26639 (2)APPI ]CANT TO FII I IN wFnMlulATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.\ .
CITY OF CUPERTINO 1•LL'Sitll.\C. . S1ECN,\NIGU.
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDENTIFICATION
PERMITNO, 26639
BUILUN/G1G ADDRESS: /1^I\ �{ s
ZI lQ� S I f UNIT¢ OTp
SANITARYNO.
APPLICATIONSUBMITTALDATE
OW �R.l'NAM6: �� PHONE;
GO, ; OR'S NAME: (e2 LIC NU'.
IY. {/a0.tJ�
NIC
COUTROL a
HITECTEN Y ER: LIC NO: c
I C/'�
FSS:
0
❑
NTA PHONE ,'IJgZ
L t}p,�fNA DN1(D
l.I1 `I'
3 L SOL'µ v
QTY. "Q--� _
' ELECTRIC PERMIT. -'. FEE
BUILDING PERMIT II�rFO _
B ECT PLUNK MECH
(ypT\
PERMIT ISSUANCE �+
LICENSED CONTRACTOR'S DECLARATION
1 hcrcby affirm thin I am IiccnxJ utkaprovision afCTapmr9(commrncingwiN
APPLIANCES - RESIDENTIAL
TOB DESCRIPTION
Secom; 7 Xpl of Division 3 of the Business and Professions Code. and my license is in
PANEIS
full force and effect.
Le , Clas Lica
UP 70200 AMPS
�'�
S%_
ODI IIK)O AMPS
tae Coal tDECLARATION
ARC,HOVER
1 understand my plans shall be used as public records.
—T
1000 AMPS
^SQ. FT. .0t0 AREA
�rsSISQ. FT.
SIGNS ELECTRICAL
IY J vs.
�1
�•'
Licensed Professional
OWNER-BUILDERptto.. re ContTION
1 hcmby affirm that 1 am exempt from Ne Convector's License law for the
following ¢assn (Section Business and Professions Code: Any city
SEECLM.CIM
OR POL]i
TEMP, METER OR POLE NST.
co3L3,
structure
which its uti a permit re construct, ¢tree improve, demolish, fi repair any snverem
.arsofar
�7
POWER DEVICES
thtnoinicemed of the Ce Busies Lianx law (Chapin
to the rec Commences License Law
the) of Division
That m is licensed pursuantSection
9(comm<ncing wim$nlion)0001 of DivixionJof Jan Business erk Pra(mimu Calc)
Setitan he is exempt Nemfrom and the basis for the alleged palmation. Any violation of
Section IDA.S byaimmedapplicant for permit the applicant toacivil penalty of
SWIMMING POOL ELECTRIC
VALUATION
�
�� ^ ��
OUTLETS - SWITCHES - FI%NRES
not more Nan five hundred dollars (5500).
(S5W).
❑ I.mowneroftheprop M,ormyemploymwiJlwagnulhcirmlemmpertsadon.
NEW RESIDENTIAL ELECIR
(/'
STORIES
TYPE CONSTRCCTIOh'
will dothework, and the imm�dede offendfmsale(Sep.]014, B
and Professions ontowner
he Contractors
Qke: The Commcton. License Law does not apply to an owner of
property who bu
owner layers, pds or improves thertom and who donsuch wank hilrsselfor lhroughhia
cmPloYees.ProvideJ(ha such improvcmcneuenotinundedwaffcrtd for sola. If..
OCC. GROUP
RES. UNITS
however.lhe buildingor improvement is sold wiNinone yeuof compieden.lheowner-
builder will have the burden of proving that he did not build or improve for purpose of
"s - .. s
QTY:=•i:.: •PLUMBINGPERMIT.(.I ,.'FEE
sale.).
❑ Lasownerofthepropeny.amexclusivdyconawlt gwilhlicenudcon=tonm
FLOODZONE
ApN
construct the project (Sec. ]1)14, Business and Professiorn Code:) The Contractor's
License Law don not apply to an owner o f property w ho builds or improvn therton,and
PERMIT ISSUANCE
whoconlracts for such projects with a convactm(s) licensed pursuant o the Convector's
License law.
ALTER DlFA1N &VENT - A (EA)
.. .:. -y .. '. FEE SUMMARY
❑ 1 am exempt under Sec. , B A P C for this reason
BACK FLOW CT. D CE
UTY DE
SANITARY `
RECEIPT a
Owner Da¢
DRAINS.FL ,IR .
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YV
I hereby affirm that l have a certificate sf neratr to self -imam. ora certificate of
.Vmken' Compensation Insurance or a certified copy thereof I'm. 3800, Lab C.) which
_
FIXTU P
RECEIPT¢
PARK FEE Y N
covers all employee's under this permit.
Policy is
GAS - EA. SYS -I U ETS
IPT N
BUI N(TUIVTSION FEES
'PLANCHECK
Company
GAS -FA SlEM-OVER ( )
❑ Certified copy is hereby famished,
GREAS YDO WAS CEPTOR
GRADING _
❑ CeniliedcopyisfledwiNt cciryims dondivisim.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
S P
SOILS �N
SEW ARY - STORM EA. 30017.
(This section need not becompleled iflhe permit is formic humreddeellars(SIM)
GY FE'
KJ
or leu.)
W TER HEA WIVENT/ELECTR
7PAID
I certify that in the p oformance of the work for which this Permit u issued, l shall
not employ any person in any m V, as to become subject to the Workers'
WATER SYSTEMRREATING
Cumpemuionlawsof Califomia. Date
Applicant
Dam lips¢
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
screams subject to the Worker's Compmsaden provisions of the labor Code. you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
forthwith comply with such provisions or this permit shall be deemed invoked.
BUILDING FEE �y
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a corvvucton lending agency for the performance of
the work for which this permit is issued (Sec. J041, Civ. CJ
A
ELECTRIC FEE
Lender's Name
Lenders AJdless
1 certify That I have lead this application and sla¢ that the above infmmuion is
correct. Iagree to comply with a ll city and county wdinames said sta¢ laws relating to
QTY. �ry au .MECHANICAL PERMIT `FEE.
•r
'
PLUN8ING FEE
PERMIT ISSUANCE
NECBANICAL FEE
C4
building convection, and hereby audience representatives of thisciry in enter upon the
al ove mentioned prspcny far inapeclrm purposes.
CONSTRUCTION TAX1
ALTER OR ADD TO MECH.
%ave, indemnify and keep bvmless she City of Cupertino against
nsaa dexpen!- hlruyinanywayucrueagamoroid Ciry
AIR HANDLING UNIT (TO WEBB CFM)
onayue rid, grunts gof is p'Z
inlnbilitice.judgmen¢.
AIR HANDLING UNIT (OVER 20.0110 CFM)
Signature, pp aanbCnala Dme
EXHAUST HOOD(WIDUCI
PAID
HEATING UNIT(TO W." BTU)
HAZARDOUSMATERIALS DISCLOSURE
Da¢ Receipts
Will the applicant or l uwre building occupant sure or handle hazardous material
as ddimed by the Cupertino Municipal Cole. Clnpter 9.12, arta fl a Health and Safety
HEATING UNIT (OVER 1013,000 BTU)
AI
Calc, Scctinn 35332(a)^.
C1 Yce 11 No
VENTILATION PAN (SINGLE RESID)
Will thea licanmrfumrtbuilJin yuipmen
pp 6,zcupamuuc sur devil¢ which<mit
BOILER - COMP UHP OR IW.01111 BTU)
ISSUANCE DATE
aeudous air comamilunts ex defined by the Bay Area Air Quality Management
a'
' El yes ❑ No
t
[zJ
OC
BOILER COMP(OVER 100.00)BTU) I
NEW RESIDENTIAL MECH. SQ. IT.
1 have read the hoodoos motions rpquim 533a under Chapter erm d that
California Safoccur CWy.ave ale O53o3,233ll and03334. 1ualcnotif that
T
/ ^�
building dos
if the buildingdoes
v,uir currently horns Imam,that itismymsanocofla to notify the
'cupmn of the re4uiremems whicM1 must M met prior io issuance of a Cenificme of
,JU
�..
Gn'upancy.
ISSUED BY:
Owner nr:mihmized agent Dae—
• .,
�rrict