19958APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Pro ai ldemlfkatlon
Be=: Be -STn u ITS3 - P0
PERMIT NO.
• 19958
OFMVME
G I,O
CITY OF CUPERTINO, BUILDING DIVISION
APPLICATION / PERMIT
BULDINGELECTRICALPLUMBINGMFLHANICAL
APPLICATION SUBPrr
6 —
C tnR¢'aNem:>y Cf��
LL L,. RlJG1tU Lc. No:
CATEGORY
CONTROL#
AnhRen/En herr: Lk. No:
1 G- 6
Qry ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addnas 6 �.
PERMITIS DANCE
® 1:1 1:1- ❑
LICF,NSED CONTRACTOR'S DECLARATION
IM1ereby offirm that lambeeneed urderpmvWore of asaptrr9 (mmunmc
Ingwllh Solan 700p)of Dhddm3oftheBuslrcasand ProfesslmsCode, and
Iberue In in fun forte and effen.
Limy Chs. LIr.Y
Date Contractor
ARCHITECTS DECLARATION
f underenrd my plam.he! be used n pubIlemerds.
Licensed fbnal ..
l'mm
NERxULDER DECLARATION
Ihereby affirm that Iamexemptfrom the Co bLicense,
dare. the
fo(Section stiraMPefessibre Any drryor
mt,etywhkh requires permit to mrstmettirnprove,demolish, or
any W�ethim prior to h.nm, atrortry imsthe applicant fcre,,mit to
file a signed statement that he Is d pursuant to the provisions of the
on n.a .La(Chapter9 (.mrc..cing wkh Se of Dvi-
Won3ofthe Business indmhebexempt Nherefrom.rd
the W ala for the alkged essmptlon. Any v ,Welon of Sailor 70II5 by any
appncantforapemdteub)eUtheappllcanit..dWIPe.hydnnmorelWn
five hundred ddles(SM.
❑. a owner of the property, m my employer whh wage u Heir role
mmpertw0m, wUldothe we,R,and the.m b not trdeededor offered for
sale (Sec. 7046, Business and Prcfmbv Cade: The Contradoes Llceme Law
does not apply to an owner d property who bunds or improve therron,and
who don such work himself eaNro ugh his own employees, provided that such
ImprovemeNa.re not Intended or offered fee sale. If, however, the building or
Impmvcmer, badd within one yrs rofcmnpletbrS the will Wee
t) uden d proving that he did not bund or improve for purpose of sale.).
I, owner of the property, am each alvely contracting with limited
I to er.teed the projen(See, 70K BeslnerM aPrd®bre Code:
The Codnnurs License Law don not apply to an owner of property who
Wild, or Improve thereem, and who mntnm for ouch p(ojeda with a
cpymoKs) Ikensed pumaaet to the Cmtndca. License Law.BAOCFlDWPROTECT.
LJ I am exempt under Ser. k P C for this reasonnUTSIDF
APFLLV4CESRESIDFM7AL
)DB DISCIiBrT10N
}lj T ii ,
11 1 ("Y�F�Cit
PANELS
I-IODDh
OVER 1000 AMPSWARFA
/T� EQy'R
_
,
$/SQ. FT.
SIGNSELECTRICAL,
t—TWOW
SPECIAL CIRCUIT
_/MI9C
gyp,MITER OR POLE INST.
POWER DEVICES
SVPdhNG POOL ELECTRIC
OUTLE(SSWITCHFSFIXTTMES
VALUATION
sip f--•
NEW RESIDENTIAL ELEM �(,.
STORIES
IYPE CONSTRUCTION
V
TOTAL
QTY, PLUMBING PERMIT FEE -
OCC.GROUP,
RkS UN115 '
PERMIT ISSUANCE
A),TFR-DRAW &VENT -WATER (FA)
FIDOD ZDNE
AIW
FEE SUMMARY
DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
FLCIlIRES-PER TRAP
SANITARY Y N
RECEBT Y
Owner Date
WOR "AN I h.e. SATIO ATION
❑I herby afMn Nn I have • ocrtlfb rat d pythereo m a
¢rti0cate of Worken'Cmnperwtlm lreunn maartlfkd mpythertaf Dec
3800, Lab G)
Y
SQiOOL TAX Y_ N_
RECEIPT Y
GAS EA. SYSI.F1.1-1 INC60UTLE15
PARK FEE Y N '
GAS EA.SYSTEN(-0VER
Cam y -
BUILDING D6(EA) DING DTY
I V iSION H.
[ertNed ropy Is heed with the
F-1 Certified ropy b (red with the my impMbn dlvW m.
CERTIFICATE OF EXUAPTION FROM WOR KERS
COMPENSATIONINSURANCE
(Thb.mbn need not h compined 0 the pemat b feronehundreddollar
($10(norlm.)
I mmlythat b m ¢ the perfounof the work for which this permit is baud,
1 shall not employ any Perera In any manner an w to become s ubjeet to the
Workcn' Compenntbn Laws of Celfornla. Date
Appllcant
GREASE/RNDUSTRL WASTE WTERCEPIOR
PLANCHECK FEE
PAID
Date" Reocf tp
CREASE TRAP
SEWER SANITARY SIORM FA NOET.
WATER HEATER w/vpxr/FF.rGTR
ENERGYFEE Y N
'
PAID
Date Recd til
WATER SYSTEM/TIiFATINC
NEWRFSIDENIIALPI.MB. SQ.FT.
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should been. saby l to the Workers' Compenuatbn puwbloro of the Labor
Code, you conn forthwith comply, with sed, pmvblose orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyelfrm that thercb a mretmnlm lendingagency for the perform,
LeMer.Nere for whkh Nis Verna hhnned (SK 30Y7, Civ.CJ
Lender'. Name
Iandemlythen
Ice .I.rI Woremad y with all
0 cry anddnatethatihrabovedstateaws
b mmG. Iagneto complywkh alldtyaM muntyordlnanm. and state Laws
rtlat o enteru upon theabov, on boned grope y orlae nprnenUuvn of this
cityW)aree tou.alaove-mentbned property l Wpectbn purposes.
(We) .gree to cave, IridemNty an d keep FurMm the City of Cupertlrio
.ga Eat WbWtb,judgments, mneaMexpen.n whkh may Many wayamme
ago Wt raid CNyb Itlueroeoflk gcamingd his prrmB.
s�
Sigvture of Appllant/6enervser v
Date
HALARDOUB MATERIAL DISC SURE
oaipalCode,Chaandk ha and the
Wrr�frrla asdefinedthe uperHeo Municipal
1l,ahhlasdafeiy Wthe moot, 55 Mu NdpalCode, Chapter 9.17, and the
hleahhaM Safety Code Benign 25532(a)7 r
nYn �W
rete[apard.. tunbuilding oavpantuse the 1cleipmert Ams devlmx
whkheMt gemeru. airrict? na Ma as dNlr�ed by the Bay Area Air
Quailiy MavgamentDMrkt7
Ihavrrtadtheha m smaterlabnquMmnbunderChapter6.95of
ted CaOf.UItr &Safety Code,Setlom25505,8533and25536.I
uMersund that if the Wilding dm not eurrently have arena". that It is my
roponslbnliy to edify the o pard of the requirements whlrh must be met
prior to lauance of a Certificaw ofonvpancy.
•
TOTAL:
BUILDING
5EISMIC FE
Z
' TOTAL:
ELECTRIC FEE "
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICALFEE
PERMIT 1SST1AN'CC
FEES PAID -
ALTIIt OR ADD7O MECH.
AIR EfANDLINC UNIT(IOIO,lAO CFM)
Date Reci tp
SUBTOTAL:
AIR HANDLING UNIT l0,CITM)
0006
CONSTRUCIIONTAX
EXHAUST HOOD (W/0]X:17
CONSTRUCTION TAX PAID:
]]EATING IWTT (TO 100,00011771)
Date Re to tH
HEATING UMT(OVER 100,000 BTU)
TOTAL:
it
VENTILATION FAN (BINDLE RESiD)
_
IS$UAN6ErDATE
.. �
is
'City �Iln2ttlB6
(r'f
,,.0 )
��.�,r�� tea, .6.a,. ��p�(4 •.
ISSUEDBY: JW /ItNls-�"�`�s'
BOILFRCOMPI)ER'DR IW,IXA BTlp
BOILERCOMP(OVER tW,0(y BTU)
NEW RESIDENTIAL MECH.—SQ—FT.
Owner m authorized agent Date
TOTAL:
OFFICE COPY