19959APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identlrlratlon -
BuBgO:Q
PERwTNO.
19959
r¢ s aces: Phmrt:
R)Ktit—t 6-RquP
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
APPLICATT01A
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Contractor's Name: �.,a LIc. Na
�N j W71 751BUILDINGELECTRKALPLUMBINGMOCFIANiCAL
CATEGORY
COIRof,a
-.
ArcAneR/En nnr9—'
9" _J.3
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
c
Add— �S6 y
,�r�7—(,�
t!-1 El 1:1 E
PERMITIS+UANCE
LICENSED CONTRACTORS DECIARATION
Thereby Wbm Wtl mBmseduMerpro W« ofCM1apar9(mm c
Ing wit of DlvWon3ofthe Bunmaand Profese1.Cc de,and toy
APPUANCESRESIDENTIAL
JOB DESCRIPTION
license h In M11 force, and dfee.
PANELS
LiceDat Chas/ -
Dae Contrador . .
yr --v i
I�(
AMPS
ARCHHECPS DECORATION
I urdernard my plies null be used u public recoada
OVERIOOOAMPS
SQ. Fr. FLOOR AREA
9/SQ.FT.
SIGNS E
Licensed Pmfe nal
' Al
OWNER -BUILDER DECLARATION
I hereby affirm that I am eaempt fmm the Comradorb Ll IAw far the
SPrf1ALCIRCUf7'/
eY
(olbwuig rea+mt. (Setlion 70715, Buslnm avd Pro(eabes Cade Any dry or
countywhkhrequ4 aper wmvt Malter,lmprov,oe lbh,orrepnr
anya =mpaortoibhe ma atwrequl theappha tforauchpemdtto
file • algned rtmb B
ateem the he rerupursuant
ed to the provlsloro of the
TF7�@'MEITR OR
POWER DEVICES 3
ER
"
Contractor's Lkerae, Law(Chapter 9(comnrncing wish Section 9000) of Divi.
ebn 3 of the Business and Prefembrm Code) ortbat he b exempt therefmmard
SWIMMING IDOL ELECTRIC
VALUATION
the liceh for the alleged exemption. My tviolation of nadbn nor nr by any
appuondred apermB$500).M the appucanttoatlWl penalty of nor more than
OUTLETS-SWITCHES
(� S� [�. QQ
Cl p7
NEWRESIDENTIALELECTR SQFr.
Ove ,.. ddW thepr). -
L owner of that property, or empbyen wages there dole
SIORI
TYPECONSIRIxTION
s he of r
and thaatrude: hr not Warded omit. Law
rald (Sec 9016,
. to5nutlon, lIu- the and hams Law
alnow
Profnebro Cade:IW3or
'
-
V•
-
to owner
don ..&ot apply toanownerolproperty h1t o recopl y., wvidedt at and
i poen
whodoesaueM1work M1lmssBormrough hlaownemplgen,prwdNthatuch
OCC -CROUP
RES llf 775
Impmvememaarerutlntendedorofferedforuk. IL hawevu,the WlldlnBu
trop ovemem haald whhln arieyuro(<ompleHaRthe ownnbuudarwW have
TOTAL
F•i
IL-.
it rden of pru Ing that he did nt build or improve for purpoe M sule.).
L u avnu of the property, am exclusively mnVxtlng wdh I—.—
t ors to mmtruct the pmjed (Sec 9011, Buelness and Profeubv Cade.
QTy, PLUMBING PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
The Contotlors 11—o Law dm nd apply to an owner d property wlw
builds or Impewes thereon, and who corned for much pojeda with a
nDlr+der(s) Boensed purwant to the Cmrcraders License Law.
Lf I am ..Pt urWu See. k P C for this n
'
ALTER -DRAW 4 VENT -WATER IFA)
FEE SUMMARY
BACK FLOW PRO=. DEVICE
DRAINS- FLOOR, RODF, AREA, COND.
SANITARY Y— N—
R�FIIT 0
5p.a��r
Owner TE/I �R] C OMPENS TION
WORKMAN COMPENSATION IO.N
M1 hereby affirm thn I have • certlflate t to aetf-Iwrt, m a
cenWm<of Worken'Compenutlonlvuran ma ertuled copythered(Sec.
380, Iib C.I
Policy
F1X7VI�i PER 7.RAIs
SCHOOL TA% Y_ N—
RECEIPT
t,�S EA gYSfEM-1 WC4OIfTLETS
PARK FEE Y N —
RECEIPT
- CAS PA.SYSTFhf-0VFR6(EA)
Com ray
- BUILDING DIVISION FEES
�certWed copy h herebyfuMmed.
�Ced Wed ropy b filed with the city inspection division.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
'
GREASE TRAP
CERTIFICATE OF EKEMPHON FROM WORKERS'
PAID _
COMPENSATION INSURANCE
(I'hhaectbn need rad be completect If the Perroth foronahundred dollar
SEWER -SANITARY -STORM E.A. 31Yft)FT.
Dale Revel IM
NORTEK HEATER W/VIM/UIi1'R
ENERGY FEE Y N —
(3700)orkss.)
I¢rtBy mat In the p<dorrrwmafthe work (arwMrh lhb pemdtbhaucd,
I shat oat employ any pectora N any manner w u to become wbjed to the
workers' Compenvtlon Laws of California. Dae
WATER SYSTEM/TREATING
PAID
Applicant
NEW RESIDENTIAL PLMB. SQFf.
'Date Reeei tit
NOTICE TO APPLICANT: H, after making thio Certiflnle of Exemption, you
TOTAL:
should become abject to the Workers' Comperuatbn provisions of the labor
Code, you must forthwith ownply with etch provhbes or this permh "I be
deemed revoked.
BUILDING
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there best
a corudlan lending agency for the perform
ance of the work for which thh permh is le ued (See 3097, CW. C.)
lender: Nam
tender. Add.
I nertitytlut I have read this appllcatbnard sate that that above Informalm
Is correct. l agree to comply, withal dty, and county ordlnanecs and nate laws
To'rAL
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE "
PERMIT ISSUANCE
FEES PAID:
Mating to building coneructimi, and hereby authodPe mpnnenteivea of this
city, to enter upon the abavcmentbned property for Inspection purpoeem.
(We) agrn to ssve, i demuJty an d knp harMea the City of Ct pertbn
agerst Babilltb,pdgmeus, mets and expenses which rruy In any way accrue
age Wt ssld CXyNconxqueroeol the gnmirig mh permit.
� � /9U
ALTER OR ADD TO M2CEL -
Date, ReeeiptM
AIR HANDLING UNIT CT010,000 CFM)
SUBTOTAL:
AIRHANDLING UNIT (OVER 1Q000CFM)
CONSTRUCTION TAX
nt/
Signature of Applicant/Cunneser to
I
FI(FIAUSr HOOD
CONSTRUCTION TAX PAID:
HAlARDOUSMATFRIADISCLOSURE
-
HEATING UNIT 1W,=BTU)
(I
Will the applicam or/uterebudding.paot storeorhardle havrdrns
remerlal as defined by the Cupenion MuMapal Code, Chapter 9.1 3, and the
Date. Recei Ip
HEA IIN'G UMT (OVER 100,DOO BTU)
TOTAL:
He rah aM Senty Code SSWi.2S533(e?
.I�I Yn I_INo
ill the appllcamw turebullding occupant use equlpmem ordevkea
which eMt haardoua air centamW ma ate deOrcd by the Ray Area Air
VENTILATION FAN( SINGLE RFSID)
ISSUANCE DATE
BOHYR-COMP QTR' OR 100,000 BTU)
uty Management District?
a
Yn No
hava read the ha us necdah requiremenh under Chapter 6.9S of
the Cnld.mi Health&Safely Cade,SMbru35505,35S33and2S53/. I
- l I fi r,
�. i'�c
BOILER-COMP(OVER l 00,OOD BTIA
NEW RESIDENTIAL MECH. SQ.FT
understand that if the building don nm arrrently have a tenant, that It is my
resporulbulty to notify the part ol the mqubemenn which rruat be met
prior to/ anco of a Certificate ofOccuparcy.
T, /�
Cilj cf (;11!!Brtino
ISSUED BY. 3a��13JC{�
Owner m authorind agent Date
TOTAL
OFFICE COPY