19962APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PmM Identlfkalon
Building Add.:
PLRATNO.
e. c3't S S3
1'9962
rs ase:I Phone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION If PERMIT
BIIILDINGdECfRICALPLUMBINGMECHANIGV.
6 — 2e 8/q
em rtor'eName: y. Lk. Na
O L•L GQ 1 SOU
CATEGORY
CONTROL♦
ArchXed/Emgi
Z G
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO,
y C
Address ,jO k EST S
PERMITISSUANCE
® ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
lk yaH thatlamlbmaedunderpmvhmsn Chapter9(mmmmc
Ingwith Section7000)ot Divldm3oflhe Budnnaand Pmfnatm.Cade, and
APPLIANCFSRESIDEMTAL
JOBRQrIl ON
Itrerse is in full force and effM
PANELS
Limn:Class Lle.I
Date Comndar
ARCHITECTS DECLARATION
I understand my plans shall be used n public recedes
XII -1000 r
OVER 1000 AhiP5 .,s
FLOOR AREA
$/SQ.FT.
License.! Prdembrul
OWNER -BUILDER DECLARATION
1 hereby affirm that I atn exempt from the Contrattori Lleens, law for the
SIGNS ELECTRICAL
I.1aA2E
SPECIAL CIRCUIT/MISC sr.a'a
following moon.(Sedion 7MlS, Business a nd Professions Codr. Any tlty, or
cvuntywhkhrequhnaper tomnslmd,alter,improve,demolish,orrepMr
TEMP.METERORPOLEMST,
t
-�/
myalmmampriortoiUl ame,alwrNuX theappUX tfmsuchper to
The a signed statement that he b Ihxrued pursuant to the provision, of the
Contndori License Law (Chapter 9(mrmmndng with Section ] )or DIW-
stn 3 Of the Business and PuofembnsCode) or that he es exempt themfromaM
POWER DEVICES
SWIMNUNGPOOLELECTRIC
VALUATION
the kat for the albged esemplbn. Any WoIxtion of Sedlor 70115 by any
appu.a tforaperm bj theapptkc ttoadvllperully Nnatnnmthan
OLTI-E'�FDCI"URES
��•
NEW RESIDENTIAL ELECTR _SOFT.
flv�mundmlddWe(pro
u I, a owner of The property, or my empbyem wkh w.gn ex tkX wk
STORIES
TYPEODNSIRUCTION
c Fenxadm,willdothework,andtheatmdure boot btemdedor offered for
sale (Sec 7044, Bu.treu and IPrdesebro Code: The C..euxe. U. law
v
does wt apply to an owner of property who builds or improvn thereon, and
who dmewdmwork himself orlhrough hbownempicyenovid that ch
, pred ar
OCG GROUT'
RLS. IMI15
Impro,,mems ane rot intended oroffered foraale. If, however, the bWbing or
lmpmverrcm bwid within oneyexr ldbm,the uBderwW heve
TOTAL;
K --
s build a for pu
t Nen orner of tthttkdky,am exdor tmprovefacingwit lemse
LV 1, or owner of the a property, am er0K fhosi eta, a" re with Licenseee
orstoconswdthewdoe (See7 Podrobrit Code
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ElOOD ZDNE
APN
pplyt an nand
The . or Imori Linrue Gov does rad apply m , f owner d property who
hex0d. or Bnhomse thereon, and who m ones for ads wRvjean with a
oLJIm(eexempted purwwmthe emtrae:or. Limr�C foLaw.r
LI I am exempt order Sec. B 6 P C for Ih ren
ALTER -DRAIN k VENT- WATER (EA)
FEESUMMARY
BACK FLOW PROTECT DEVICE
DRAINSFLODR ROOF, AREA, CONTI.
SANRARY Y_ N_
RECEIPT 9
Owner
WORKMANCOMPENSATIO RATION
❑f hereby Whron that I have a mat h o c t to se -woo, m a
anlflaneol Workers'Canpemaflonlmur m ma ezrtl/led copy thereof Qec.
3800, Lab C.)
FDCILRFS PFA TRAP
SC}IOOL TAX Y _ N
RFCEPTi
GAS FA. SYSTEM -1 INC -4 OUTLETS
PARK FTE Y_ N_
Paley /
RECmrT I
GAS EA. SYSTTM-0VFR l (['A)
Com ray
BUILDING DIVISION FEES
❑�Cedi➢ed ropy b heed with
❑ Ceniried ropy b (fled Mth the Wy lnsptttbn df Wim.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
. ,
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
PAID
SEW FR-SANH'ARY-STORM FA. XIOFI'.
COMPENSATION INSURANCE
(Thissedbn need nes k msplded B the paomh b forom hundred dollen
Dale Rcaci IM
atOD) mfyth the p per. ..anyuse of the work for toohlM.permblwed,
Irsout emplat oy
I dun not empty any person f any manner at u b become ubjxt lathe
i Campewlbn Law. of GII(orb. Date
WATERf¢ATERw/VENT/ELCTR
ENERGYFEE Y N
.
PAID
WATER SYSTEM/TREATING -
Applh, m
Date Recei IN
NEW RE4DENTTAL PU.IB. 9QFT.
NOTICE
NOTICETO AIPIPLICAM:Il after rtuklnmg lhb Certificate Of Exemption, you
should hemme.ubjed to the Workers' Compensation provisions of the labor
TOTAL
Code,ym maust forthwith mm ply with such proWlonsorthh permit shall he
doomedev
roked.
I LDING ME
SEISMIC E
ro
CONSTRUCTION LENDING AGENCY
I herebyaffirmttut them b amnsiudimm kMingagency forthe perfomm
arae of the work for which this permb Issued sued (See G) 3097, Civ.
- TOTAL
ELECTRIC FEE .
PLUMBING FEE
lerdee. Name
tendtea Addm„
I cenvy Nd i have readthb appB tbnaed aatethal the above informadm
bmrrttl. Iagreetocomplywith all cityand county ordlnanoesand state ]am
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEES PAI D:'
relating to building construction, and hereby .uthor o e reprexntatNn of this
dry to entnupon the above-mentlonud property for 4up—i'm purpose.
(We) agree to save, bidemrdfy an d keep ha rod. the City or Cupertino
ALTFRORADDTOM�
Date REYCi t#
,
SUBTOTAL:
aga0ut liabilities, judgmenle, m.bsnd expenms which may banyw.ya.e
against said City in mnsequenm of the granting sipt .permit.
�YLIZGM � �Nc-/�.,.�I�I /9Q
AIR HANDLING(TNIT OO 10,0D0 CFM)
ATR FIANDU NG ♦INR (DYER l0,00pCED
GONSTRUCT70N TAX
rt/
Sigvtum or AppBontARDOUS Dale
EKTiAUSI HOOD CW/DUCE,
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS 1 IA URE
HEATING UMT('IO 100,000 BTU)
orhandle havrdms
Willcries the efinedmae up Cupertino
gampal Code,
matada In ddlnedbythettion252(a)? lCnde, Clupter 9.12, and the
Date RCCei tIt
IiFATWG UNIT (OVER 100,000 BTU)
TOTAL:
licalthaM Safety Cade Section 25532W2
❑ Ye, No
VENTILATION FAN RFSID)
.IS ��DATE
Will thea 0antm tum Wilding tux equipment or device
PP goceuPan rcNP
whicheMt airrict? tan de0ned by the Bay Arca Alr
BOILER -COMP o}N OR 100,000 BTU)
Management
Quality Managamem Dbtrkt7
Yes No
have mad the ha materials requirements under Chapter 6.95 of
^-1 Q �••�J
BOILER-ODMP(OVER 100,000 BTU)
the CaBfomb Heahh ,k Safety COde, SMbnu 255M, 75D3 and 25534.1
t' ,
NEW RESIDENTIAL MECFI. SQ17
urdcstaM thetlf thebullding don nm mrtently heveatenanl,lhetlt fs rtry
noponsibilitytonotifytheoavpam!the requlrement.whkh mustk met
prlorto issuance ofaCcnlfbm
tcofOtparuy. -
Cifi irf Curlerilno
�
ISSUED BY:_
Owner or authodvcl agent Date
TOTAL
OFFICE COPY