#
ARC TECIENGINEBR: LIC NO: DRESS: /
/a /¢CS S/
CDNTACT: PHONE: p 'S;f•:Nry.'-"''a.""'•LF'�"^'"' ;;�s � d iFEE�"''ri< %e21:'.Y.�'n'.`�BUILDING PERMIT DiFO .
Y'4t.A s ? EIKKKIC•awxrlwr:+._tr r: :':l •.^_�,«ia.•. ELECT PLUMB MECH
PERMIT ISSUANCE 1:1 11 ID
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESC PILON
GYZ Ihercby affirm that)em licensed underpovisioruafChapter9(commerning with
+1100 Section 7")of Division 3ofthe Business and Professions Code.and my license is PANES
F-W, full force and effect.
Lio.me Clw sec.« UPM:Ioct I.iPS
gl
in?y Dare Comom 201-IB(A AMPS SQ.FT.FLOOR AREA jSQ.FT.
Lo.z ARCI]ITECTS DECLARATION OVER 1000AMPS
to-QQ 1 understand my plans shall be used as public mcm& II '
R=F W SIGNS ELECTRICAL
<,9F Licensed ProfessionalALED
OWNER-BUILDER DECLARATION SPECIALCIRCUTTMISC. /' II •j f� II I tl I
0y 1 hereby affirm Net 1 un exempt from the Conmctm'ar License Lew for Ne `' IY.�" ` 1�•
:13 a rn following mason.(Section construct,
t,sines stdion,de o li Code:Any ciry a mount TEMP•METER OR POLE BJST.
u' which requires a Permit to conswn,alter,improve,demolish as repair any swcsure
7MM 2' prim to its issuance,ilio require theePAiant fm such permit to file a signed sutement
POWER DEVICES r
.C O p Net he is licensed pursuant m the provision of the Continuities License law(Chaps SWIMMING POOL ELECTRIC G VALUATION
-iado�L 9(commeisewmwith Section ud0 eDivisian3ofNeBnumTn a .Myvms Code) �� ����
W_rn Scetio"Atheisexempt therefrom and Ne Mxiat subjects
do aempdan.Mvil Penalty
of
F 4<) Secsiom men by anyished!.,[a.,for.permit subjects tin apPliantwacivil peniltY of OUTLETS-SWTTCIfFS-FIXTURES
no,mmethan RvfffiCP eddollars(5500). NEW REsuJEM7ALELECIR _SQ FT. STORIES TYPE ONSTR COOK
aK 0 ❑ Lnowncrandtheimmune imotinumdoolonthwegosssheirsale 044,flutian,
3$ will dothewon.and the immune ibnosinmdedm offend fmsile(S,on an,Bnims
and Profession.obu Cade:The Contractor.,IJanse Law does ret apply lf an owner iof
s
pmpemp)oy .Mvi m suchimpmva nmdoessachwok haroffeorthroughhis OCC.GROUP RES.UNITS
onoven.ogees.prog.,improve impmvomntsarenot imendedmoffcrtd Intends.If,
however wilt
have
l the
b r improvement ofpment u sold e i i in ooe yon of completion,theinsmor.
of TOTAL:
builder will Tuve the bumrn of proving Jut he did not build m improve for puryose of ��}�'{�
y�' r e, '3+I:1'91tu,i'vA'X.p,ilii-',-P..`. t.`.Y-
❑ I,00wncrof the proparry.ere eaclusivelyconrracting With liconsedcanmctonw C ` `$` sLGMBING PERdBT�- tiC:tt � FLOOD ON Aped
amwn the Project(Sec.70f4,Business and Professions Cade:)The Contracuras
License Law doesnotaMly toinownerofpapeny whobuildsm improves thereon,and PERMIT ISSUANCE
who contracts fmsuch projects with accountants)Bcansed pursuant rathe Comand¢
Liceme Law. ALTER-GRAIN&VENT-WATER(EA) `•`+X�,ZY`a'yj,,;nvE u•.-FEE SUA/MARY:.]..,.i.`�;{-i i••
❑ tare exempt under Sec. ,B&P C fm that recon - B`FEbS
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dau RECEIPT#
DRAWS-FLOOR,ROOF,AREA•COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
01 [3 Ihembye L=Jut]haveacenifiweofmnsrntwulf.imm,orac ficamof FIXTURES-PER TRAP RECEIPT#
Wmkco[Compensation Insurance.,a unified copy themof(See.3800,Iib C. which PARK FEE Y N_
T coved ill employees under this PermitCEIPT#
GAS-EA.SYS'IEM-I INCINC.40UTLEfS
Policy N BUILDING DIVISION FEES
Company OAS.F.A.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifed copy is hereby fumishaL
❑ Cenifed copy is fled with the city inspection division. GREASE/DIDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foranehundrtd dollars(SIM) SEWER-SANITARY-STORM F.A.203FT. ENERGY FEE
or In..)
I comfy that in the pckormence of the wast for which this Permit is issued,l shell WATER HEATER W/VENTIELECTR
not employ any person in any member w as in become subject in the Workers' PAID
Compemationlawsof Catifomia Dau WATER SYSfEMTREATMG Dau Raccipt0
O z Applicant
z 0 NOTICE TO APPLICANT,If,after making this Oneframisf Exempdon,yau should NEW RESIDENOAL PLMB. SQ.FT. TOTAL:
became subject to the Wokds Compmauum provision of the labor Code,you most
O: foMwith comply withsuch Provisions or this pmardt shag be demand revoted. BUILDING FEE rp Giirrww'
LQ 7� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z:) z Ihereby affirm But Jure see camtrucfion lendingegeney for the perfomunceof TOTAL: ELECTRIC FEE
J O the work for which this permit 1¢issued(Sec.3W7,Civ.C.)
Z — Lenders Name y+v av �_.(waymr-Ts•.:,n:a:a eau.;ep;gaev;;-,,y-•'tixa.::yi!' PLUMBING FEE
Lenders Address QTY:�IC aAiCHANICAL''PERMIT..;q;„?fpp'-n3,,[' FEB_v'
1 comfy that I have read Nis appliatian and arson that the above information is ” " 'tn-h^�'" y -_ MECHANICAL FEE
cmrtex lagswcomplywithillciyand county ordinarnes andswelawar rtlering to PERMIT ISSUANCE h
n' building conswction,and hereby euthonartpresenutivesof this city to enter upon the
CA CONSTRUCTION TAX
U z ebov emioned properly for inspection puryosea. ALTER OR ADD TO MECH.
(W
(We)agree to savant indemnify and keep harmines the City of Cupertino against
liebilities,judgmenss,costs endexpenses which may inany way amueagai sad Ciry AIR HANDLING UNIT(TO IO.IXq CFM)
in of the
AIR HANDLING UNIT(OVER 10,"CFM)
rSigeminApplicarmUConmeactor OJ9 EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 RTU) Data Reutpt p
Will the applicant or future Wilding estimates store or handle himadous mannil HEATING UNIT(OVER IM."BTU7 O
ea defined by the Cupenino Municipal Cade.Chapter 9.12.and the Heslth and Safety
Cade.Seniors 25532(a)?
11 Yet 11 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will th,it,licaminfumte buildingoccusant utoo,dpmentordeviaswhichemit BOILER-COMP DHP OR 100,000 STIR
• hazardous umn air coninunu defined by the Bay Arse Air Quality Management BOILER-COMP(OVER IW.000 BTU)
District?
13 Year 0N NEW RESIDENTIAL MECH. SQ.FT.
Y•
1 have read the hawdous materials requirements under Chapter 6.95 of the
CAifomialkilth&SafetyCode,Section¢25505.25533andZS34. lundentandthat r /I fico
if the building does not currently have a mount.that it is my responsibility to notify the MK O
occupant of the requirements which most he met pnor I.issuance of it Certificate of
Occupancy. Le/r r r
d
Owner or authmiud agent Date TOTAL: ISSUED BY: r
OFFICE
•