21462APPLICANT TO FILL IN INFORMATION WITHIN REO LINFS _ HAF RAI I .POINT PFN ONI V .'.
Bulldin Pro ad
+ n Identification
Bullding ao: CI*W'I/oc�'r� r'
PERMITNO. -
.. ;:.,,- 2146Z ..
Owner e one:
A
'CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
G
-' - Z D
conmact Name uc.Nai .
BUILDING-ELF-CTRICALPLUMBING-MECHAMCAL
CA RY
CONTROL p
Architect/Engineer. - c. N.
La
QTY' ELECTRIC PERMIT FEE
, BUILDING PERMIT INFO
-
Address:' .. ,.. .
--
PERMITISSUANCE
PLUMB TALL"
•�' E D;.
LICENSED CONTR
IMhSy Olrmth9tlamlc .funs under i dPmfe aonsr9(commrnc
under provisions
time-.infun forces ddieon3o(the Buelneaeand ProfesrtoneCode, and my
license is In full force and k. #
License Cb® Lk.p
APPLIANCES-RESIDENTIALingwit
JOB DESCRIPTION -
i LL ��
`Gly
PANELS
Date Contractor
UP TO 200 AMPS-
2014000 AMPS
' ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. Ft;
SIGNSELECIRICAL
Licensed Professional -
OWNER -BUILDER DECLARATION
I herebyaffion that I sm exempt from the Contractor's License law forth,
following reason. that
7031.5, Business and Professions Code: Any city or
cmntywhkh requimsa perMtw.mtruct, alter, improve, dennlish,ormpalr
anystm=mprlortoltalowance,alwrequirestheapplcantfor.uchpert tto
file a signed statement that he b Ilcamod.pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3ofthe Business and Profekirove Code) or that he b exempt therefrom and
haab for the alleged exemption. Any violation of Section 7011.5 by any=pphcantf.r.p.r t.bje theapphcanttoadvilpemitydnat mthanTC
a mired dollars (S500).I as owner of the roe Y P Y 8 IENTIA
p p rty, or m em to sen with ora ea as thele soleompemadon,
{
`
SPECIALCIRCUIT/M
TpMp METERO IPQL INST.
POWERDEVICE ..
ELECTRIC
XTURESfl
VALUATIONthe
EC7R SQ.FI',
STORIES
TYPE CONSTRUCTION
will do the work and the Structure b rot intended or offered for
sale (Sec. 7044, Business and Pnefea.lom Code: The Contractors Llanie Law
does not apply to an owner of property who build, or imp hereon, and
who does suchwork himself or through hisownemployeee,p thatsuch
tmprovementsam-oH tendedorofferedfmsale. If, how ever, t' ulidingm
improvementlasoldwithinoneyearofcompldion,the no 11 will have
theburden of proving that he did rot build or Improve for purpoe (eaI )!
0 L as owner of the property, am exclusively antracting wit me
contractors to construct the project (Sec. 7044, Business and Profen
The Contractor's License Law does not apply to an owner of prope he
Wilds or'Imprwes thereon, and who contracts for such pkajace h a
abactor(.) licensed pursuant m the Contractor's License Law.
LJ 11m exempt under Sea B & P C (a b reasonP
'
'
G IAL;
QTy, UM$ING PER II` FEE.`.
OCG GROIIIP
=
RFS UNITS
'
FLOOD ZONE
APN'
-
PERI&F"
ISSUANCE
ALTER -DRAIN & 'WATER (Ela
'I
FLOW. ) CE
'FEE SUMMARY
Owmr Date -
A, AREA; COND.
4FATURES.
SANITARY Y_ N—
BEE It
WORIUrIAN COMPENSATION DECLARATION
that I have a certificate of consent to self -Insure, or 1RECEI'P
Comperealionlesu mor oracestlRed copythereof(Sec.
Lati CJPolley p
SCIdOOL TAX Y— N—
p
C.40UTLE15
PARK FEE. -' Y NPolis
REC= N.Com
any
any
R4(EA)
- BUILDING DIVISION FEES
copy b heed with the
ed.city
❑ Certified copy b filed with the city inspxtlon division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE -
GREASETRAP
. CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhlssece) need not be completed I(the permit b(orom hundred dollen
PAID
Date Reeef t#
SEWER SANITARYSTORM EA 200FP
-(S700)mly that --:
pemnlHs booed,
Ill nor cop oy anpersonIperformance any
I shag not employ any person In any manner at u to beams subject to the
manner an o to become
Wmmpensatbn Laws o(OII(omla. Date - r'
Applicant +
NOTICE
NOTICETOAPPLICANT:R after maWmgthbsation ceteof ExempHoryyou
Workers' Comp provisions
nprovbis permit s Lab be
Code, you most forthwith comply with auchprovblons or this permit shall be
Code,shoulbecome subhwithct to comply
deemed rooked. "
WATER DATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Recel t#
-
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. ' -
�• '•
TOTAL:
BUILDING FE
TOTAL
SEISMIC FEE
ELECTRIC FEE
D
CONSTRUCTION LENDING AGENCY
Ihereby af0rmthat there is a comtroction lendingagency for the perform-
ance of the work for which this permit b Issued (Sec. 3097, Civ. C.)
Lender.N.Bee
lender'sAddevea _
l ard(y that l have read this appBatbn and kaw that the above information
Iscomect. Iagrato complywith all city and county ordinances and state laws
relating to building comtmction, and hereby authorize representatives of this
city toenter upon the above-mentioned property for Inspection purposes,
(We) agree to save, indemnify an d keep harmless the City of Cu pedino
'.gonet Is ilit jadg b, carts and expenseswhich may in anywayaccme
'against said coo s ance the gr g of thl rout.
O
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE "
•
PERMIT ISSUANCE .
MECHANICAL FEE "
FEES PAID:
-
ALTER OR ADD TO MECIL-
AIR HANDLING UNIT CIO 10,000 CEM)
Date Receipt#
� - SUBTOTAL'
AIR HANDLING UNIT (OVER IQ600CFM)
CONSTRUCTION.TAX
Signa of pplimn / an actor Dae
EXHAUST HOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,000 BTU) i
Will eappllcamt or future building occupant store or handle hazardous
material a, defined by the Cupertino Municipal Code, Chapter 9.IZ, and the
He.Ithand SafetyCod loo 25531(9)7 "
' ❑ Yea No -
Date ROEe1 t#
HEATING UNIT (OVER 100,000 BTU)
-
" TOTAL:
( d
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
��®
s`J s990 "
I �NO�. ^ 1 90
WBithe applicant Arms Wildingeccupant ussequlpment or devices
which emit harardous air contaminants as defined by the Bay Area Air
alBy Management District?
. .Yes ®®No
h eaend the hazN umaterials aterials requirements under Chapter 6.95 of
Bin California Health&Sat!usCode, Sect ions 25505, 75533 and 25534.]
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
BOILER -COMP (3HP OR 300,000 BTU)
BOILER -COMP, (OVER 100,000 BN)
NEW RESIDENTIAL MECH: SQ.FI.
prt obsuaiccof rtl0ateofOccupancy.
��2y�'� /r�i9�o'
owner or au( ze agent Data
City of , Perham .
ISSUED
TOTAL:
OFFICE COPY