23146APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
. Building Project Identification-
Building Addreu:'
' 0W v�R. �`Rct.E
PERMIT NO.
'.
23146
an,e �
wriereone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BITILDING-ELECTRICALPLUMBINGMECHANICAL
�.1�
cMIIIK
o trader���/5�7 Lk. No:
"" �V J-/ '{,.Q Al� 63
CATEGORY CONTR
BUILDING PERMIT INFO
A, d/Engineer.le. No:
oo�)il ties 7'�4�• 6_12"
QTY ELECTRIC PERMIT FEE
/
Address:' 0, S/lSoqAl 7efttvqNDfl Jr
PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION +
-
Ihereby affirm that lam licensed under provisions Of Chapter9(c..1-
1xv.se.tingwith fon7000)of d dieon3eflheBual 6andlsrofeegona Code, and my
license la in full f and effect
LkenseC ss Conp %r/ C .l
Date Z L L Contractor VCaN
APPLIANCES -RESIDENTIAL
JOB DESCRI'ITDN
^ ���Q� -
1!'Y' -
PANELS
I I
(UP TO 200 AMPLql
201-10D0 AMPS
' ARCHITECPS DECLARATION
I understand my plana shall be used as public records.
"
OVERIOWAMPS
SQ. FT. FLOOR AREA - $/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
SI'ECIALCIRCUIT/Mise
OWNER -BUILDER DECLARATION
ff l am frolaw for the
I hemwing
TEMP.METEROR POLE INST.
. (Seat
m 31.5, Business a d Peafdor'slicense
or
fogowtngreh requi gaperction 031.5,mand Proprove, Code: Any mpair
nuntyrequlreta permitto alter,esti improve, demsor
aity
uch,er mit to
Structure also, reuct,quires
fileany atmduretaprior
menIts hIssuance, Is lice regpursuant to the revisionsch of to
Co a signed statement that he ler 9 (care pursuant it the provisions of the
Lew erdea oesCom) ucingorthat with xection mptthe00)of Divi-
Contracture Business Code) iothat hob exempt therefrom and
then3 of the Bu a aIle and P exemption. by any
the Baan for the alleged exemption. Any violation of Section net room
. app hundredt for dolism $500). Subjects the applicant tea civil penalty of net more than
five 1, as own r of the pr .
MI, as owner of the property, or Ory employees with wages thele
POWER DEVICES
-
VALUATION '
SWIMMING BOOL ELECTRIC
'; OUTLETSSWITCHES-FTXITTRES
W RESIDENTIAL ELECTR SQ.FI
SIORLES
TYPE CONSTRUCTION
tion, work and the r or offered for
cols
-
-
(See
(Sec. W.Jeou and ssions ode: Th Contraet ctor's
Code: The C License
License Gw
an Law
doe apply to ow f property, Improves
whodes otapply torn ownerofprough his wnemeoyees, provided that
hisownemp,Oyees,provtded
whodvessuchments
OCC.GROUP
RES. UNITE
aorkMmaendedorwgh
he ildingch
Improvements intendeeyearofoomplr offered far lkenthe owevey ilderwillhaw as,
Improvement laeold wlthinoneyxaro(completbrytbeownervbu0derwill have
TOM Cr
'
tllf,�Iiurdeo of pawing that he did net build or improve for purpose ofule.).
u L as owner of the property, am exclusively contracting with licensed
contractors to constmd the project (Sec. 7044, Business and Professions Code:
QTY, PLUMBING PERMIT 'FEE
FLOOD ZONE
APN
'
PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of property who
Wilda or improves thereon, end who contracts for such p(Ojede with a
d
caor(e) licensed punan
gB(futroths Contradorb Llmnx Law.
nal am exempt under Sec. B k P C for this renonOUTSIDE
-
ALTER -DRAIN k VENT - WATER (EA)
FEE SUMMARY '
BACK FLAW PROTECT. DEVICE +
FEES
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECF9T X
Owner Data
WORKMAN I haw. COMPENSATION DECLARATION
❑I hereby affirm that I hive o legum of consent to elf-insum, ora
3800, Late of Workers Comps tionlmurantt oracertified cepy[hereof (Sec.
Policy It ' cP 0/3399 T
C,Pa
FIXTl1RE4 PER TRAP l•'
-
SCHOOL TAX Y_ N_
RECEIPT p
GAS EA. SYSTEM -I INC4 OUTLETS
PARK FEE Y N '
REC®II'X
GAS EA. SYSTEM-OVERd(EA)
C. -ate
I T tI ON '
BUILDING DIVISION FEES
ertlfted copy is hereby te
�Certl(led copy g filed withh the cityInspection division.
ty
CERTIFICATE OF EXEMPTIONGREASE
FROM WORKERS'
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FaEE,,
d'TT/
PAID
TRAP
SEWER -SANITARY STORM F.A. 200FT.
COMPENSATION INSURANCE f
(Thtssectlenneed not becompleted ifthepermit isforone hundred dollars
.
Re
WATER ]-[EATER W/VENT'/ELECTR
ENERGY FEE Y N
q
PAID ` 1
($100)orless.)
I certBy that In the performance of the work for which this permit is "Sued,
I shall not employ any person in any manner ao as to become subject to the
Workers Compensation laws of Callfomla. Data
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making This Certificate of Exemption, you
Should became Subject to the Workers'Compensatlon provisions of the Labor
Date Revel t#
NEW RESIDENTIAL PLUM. SQ IT
•
OTAL:'
Code, you must forthwith comply with such provisions orlhis permit shall be
domed revoked.
BU DI
SEISMIC FEE;24 wawrw
CONSTRUCTION LENDING AGENCY
Ihereby affirmthat there Is a construction lending agency forthe perform.
ance otthe work for which this permit is issued (Sec.3097, CIv. C.)
Leader's NaivePLUMBING
Landers Address -
I certifythatl have read thisapplicettenand statethatthe above Information
Vcorrect. I agree to comply with all city and county ordinances and gate laws
TO
ELECTRIC FEE L
FEE 'Sd
QTY. MECHANICAL PERMIT 'FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEES PAID:
relating to building evetrudion, and hereby authorte, representatives ofthis
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against llabllltlery rydgmenta, grand expenses which may ln.ny wayaceme
Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING [)NIT QO ]0,000 CFM)
SUBTOTAL:
agairart Sal rin consap(j sof the gr Ing offife penNt Jf
q
/
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sig "
Ctore of App ontrao Date
D(]iAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAA
HAZARDOUS MATERIALS DISCLOSURE
- •
HEATING UNIT (TO IDgODO BTU), '.
111 the applicant or future building occupant afore or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safe-yesty Cod e, Section 25532(a)7
"Date Recei t#
t HEATING UNIT (OVER 108000 B= �f
TOTAL:
VENTILATION FAN (SINGLE REBID)
-•
ISSUANCE DATE
" Wllltheappllcant orfuuturebuildingoccupant use equipment ordevion
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? -
4 Yea N us e requirements of ,
have read the hazy oet
Brad
-
P A I D
,
BOILER -COMP OHP OR 100,000BTU)
BOILER -COMP (OVER 100,000 BTU)
Code,materiSections2553 255 4.-1
the creta rola Health & building
Code, Sed urre ntly have a meant, nd 25534: I '
understand that notif the the ocgdon not erequire encs whichthat It is at
requirements which must be rtet
responsibilityriortc of aCabe occupant of Cheops my.
prior to Issuance ofa Certltkate o(Oavpanry.
11 1
FEBk 2 T
2 7 ���
NEW RESIDENTIAL MECH. SQ.FT.
ISCITY
SLIEDBY:
Owner or authorized agent Date
TOT ,
OFFICE COPY