19926C_r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Bulldhy Address: -
Zai/
a
199,26
7re amu
Z ?5.3
CITY OF CUPERTINO"BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGaI CA41'LUMBINGMECHANICAL
1 n
ContraMvr'>Name: j� Na
r '"a ✓�' z7o A 4 /
CATEGORY CONTROL r
o
Arch neem Glc No:l
QTY ELECTRIC PERMIT FEE
BUILDING PERMITINFO
Add. -
PERMTISSUANCE
j0j ❑ ❑ ❑
II
LICENSED CONTRACTOR'S DECLARATION
Ihereby
hSecia 70 slut lamllcawed under inessaaaof Chapter9(,indec
IIII in fun7000) fDNW ofthe BugmvadPro( Code,and
license le In full and eelf i7
came c Lk. a 4
Drte oMractor
APPLIANCES -RESIDENTIAL
x1BD �OaN.I
U� I
tL
� a �I
PANELS
I
701-1 AMPS
RCHITECPS DEC A
Iundenland my phn shaiheused apubic remedy
OVERl"AMPS
SQ. FT. FLOOR AREA
$/SQ.FL.
SIGNSEt F(TRICAL
Licensed Professions]
SPECIALCIICUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the ContraRori License Taw for the
TEMP. METER OR POLE
following reason. t5ectlan 70715, Business and Professions Cade: Any city or
muntywhkhrequ4 apert tomnel cL&Iler,Impmve,de=lLLh,orreptlr
anystructure pr4xto its bsuame,alw nqulrestheappl]cant for such pemJt to
fie a signed statement that he Is licensed pursuant to the provision of the
polyp -R DEVICES
.G POOL VT
O TC ES
Contractor'slkene Law (Chapter9(commencing with Section 700D)d DM-
Sion 3 of the But P
alness and mfe o lora Cade) mthrt he b exempt therefromand
the base, for the Mleged exemption. Any violation of Stolon 70115 by any
app0ontforaperm b)e theappianttoad"lpe.hydnatmorctlun
VALUATIO U
�vaV.t a
NEW RESID
SQATr.
live hundred dollars (S.ri001.
❑I, as owner of the property, or my employee with wages as their sole
STORIES
TYPE CONSTRUCTION
compewtion, will doth work and the structure e, not Intended or offered for
sa4 (Sec 70K Buslresa and Profession Cade: The Comraciers l icene Taw
does not apply to an owner of property who bunds or impoomes thereon, and
whodosuchworkidmaei orthragh Msownemployees, provided that such
OCCCROUP
RFS UNITS
Imprvverrcnts arc one intended orommi foraale. If, however, Lubulkling or
TOTAL:
Improvement bsold wlthinorcyearofmmpletiou,theowKrWiderwW have
tis-taordenodprovingthatheclibironthudd orimprovefmpurpoaeafaale.).
LJ L a owner of the property, am exclolvely carmacting wish Ifcessed
oantracten to mnutrud the project (Sm 70W, BusNessand Prefeeiora Code:
QTY. PLUMBIN ERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contnctor's Li erse Taw dm not apply to an owner of property who
bulkb or imp. th. , and who contracts for such prpjens with a
C91111acto,O) lJormed pureuant to the Contractor'. License law.SCK
LJ I am exempt under Sec B & P C for this reasonOUYSIOE
ALTER -DRAW & VENT- WATER (EA)
FEE SUMMARY
FLOW PROTECT. DEVICE
FEES
DRAINS FImR ROOF, AREA, COND.
SANITARY Y_ N_
RBCEI'I If
Avner DMe
WORKMAN COMPENSATION DECLARATION
❑1 herebbyy sfflrm that I have a eertlfiate of consent to self-Insurt, a a
anilcate I orken Compensation lnunnce or a notified copy themaf($ee
3BW,Lab C.) -
Palley a
FD(.DSP�.a
SQTOOL 7A% Y_ N_
REC=#
GA-SFA.SYS EM[ -1 WGIOUrLEIS
PARK FEE Y_ N_
AFGWPI F
GAS EA. SYSIFMOVFR I (EA)
Com ray
BUILDING DIVISION FEES
Certified copy b hereby himished.
envied copy b filed with the city inspection divistmr.
CERTIFICATEFR
OF EXI]MPTION OM WORKERS
GgpAgE/WIXISIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID /�/�O
GREASE TRAP
COMPENSATION INSURANCE
(rhbrecilon need net becompleted ithe penNt b far ore hundred dollars
Date Revel to
p�
[}J.
SEWER -SANITARY -STORM EA 20017
WATER DATER W/VENT/W.FCTR
ENERGYFEE Y N
MOOJ Of Iea')
ImniyiMl tMperformanaofineworkforwM&thapemdtblaaued,
WATER SYSIDN/T.RG.DNG
I shat not employ any person N any manner n as to become xubj Y to the
Worker: Compensatiomiawam Cstlfome,. Date
PAID
NEW RESIDENTIAL PII.SB. SOFT'.
cintOAPPLICANT:If, age nuking this Certificate of Exemptlan, you
AppliA uCE
should bxxxmne subjc othe Worksm'Compervatlon provision ofthe Labor
Date Remi t
TOT
3
_I
Vl s
Code, you at forthwith umnply with such provblon rthis permit shall be
deemed revoked.
$EISMI
s
CONSTRUCTION LENDING AGENCY
Ihemby MRnmthatthertbamratructirm lendingagcruy for the pedorm
ance of the work for which this pemdt b issued (Sec 3071, Clv. G)
Odder'. Name
Lendee.Add.
I adiythatl have mad this applicationaod statethat the above Infomatlan
Is correct. l agoeeto comply with all city and county ordinances and gate laws
TOTAAL
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES Ir[rl'Jr'3
Mating to building mngruction, and hereby authonbe representative of this
dtytoenter Ponthe above-mentioned property fee inspection purposes.
(We) m save, Indemnify an d kap hsrmdm the City of Cupertino
against b t",jidgrrems saMepenew#k ylnanywayae a
i
ALTEAORADD]OMECH.
-
Date Ip[»
AIR IiANDLING EINIT (rO 10,000 CFM)
SUBT
TAL:
a .ail Cityio errs of the granting of this permit.
AIR HANDLING L)NH TONER 10,000CFT0
CONSTRUCTION TA
of Apphcant/Contractor a
EGLAUS'r HOOD(W/DUCT)
CONSTRUCTION TA PAID:
_
HAl RDOUS MATERIALS DISCLOSURE
HEATING UNIT OO IW,OW BTI)
Date Rcce
Wil the applkanlmfulu re WRding unu pant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ho.eh.M Safety Cade Scall.. 7S537(.)r
❑ Y. No
Will the appicanta tun Wilding occupant use equlprnent or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
ID
VENTILATION FAN TINGLE REED)
I]RAMP
ISSUANCE DATE
which emut haraNas air comambants as defined by the Bay Area Air
Qua llty Ma ragement DMrkt7
1 Ye jj:�jj No
RD
Q—AM
BOILER-NMPM
CHIP OR 100,000 BT"U)
BOILFR.ODMP(OVIM 100,00) M)
have mad the h..., materiae, requirements under Chapter 6.95 of
rhe Gilomb Health&Safety Code,SMion25505,75D3and7S531. I
understand that if building does ret currently have atenanl, that It is my
r� (),
�'r�N N 3 �990Ctf)
NEW RESIDENTIAL MECH. SQFr.
m,ponlbORy to notify the occupant of the requlmments which most be met
pour to esuaree d a Certiflateof Occupancy.
nsa .E.,
W•tY Of f:BI ,,�whFIU
ISSUED BY: 0 W V
Owner or authorized agent Date
]OTA L:
OFFICE COPY