20680APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY N e' Q
Building Project Identification - -
Building Address:.
PERMIT NO.
G lhJ t}J{
20680, 0 6 8 0
r e one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BU[LDINGELFGTRICAI.PLUMBING-MECHAMCAL
A A
Contractor's Name: Lic. No:
'Ited/Engineer.Lic. 15 hA 4G.
I Police
CATEGORY.
CONTROL p
'N.
QTY ELECTRIC PERMIT FEE
PERM[TISSUANCE
' BUILDING PERMIT INFO
Address: -'� �. S J
1:1 ❑ ❑
' LICENSED CONTR under S'DECns of ChON
I hereby Chapte Code,(common
Buick,i inform Dloffd 3o(the Buslnessand ProtealonsCode,grad my
license le in (u force grad effect.
Llmnep Ghia(` -1V1 -I0JS1
APPLIANCES-RESIDENTIALlngwi
JOe DESCRIPf'ION'.
'
,PANELS
Cmdr
Date r(�f�l_I g•L']_.ContraRor pl.0
ARCHITECTS DECLARATION I
201-1000 AMPS
I understand my plain shall be used v public records.
OVER 1000
SQ. FT. FLOOR AR
$/SQ. FI.
SIGNSELECTRI
Licensed Professional -
-
OWIameBUILDER DECLARATION
I hang nese n. that on 7 31.5, B fromass a Contractor's License Law forehe
following reason. (Section 7(131.5, Business and r, impmw, Code: Any city it
myscmntywhich requiresa issuanromruraqui sth Improve,demsuch,enmittr
mystructure priortstatement hat he ealsois lice sed pursuant t the poo inions of t e
file a signed statement that he k licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and Professlmu Code) or that he is exempt therefrom and
by any
the bask for the alleged sects th exemption. Any violation of Salton net room
fiveapplicant doermhsubjeaethe applicanntoa dull penalty of not more than
flue hundred owner of the pr .
M compensation, a owner of the property, or my employees with wages there sok
.1. (St70" will Businethe ssd for
.1. (St. andf
andweek, fmakend the structure k nottractsintended or Line.
ru Code:The License Law
Law
anoowner
SPECIALCIRCUIT SC
TEMP ETEC L ST.
ppyy:R EVI
ENE
L ELEC '
OUTLETS HESH ES
VALUATION .
YY 1
U v
NEW RESID ELECTR SQ,FL
STO
TYPE CONSTRUCTION
apply to prop or unpdor's
whorlout applytorkh( n if fth ghh[s o nem oyeepp eidedthn, and
wprovementsam khlmsended mugh hiaowne. If,ho eprovidedthatsuor
Improvements intendedorofferedfor eak.If,h new builderwilI have
improvement of kwldwltMn he did notbuildor ImNtheprove frpurose of stahave
ilLjLas weer ft heng that hedldnamexclarlmprove (or purpose o(sak.).
LJ I, ae owner of the property, am exduaively mcloseting with It...d
contractors W metmct the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
bu
Wilds or Impureness thereon, and who mntrad, for such projects with a
ognfT�dm(a) licensed pursuant to the Contractor's Lima. Law.
LJ I am exempt under Sec B & P C for this reason
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER-DRAIN & VENT.WATER (EA) '
OCC.GROUP
RES,UNITS
'
.FLOOD ZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY'
S Owner Date
DRAINS FLOOR ROOF, ARE A, CONTI.
FTXTUREBr PER TRAP
SANITARY Y_ N_
' WORKMAN COMPENSATION DECLARATIONRF.CET`TN
❑b hereby affirm that I have a certificate of consent to self -Insure, ora
SCHOOLTAX Y N
certificate ofWorken' Compensation Insurance ora certified copy thereof (Sec.
3800, Lab CJ -
Policya ' '
RECEB'Tp
GAS EA. SYSTEM -1 INCA OUTLETS
-
PARK FEE Y ' N
RECEIPT N
CO ray
�Certied copyk filed hereby
Certified copy b flied with the city inspection division.
the city
GAS EA. SYS'TEM-0VFR4(PA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECKFEE '
GREASR TRAP ..
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbame.) need net be completed if the permit k(aline hundred dollars
PAID
Date Receipt
.
'; SEWER SAMTARY STORM EA 2DErr
($1I cart lyse.)
of
Icertlf41hn In 'thework forwhirb this permit is Issued,
I shall napin In any manner at as t o jeer to the
In 'y
Date
Works Applicant
WATER HEATER W/VENT/ELECTR
.ENERGY FEE Y N —
PAID '
Date Recei t#
WATER SYSTEM/TREATING
NOTICE
shoulNOTICEaRerare
rs'Co po sation Certificate of Exemption, you
nprovkis p of the Labor
befonplywit Cuch provisions
Cgdgyou mustfMhwllh comply with such prgvbloru or this permit shall be
deemed revoked.
NEW RESIDENTIAL PLMB. FT.
_SQ.Fr.
TOTAL:
BUILD FEE
CONSTRUCTION LENDING AGENCY
I hereby aftrmthat there kameatmdlon lendingagency forthe perform-
acre of the work for which this permit is Issued (Sec, 3097, Civ. C.)
Landers Name
Lender's Address
I ce d. I dgt b have read this appBcit and c linty graih.n above d information
muntyordrepressail stat slaws
kmrrect. building complywllh all and hereby
rektng to building rovkudlon, and hereby authorize representatives of this
dt(Waitaenter property less he Cit purpose.
eeupon to sae, indemnify an
(We) agree to eve, Indemnity an d keep harmless the City of Cupertino
against liabilities, judgments, mats and'expenssa which may in anywayaccom
against said City in consequence of the granting of this permit.
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE
ALTER OR ADDTD MECH.
AIR HANDLING UNIT CTO 10,MO CFM)
MECHANICAL FEE
FEES PAID:
'
Date' Reeei t#
P
SUBTOTAL -
AIR HANDLING DNrr (OVER tB,roocFht) �
CONSTRUCTION TAX
Signatureof Applicant/C.Mractor ' Data
EXHAUSTHOODM/DucD -
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUMTU0100,"BTU)
Wlllthdapplirant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Flealth and Safety Code Section 25532(a)7
0 Yes ri No
Date RCCeI f#
HEATING UNIT (OVER, 100,000 BTU)
-TOTAL: '
VENTILATION PAN (SINGLE READ)
ISSUANCE DATE
-
JUL Q4 W90 '�GgYI.
Wkx M 'd 0
Will the applicant orfumm building occupant use equipment or devices
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management Dlstrlct7
Yes n❑ No
have read the hazartlousmaterials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
enders nd that if the building Hoes not correctly have a tenant, that It is my
respo i ity to notify the occupant of the requirements which must be met
BOILER -COMP QHP OR 100,ODD BTU)
BOILER -COMP (OVER 100,000 BN)
-
NEWRESIDENTIALMECH. 5Q.FT.
prio earmuffdificate of Occupancy• p
(0 1i
k
ISSUED BY:
nero other da en to
- -
OTAL:
OFFICE COPY,