26498 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-YLEC I RACALPERMIT NO.
APPLICATION/PERMIT PING FROG CT IDENNIFIC
BUILDING DIVISION BUILDING PROJECT CHANT ICAIl(IH 26498
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O 13,4 S-'-0'V UNIT# LOTH
O RS NAME: THONG: ^ CONTR CTOR'S NA � LIC NO:
s 1 I�a NIC CONI'ROI-#
CONTACT:Nlll'I'T:FENGINEER: LIC NO'. ADDRESS: ❑
COPHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El ❑ O
LICENSEDCONTRACfOR'Sionsof spierwATION APPLIANCES-RESIDENTIAL
py�Z Ihercby of affircor
3 ofth Busscal iness
and rifesions Coder and mmecents with ION
Kt <es. Section Division3 of tM1e Business and Professions Code,and my license is in PANELS 2 �-
� full force and effect. /l
FZW License Class Lic.# UPT02MAMPS
vr,=y Data Conrrcou 201-I(MAMP$
7 FOy� ARCHI'IEMSDECLARATION OVER IIKKIAMPS SO.F1'.FLOOR AREA $/SQ.F'f.
O Z� understand my plans shall be used as public records.
SIGNS ELECTRICAL
QY�j LianuJ Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X'W' I hereby affirm that I am exempt from the Contractors License Law for the
F40w following mason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
y which requires a permit to construct,alar,improve,demolish,or repair any swctum
.�Y2 prior to its issuance,also requires the applicant for such Permit o file a signed stmcmem POWER DEVICES
m C a0 p That he is licensed pursuant to the provisions of the C....'s License Law(Chapter
D.Ko� 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_m or that he is exempt therefrom and the breis for the alleged exemption.Any violation of
FZQ Scot ion 7031.5 by any applicant for a pennil subjects the applicant to u civil penalty of OUTLIO'S-SWITCI IES-FIXTURES
Conot num than five hundred dollars($5110).
❑ I,asownerof thepropny,ormYmpto cs with moa esaztheirso]ecom pcnsation,
STORIESTYPECONSIRUCONNEW RESIDENTIALELECfR _SQ.ET.
will Jo the work,and Ne ewcmre is not lntendedoroffemdforsale(Sm.7 4.Business
and Professions Cede:The Comuucmds License law does not apply man owner of
property who build,m improves flumem,and who does mah work himself or through his
wnemployeas,provided that such improvememsare nmirmadcdorofferM formic.If, OCC.GROUP RES.UNITS
M1owevethe building or improvement is hath within one year of completion,the owner-
b le.). ww ill have the burden of proving that he did not build or improve fm pumou of TOTAL:
ole.).
❑ Lm the pr oect(Sec.
AT4um Business
and contracting s with contractors to QTY, PLUMBING PERMIT FEE FLOOU'l.ONE APry
Lconstruct the project(See.]044,Business and Professions Cody)The ntrrctand
icen.ml.awdoesrm applyloanuwnen+f progeny whobuilds
Pa. tp t neonand RMI'1'ISSUANCIi
who comate. such projmis with acmm�mmr(s)licensed purer nit v Commdor'n
License Laos. LTF,R-DRAIN&VENT-WATER(FS) FEE SUMMARY
❑ I am exempt under Sec. P C for this BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date son SANITARY YN_
WORKMAN COMPENSA TARP ON DRAINS-FLOOR,ROORAREA,COND. RECEIPT#
❑ I hereby affirm that l hoseacenifien nu to sell-r dla tton Box SCHOOLTAX Y N
'Wm�rc'Com motion Insurance oreunified FIXTURES-PER TRAP RECEIPI'p
a pyt red(S .3800,fab C.)which PARK FEE Y _
covers ellemDloyec's under gCRnil. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT# N
Policy p
Cnmguny BUILDING DIVISION FEES
❑ CeniOed copy is hereby famished. GAS-EA.SYSI'EM-OVER 4(EA) PLANCHECK FEF,
❑ Cenilkd ropy is fled wish the city insgeninn division. GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING IIF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE SOILS FEE
("is section read not becomplcted ifthe permit is for one hundroaddollan($100) SEWER-SANITARY-STORM EA.2WET. ENERGY FEE
less.)
I certify that in the performance ofthe work mr-which this permit is issued,l shall WATER HGTER W[VENT/ELECIR
am employ my person or any manner ha m m become subject to the workers'
Q
z Compenmtion laws of CIDirnm ? PAID
Applicant ia. Date WATER SYSTEMRGTING Data R eipt p
z NOTICE TO APPLICANT:If.after making his Cenificate of Exemption.you should NEW RES]DERIAL ELMS. SQ.TT.
F cn hcrome subject to the Workers Compensation provisions of Labour Code,you must TOTAL:
fonhwith comply with such provisions or this permit shall be deemed mocked. BUILDING PIiG
7
W CONSTRUCTION LENDING AGENCY S
z Ihercby affirm that then w
is acnnsmion lending agency for the gcrformance of SEISMIC FEE
V the work for which this permit is issued(Sea 309],Civ.C.)
Lender's Name TOTAL: ELECTRIC FEE
U I<ndIaAJy ess
that
QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I«Hirt Thar I nave read this application mrd state hat the above information is
F 00.. correct.l agree to comply with all city and county ordinances andatatclawe rcleting ro PERMIT ISSUANCE MECHANICAL FEE
� buildiagconswction.and hereby aathonze representatives of this city m enter upon the
C) z above-mentioned pro 3 'nspectinn purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(Wy n mfy an harmless the City of Cupertino uBninst
liahililica,jm a a.c and pensee whit may in any way accrue ageinstml City AIR HANDLING UNIT(TO 10.000 CFM)
tr col gramin of Ibis gcmril.
AIR HANDLING UNIT-(OVER TO."CFM)
grannie of Applicun Contractor D' a XHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALSISCLOSURE HEATING UNIT(TO If0d)0D BTU) Dam Receipt#
Will the applicant or fuwrt building oecupam smrc or handle hazardous mmremd
as defined by rhe Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOg000 BTU) AI
Code,Section 25532(a)]
[I Yes 0N VENTILATION FAN(SINGLE RESID)
Will the applicant or Tom,building vacupwl use equipment.1 devices which emit BOILER-COM CHIP OR 100,003 BTU) - ISSUUAANCEDATE
huzanhma air amusminams as defined by the Bay Arc.Air Quality Mm
armgcent I ®®
in -4. BOILER-COMP(OVER 100,00)BTU) V
1 ❑Yea ❑No
NEW RESIDENTIAL MECH. SQ.FT.
I Dave read the hazardous .s materials requirements under Chapter 6.95 of the �//.L 119 _
Ca]ifomihilea]th&Safety Code,Sections 25505,25533 and 25534. Lunderstand Nat
if the buila ing does not currently have a tenant,that it is my responsibility,to notify The
occuvan
oecupso.(Ihe requirements which must be met prior m issuance of a Certificate of C/7/
cy.
ownerm. , onzed agent Dam
TOl'AL: ISSUED BYot : 71*4
OFFICE