19899APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
ITY1017 CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAI.PLUMBINC-NiMlIAMCAL
tl�urden of Pmveg that he did not build or Improve for purpose of sae.).s.`PLUMBIN
LICENSED CONTRACTOR'S DECLARATION
PERMTISSUANCE
APPLIANCMRESTC
contnctoro to mnemad the pmjed (Sec. 7044, Businessand Profasiom Code:
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc-
mgwith$ecidon 7000) of Division &the Business and Profexxmn.Cudcand my
The Comnctors License Lw don not apply to an owner of property who
COMPENSATION INSURANCE
(TMsaepion need not be completed Bthe permit b f
(51
It. lain f aad affect.
Um Cls L.-Lk.N
PANELS
cgpr(actor(s) Itm sed pursuant to the Contactes License Lw.
Dat Conlncmr_
UP TO 2DOAMPq
201.1000 AMPS
10 Z I
Zir
ARCHITECT'S DECLARATION J
understand my plans slug be used as public remmis.
LicemedPMessiavl
OVER 1000 AMPS
SIGNSELECTRICAL
G❑y
' 3
y
�p57
S L V
r
'OS
:O2
Z�n
=.- O
,2 $
OWNER -BUILDER DECLARATION
I herebyalBmnthat I am exempt from the Contractori Llcemc Lw (or the
following realm. (Section 70315, Business and Professions Code: Any city or
cvufth
ntywhk requlroaper twmmtr Malter,4 prove,dertn hornpalr
any. mmpr rtolb Wuance,alxorequWt..ppU.tfmauchpert tto
Ne a signed statement that he la gounad pursuant to the provisions of the
Cnntraaors Llceme Lw (Chapter 9 (Ao..ci g with Settees 70e0) of DjA.
sion3ofthe Busi=namd Professem Code)orthathelaex Antherefromand
the basis for the alleged example=. Any violation of Section 70315 by any
applicant for a Permit subjects lheapplicant to a civil pesky of not more than
Ov hundred dollars ($S00).
I, as owner of the property, or my employees with wages as their sole
mmpemado,wgl do the work and thertrueurs 1, Am Intended or offered for
sle ($ee 7044, Busbsna and Profinem Cade: The Contract.e. License Lw
dos not apply to an owner of property who builds or Improves there=, and
SPFCIALCIRCUI7/!
�(p. METER0
(OWER DEVICES
NG
ETS
W FNIIAL
AIR HANDLING UNIT (OVER 10,000CFM)
tl�urden of Pmveg that he did not build or Improve for purpose of sae.).s.`PLUMBIN
PERMIT.
Lj L as owner of the property, am exclusively mntranlng with licensed
GSE TRAP
contnctoro to mnemad the pmjed (Sec. 7044, Businessand Profasiom Code:
PERMIT ISSUANCE
The Comnctors License Lw don not apply to an owner of property who
COMPENSATION INSURANCE
(TMsaepion need not be completed Bthe permit b f
(51
builde or Imp. them, and who com=ets for such ptojecta with a
ALS -DRAIN 4 VENT -WATER (EA)
cgpr(actor(s) Itm sed pursuant to the Contactes License Lw.
BACK FLOW PROTECT. DEVICE
LJ I am exempt under Sec B k p C for this masa=
Owner Data
DRAINS FLOOR ROOF, AREA, GOND.
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have • certificate of consent to self -Inners, or a
PER TRM
mrtBimeorworrm-Comemd=lmu=mMaaca
G
%CW _7?7_C
M ErS
_
MN o 1-1,
TOTAL:
or authoriecd
OFFICE COPY
PfWi UT NO.
19899
❑ Certified copy in filed with the city Impaction division.
tvA�e/llvUUSIIU.WAS(EINTFRCEPTOR
GSE TRAP
Y� ❑ ❑ ❑
CERTIFICATE OF EXEMPTION FROM WORK ER
SQ. Fr. FLOOR AR
COMPENSATION INSURANCE
(TMsaepion need not be completed Bthe permit b f
(51
SANITARY -S ORM G. 200FT.
WATER HEATER W/VENT/ELECT,
Z
I A
Iamfy Nat lathe perforrnanceolthe work for ht t
I.hallnot employ any penon a any rranner n the
Wmium Compenaeion Laws of California. Date
Appgmnt
wATCR SYSTEM/TRG7TNO
NOTICE TO APPLICANT: B,afterrmkingthio t IF empt you
shouldbecomembFLttothe Warkere Compe Iso pewis of the Labor
Code, you m=at forthwith comply with such p Iomorthbperrousballbe
deemed revoked.
NEW RESIDENTIAL PCMB. —SDfT
.
O
N
>
SANITARY Y N
RECEIPrX
G
CONSTRUCTION LENDING AGENCY
z
0
H
WIcenlfythatI
C.
• N
Z
—
IherebyaffirmthattherebammtiuRlonlandingagencyforlheperform-
ance of the work for which this perrmt la issued (See 3097, CA.C.)
Landeh Name
Lnderb Address
have read thbappgatfonaM sate that the above infomati..
lamrrect.lagreee eomplywlthall ctyand county ordlnanrea and nate laws
relating to building construction, and hereby Authorlu representatives of thin
city to enter upon the above.me=boned pmperty for Inspection purposes.
to save, Indemnify an d keep harMes the City of Cupertino
l ties,pdgnrnb,cosiaandenywayaccrue
In consequence5R�y
TOTAL:
Cry. ' iT^11MECHANICAL''PERivIIT
PERMTTISxUANCE
ALTERORADDTOMFCH.
AIRHANDLINGUNRRO]0,000CFM)
AIR HANDLING UNIT (OVER 10,000CFM)
I(W)
Sif Applicant/Contnelopas
HAZARDOUSERIALS DISCLOSURE
Will the applicant or future buildingomptntm.. or handle hanrdous
nuterulaa defined by the Cu OMunicipa l Code, Chapter 9.1 2, and the
Health end Safety Code on 25532(a)7
❑ Yea No
allAUST HOOD(W/DUCT)
HFA TING UNIT (TO 1M,0D0 BTU)
HEA LING UNIT (OVER 100,000 BT1p
VENTILATION FAN (SINGLE RESIDI
Will the applicant or tore building occupant use equiprmnt or devices
which emit havardomalr roma nta.sdefinedbythe Bay Arca Air
Quality Management M
4 ea o
BOILER-ODMPOHPOR100,0(DBTU)
BOILER -COMP (OVER 100,000 BTU)
have m.dtheh. ou. materials requirements under Chapter 6.95 of
the CalJomla Health k Ss(ety Coda Sections 25505, 2ST3 and 25534. 1
understand that i(thebuilding don not currently have atenant. that It is my
r one Ility to notify thpcyupagt of the m,,ummants which must be met
NEW RESIDENTIAL MECH. SQ.FT
or authoriecd
OFFICE COPY
PfWi UT NO.
19899
APPLICATION A
.3—
CATEGORY CONTROLN
BUILDING PERMIT INFO
Y� ❑ ❑ ❑
/ JOB DESCRBMON
/17Z �� v
SQ. Fr. FLOOR AR
S/SQ. FT.
VALUATION
SRHtI
CONM
OCC.GROUP
RES. UNITS
FLOODZONE
APN
SANITARY Y N
RECEIPrX
SCHOOL TAX Y_ N
RFCEPT N
PARK FEE Y_ N
RECEIPT N
BUILDING DIVISION FEES
PLANCHECK FEE
PAID
Date Recei t#
ENERGYFEE Y N
PAID
Date RBcei t#
TOTAL:
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Recei t#
SUBTOTAL:
UCTION TAX
:CONSTRUCTIONTAX PAID:
Recei t#
TOTAL:
ISSUANCE DATE
fta
(.T. : 0 1990 n
'I oO�• us
ISSUED BY,