25679 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT NO.
CITY OF CUPERTINO APPLICATION/PERMIT PI-UMBINO-.M f:CHANCA[
BUILDING.DIVISION BUILDING PROIKCI IBNNTIF'ICAI ION 25679
BUILDING ADDRESS: // .fA S6S- Ga SANDARYNO. APPLICATION SUBMI'PI'AL DATE
O 1P / 1V/s � UNIT# LOT D O�Z�/�
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
s �)/^ `/ Q ,0 NIC CONTROL#
A CI 111 huI'/ENGINMR: LIC NO: ADDRESS ❑
t CONTACT. PHONE: "}°:."s f - '? "
/I/I CA ✓ CU 4 .r �' ¢- BUILDING PERMIT INFO
7 Y: .>1 PLEC,TRIC PPRMIT FEE
PLUMB MRCH
PERMIT ISSUANCE ❑ ❑
LICENSED CONfMACfOR'S DECLARATION APPLIANCES.RESIDENTIAL LOB OF.SCRI 'ION
Q04Z I hereby ofrrn that l am licensed underprovisions ofairpter9(commencing with 1 �
FJ00 Section 700X)cf Dlvislon 3 of Lha Business and Formations Cade,and
my license ism PANELS `W9w
pdUE full force end effect' T S6SK IIP T0200 AMPS
FZy) Licenu Class _ ic.p 201-1000 AMPS
melon
yaw Date `� a e:J
Fti ARCHITECTS DECLARATION SQ.IT.FLOOR AREA $/SQ.FT.
'Z O sn a OVER 11%Ip AMPS
O'L—'O 1 understand y plans WaB bar
as public records. _ t na4t�k ��
r y f2 til SIGNS ELECTRICAL 1 p p u 11 N
Q�WV Licenud l'rnlbstional OWNER-BUILDER DECLARATION SPECIALCIRCUIDMISC. ^I ��`�� [� I'i II II L� IK
NK O,U 1 hereby affim that 1 em exempt firm,the Commences License Lew fm the `�{' a f� l
W 3 LL y following reason.(Section 703 1.5,Business enda moCode:Any city arceumy TEMP.METER OR POLE INST.
F 0 which requirtn a mm permit construct dire,improve,ve,demolish,or repair any structure
Y� prionnitslssuunce,�ls�rcyuircethe�pplic�ntfnrsuchpeminofile#signeJsmtement
mem POWER DEVICES DAT
that he is licensed puts ant to the provisions ofine Commonor's License Law(Chapter _
aXe 9(commencing with Section 700)uf Division 3 ofthe Business and Professions Code) SWIMMINGPOOLELELTRIC VALUAIION
yI_y or that he is exempt herefrom and the basis for the Waged exemption.Any violation of
F Z Q Section 7031.5 by any applicant for a permit subjects the applicant m e civil parody of OUTLETS-SWITCHES-FIXTURES
x•'2.0 not more than five hundred dollars(S500). NEW RESIDENTIAL ELECTR _SQ.BT.
y a ❑ I.asnwneruftheproperty,ormyemployeeswithwagesastheirsolecompensauon, STORIES TYPE CONS'I'RUCPION
ywill do the work,and the structure is not intended m idered forsale(Sec.700,Business
and Prom.sions Crude:The Contractor's License Law does not apply to on owner of
property who builds mimprova thereon,and admilms suchwork hintselforttuoughhix OCC.GROUP RES.UNITS
wnemployeas,provided that such improvemansarenot intendedoroffered fined,It
however,the buildingor improvement is sold within one year ofcompletion,theowner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
t❑ las owner rObeproperty,a nexdry
exclusively contracting with licensed emoractionato QTY.11 PLUMBING:PERMITI '-, FEP." I1.00D'LONL> APN
construct the project(Sec.7641,Business end Professions Cad, h.—m-ear's
License law does not apply toanan
ownerofpropy whobuildscrimpmHer
ves eon.end PERMITISSUANCE
who cuntrems nonsuch projects with itconmeor(s)licensed pursuant m te hConmetors SUMM
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE ARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUI ID I.
SANITARY YN_
Owntt Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,GOND, SCHOOLTAX YN
❑ I hereby affirm that l have a certificate ofcansern to calf-insure.ore catificete of RHCEIPTp
Warkeri Compensation Insurance macertified copy thertof(SecJggl,lab CJ FIXTURES-PER TRAP which PARK FEE Y N_
covers all employee'sµoder this perm it „� GAS-IA.SYSTEM- INC.4 OUTLETS RP E 'rq
Policy# �1-L—Z- B0 /:2 _ BUILDING rAVfSION FE'
Company GAS-EA.SYSTEM-OVER 4(HA) PLANCI IECK FEE
❑ CenifiedcnpyisherabyfumishW.
❑ Certified copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FIB.,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPIINSATION INSURANCE
(Thisseadmineed nmhecamplemd iffiepcmit is foronehundraldollars($100) SEWER-SANITARY-STORM EA.2001rr. ENERGY FISH
mless.)
I certify that in the pafomanca of Ne work for which this perm,is issued.I shall WATER HEALER W/VENT/ELECfR
not employ any,person in any manner sou m became subject to the Workers' PAID
Z CompensationlAwsof Celifomia. Data WATER SYSTEM)TREATING to Receipt#
Applicant
z� NOTICE TO APPLICANT:If,after making this CeriOcam of Exemption,you should NEW RF.SI DEM IAL PLME, SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must Alt
> forthwith comply with such pronsiore ar Nis)emit shell be deemed revoked. BUILDING PEIf
T?
CQ CONSTRUCTION LENDING AGENCY SEISMIC FITE
UZ I hereby affim That then is a construction lending agency for the performance of
O the work for which This pa nit is issued(See.ID97,Civ.C.) TOTAL: ELECTRIC IPE
I ander s Name
ka F tenders Addrcat QTY' ;�'` • '?MECHANICAL PERMIT t FEE PLUMBING F E
V I really thin 1 have rceJ this application and state Net tha above informed.is IV" '" '
�" LQ correct Tags mcomply with ell city and county oNinences end emir]ewe mleting to PERMIT ISSUANCE MECHANICAJ IPE
F' 7 buildingrotio
nstrucn,and herobmp
yealorim resemmivesoforhadry toenmrupon the
V .7 "Eme-mentioned property for inspection piriamea. ALTERORADDTOMECH. CONSTRUCfI TAX
(We)agree to save,indemnify and keep hamlets the City of Cupertino against
liahilities,judgments,cosmmid expenses which may Iran,way avermauguinat said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this pamit.
AIR HANDLING UNIT(OVER 10,(100 CFM)
Signature of Applicanf7 to EXHAUST HOOD(WIDUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITGO 100,000 BTU) Dem Receipt#
Will theapplicnat or]kions building occupant sore or handle hamurdous material HEATING UNIT(OVER 1!01,000 BTU) 'O'1'
as defined by the Caperton Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)?
11 Yes ❑No VENTILATION FAN(SINGLE RMID)
Will the upplicuntorfmare huildingoccupum useequipmem ordevicet whichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSU %F, Ahazandous air contaminants ns defined by the Boy Arco Air Quality Management BOILER-COMP(OVER 1110,000 BTU)District] ❑ P A
Yes ❑No NEW BPSIDI?HILAE MECH. SQ.Pf.
1 have rad the hazardous materials requirements under Chapter 6.95 of the OCT 2 71
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Net
if the building does not currently have a tenant that it is my resp nsmi lily to notify the
ccupom of Nc reyuirementa which muxt be met prior k issuuncu of Cedifieam of
Occupancy. ♦ COPY Of rLIPL#1 IV
Ins
Owner oozed ageOwner orizs'd a8c Oate TOTAL: ISSUED BY:
0