25654 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUT. G- A PERMIT NO. 25654
APPLICATION/PERMIT PING PRSG-7f IDEN NICAL
BUILDING DIVISION BUILDING PROJECF IDENTIFICATION
BUILDING ADDRESS: `\ 1/[/J__ RSANITARY NO. APRJCA'110NSUNMfITAL DATE
�� � 4 S UNY LOT �e .20
OWNF A E 1, PHONE: CTOR'SNAME, IJ.CC N_O: ( N/C CONTROL
LL f L
RCIII'IECI/ENGI LIC NO: S: ❑
_ ICG C
CONTACT: PHONEBUILDING PERMIT INFO
QTY. IiLE CPERMIT FEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
t]CZ I hereby affirm Our l am licenxJ uovin provisioruofChapterct nvrercingwith JOB C
F2 2 Idnn7000)mf Division 3 of the Businasv end mu ProfcmiLode.aM mBarns in Bais in PANIMS an
Ct�JF. S full Once anti affect.
FjtyVj I.iccn.nc Clam IJc.Y UP T0311fJAMl'S
m D� IIDm Cmtnnnr4111-I(XX)AMPS SQ.IT.FLOOR AREA $/SQ,FT.
ZFONZ, ARCIIIfI=SD1'CIARATION OVER I"AMPS
OZ_C I understand mY plmu shall be used as public ranrds.
SIGNS U1JEMICAL
Barn hofcsional
aL,yyu OWNER-BUILDER DECLARATION SPECT ECIR T 1 .a
sedx O4alcc.. 1 Meloy aRmm that I am exempt from dte Cmvamor's Limine Law f«du r
W 3 y following raml lSccdm]0313.Business and Rofessims Code:My city or ev onry TEMP.METE OR LEIN;S�T.'. �.
F u.Oa E 11a
which requim a penin to cantrvct.alter,improve,demolish.on repair any smrature POWER DI:V 13' In \`l 'J
that s!!I JN-�J�1 primto iui.asuwa,aLw tcquito Provisions
fawchpennitto Bleaae, sr-,urm - I—
<O 9ocheisrocir,d S,,ctintothe OfDiimmof the Cmvannr's and Podlaw(Clupter
� 9(mnmencing with Sation]0001 oflJlviaim Jof the Businev end Rmfaaima Coda) SWIMMING POOL ELECTRIC VALUAT
err Nut Mie exempt thcxfvm and the hams for the alleged eaemptinn.MYviWwinn of
Sectirm]O31.5 by any applicant for a cont suhjects the eppliunt m a civ 11 penalty of OUCI. S-SWCC /yw{./r-r►,•�� _
�
C gTmnmlhan Ed
vehwrtddallmrs(S500).� ❑ I.mowm�mfthcpmperty.armyemployceswithwagesmNeiraolecompt.matin, NEW RISIUI:lIf1ALCISCTt SQ.Ff. ORIS TYPL CIION
d _ will do Newons CcdN Thac con.oc"License,
dkx,mrsa am,1 ad Burmese
and I4ofeavots Codc:The Cmtrrrals License law time rat aPWY to m owner M ,
1*mPentY whob ddso impnovea thvmn,artlwledoeauchw,xk hroselfm through his
oxnempbyccs,pmvidMthan such htsprovrnrnuax mrintrndcdmoffe�fmvle.IL ROMP RFS.UNITS
however,tle buildNgoimptovenent is sdd withioarc ycv ofcAftplclim,the owrcr- TOTAL:
buihkr will have Ne burden of ptoving that he did ma buildm imptove fm purymx of
ole).
❑ 1,mowrcrmfthepmpcny.amexclueivelycmtrx gwiNlicmnx nmoomto QTY' PLUMBING PERMIT FEE -----1T55-D70—NE
APN
I'nxtrud the project(Sr,7(44,Binin—anti Profemims Code:)The Qmuaol.on
ianu law Joemapply lmm�mwrcrnfpmpmy whubuilduoini"vesNncon,and PERMIT ISSUANCE
wM)nMlnnsfmwcb M*tswi0ewnnit s)IkrnsN uemlothe Commcmr's
lie ALIFR-DRAIN&VERT-WATER(PA) FEB SUMMARY
sla
\ ❑rnl w.am cxrngt oder Sec. .B A 1'C fm Nis reascm BACK FLOW PROTECT.DEVICE. SANITARY YINE N
Owoc' Dau DRAINS-FLOOR,ROOF,AREA,CONT, RECFJPTY
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherebyaff tlmtlhaveacenirut ofcoamttoxf-inum.om¢ iftmeof FlXTURLS-PER TRAP
Wmkers'Comfetnatim Ina.ma cenlBal copy thomf(Sec.3800,Lab(1)whiah PARK FEE Y N
rs all employee's under tibia permit. OAS-EA.SYS711NI-I INC 4 OUTLET'S RECEIPTY
Pulley Y BUILDING DIVISION FEES
CnnPany GAS-EA.SYSIEMAVER 4(EA) PIANCIIECK FEF.
❑ Ccnified copy is Awl w fumlaMd.
ElCcnified aqy it fled with lM airy lmlFelim Division. ORFA5171NU1/S1'RL WASTE INTERCFJTON ORATING PRE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOBS I'm
LYJMPENSATION INSURANCE
(This sat:tiro rcM rot be completM lfite pwtit is fm me hundead eollas(S UWB SEWER-SANITARY-STORM EA.200T. ENERGY FEE
m lass)
I enOfy that in the parfmtwta of the work for which thupernnit u iswed,I"I WATER IIEATJt W/VP.NT'/MECIR
tot employ my permit in any sumer no as to become.object to tale WmrkenPAID
z Compuuutionlawsof Cdifmnin. Date WATER SYSTEM/TREATING The RaeipiN
Appli[rvV
z NOTICE TO APPLICANT:If,afar making thin Cmifcatecf ExempOco,ymahould NEW RESIDENTIAL B. SQ,FT.
TO
h to a,wbjn'.l to the Worker's Cmnpcnaatim provisions of the Labor Code.you mon
a > tinthw it h emtply with such Powis—or thinpermit shell Is,docroad revoked. BUILDING FEB
rs Q CONSTRUCTION LENDING AGENCY SEISMIC FFR
5 Ihereby aff.Ow Nate isa mnstructim kMing agency for the perf.n of
L) O the work her whmL this permit is ismad(Se.1(9],Civ.C) TOTAL_ ELECTRIC PIL
lender's Name
C)F Lader',Addreei QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LU 1 certify dour have reed Nis applieotion aM a=than do above inftmtuim u MECHANICAL FEEmoat. I Lara to comply with all city aM around,ad'vunce and sue laws ulm,to PERMIT ISSUANCE.
building cmmaucdon.and hereby author.neptexwtive ofthis my tomo+upon Ne
U z CONSTRUCTION TAX
dvoc mnnliond!prmperty for itul,aclion'rpr,ea. ALTER OR ADD TO MECII.
.. (We)agree m save,indemnify and kcap Lord.tbe City or Cupeninu ngaivl
liubilal judge v.co'un dra'uscssh0uwyr I rarywaywirucagalost. 'd City MRIIANDLINGUNff(T0I0,000CFM)
in c tca g igof it.
f 1 /� AIR HANDLING UNIT(OVER I0,00D CFM)
Sin Appli or `v EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU)- Date R."
ill ale applicmu mrfutum huddingamvlmu arae or hmtlle hnssndous Serial BEATING UNIT(OVER 100,000 BTU)
m defined by the,Cupertino Municipal Cade.Chapter 9.13,told the Health tad Sa(cry
Code.Section ^
ye,
❑Ye x). ❑No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will Neamliwntorfutumhulldingoccupant use equipment odevias which unit BOILER-COMP OIIP OR 100,000 BTU) P A I D
hvarri—air cmmnirema an defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTUJ
District!
❑Ym ❑No NEW RESIDENTIAL MECH.—SQ.FT. OCT 2 0 'egg
1 have and its,harndmua matvim,requimocros under Cluptar 6.95 of Nc /s
Califonia llmlth,l:Safoy Code.Senimns 35505.35533 and T55M. IunlcauM Ow nllY Ur (iUrCl'I IIY�
if lye buildingm m rt
dorctutuly have•awn,thin u m
it y respomibility to toafY the
o oupmm of the raquimncma which ra,,.t ba mal prior to immrre of a Certificate,of
Occupancy.
(Triter err uuthmrved'an' Date H I
TOTAL ISSUED BY:
OFFICE