19963APPLICAN�TO'FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'M Identiflralian
Building Add.:
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Phone:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Con der.Name: Lk.N
BUIIDINGELECTRICALPLUMBIN MECHAMCAL
A R En neer:
.—L7� I
QiY ELECTRIC PERMIT FEE
Addrne:
I'FRh11TI55UANCE
LICENSED CONTRACTOR'S DECLARATION
thombyeflrmlhatlamhce uMupwvWl of Chapter9(®nmenc
APPUANCESRF_SIDENTIAL
ingwlth Suction70W)ofDiddon3ofthe Budasand Pmfevbru e,andnly
Ikerm Is In full (ora and effect.
PANELS
Lleen.e Clas LIC/
Date "Comractor
UP TO 2DO ANIPS
INI-10DOAMPS
ARCHITECT'S DECLARATION
I emleroard my ptim.hall be need as public records.
OVERIOOB AMPS
SIGNS E ECTRICAL FIXIA
Lk..d Pmfeshmad
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt!sure the Comraeorblarue LLaw fa the
SPECIAL CEtCIRT/A1LSC
TEMP. MEIQt OR POLE INS!.
following maarm. L5eelon 70315, Budne a and Profesbv Code: Any dty or
muntywhkhrequbceapemdttomstwe,alter,Improve,denn h,ormpatr
anyetmeum prlmto lb bwrarce, also rcqubeatFe appBanl(m ouch pemdt to
file a signed statement that he la Raved pursuant to the provbloro of the
POWER DEVICES
[h ITS
SWAIMING POOL E.ECfEC '
Core..rbLiee. Law Chair, 9(commeneng wkh Seclbn MOD) ef DWI-
Z3 3 of the Ruainemand Prdealloru CMO., that he b exempt therefromard
the baala for the dleged exemption. Any violation of Scab. 70315 by any
appbont fora pem it wbjeen the applicant to • cielI penalty d.ot more than
OUTI.EISSWITCHESFIXTUAFS
NEW RESIDENTIAL LUDO [R SQsT.
Rv hundmiddlara(S5 B).
M I, a. owner of the pmperty, or my employee ankh wage a their wk
mmperuatlan, will dothe wok and thealmeV m b cot intended or offered for
dale 7066, and Pmfesbv Code:The CoNnnol. Law
,
notin
doge rmt apply to an owrcr d property who W lids. or Imprwn thrrtoR and
the.
who dwwchworkMmseBmthrwgh hl.vwnemplgen, provded that such
Improvement. m not irate.olds oro(fcrtd for ale. l( hcwever,thebullding or
ImpmvemcmbwMw ffiomyearofcomplebn,theownerbullduwlllhave
TOTAL
t 4 renofpmng But he dim W
nut Od or improve for purpose ofule.).
du Wowner d the property, am euhodvely contracting with Ileenaed
tncton to meatruct the period (Sec. 70K Bunlnes and Prolembv Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
The Contractor'. Liaerise Law does not apply to an owner of Property who
Wilda or Imp. therm., and who contracts fee such piyjeca with a
,v,�y-DRAIN k VFNI -WATER (EA)
r9aZaeor(e) licensed pursuant to the Cuntmaor'. Lleenue Law.
LJ I am tempt under Sec 4 P C_ for thio reams
I
BACK FLOW PROTECT. DEVICE
DRAINS FLODR ROOF, AREA, CONE).
�UI,F� F—
WORIQ,tAN COMPENSATION c TION
❑ 1 �ertb� a(0nn tFat I have . anlBate ,
rat to .ell -boars, a
FTATURF_S PER TRAP
Imo—e of Wo—'Compe—no mannanee u a angled copy thereof Lee.
38W, Ub C.)
GAS EA. SYSTEM -1 INC/.OUTLETS
Polleyit
GAS EA. SYSTEM-0OVER l (FA)
cam gray
I I Cer ined ropy, b bemlry tum a efty
LF JR Certified copy b fibs with the dty Irupectlon dlvidon.
GREASE/INDUFTRL. WASTE INTERCEPTOR
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE -
(I'hl..ctle. need not be rompleted B te hperms of ler.. hundred dollars
SEWER -SANITARY -STORM STORM EA 200FT
(5100) m les3
I comfy thatbthe peranunadthework so as to hcurethis emW lobo the
1 duo not employ any peeon b any rtuW. at ore to become subject to the
W ampeneatbn law.dCawarnb. Dale
WATER HEATER W/ VENT/aS=
WATER SYSTEM/TREATING
pli.o
Appllant
NOTICE TO APPLICANT: IL after making this CertBlale of Exemption, you
NEW RESIDENTIAL PCMB. 9QFT.
should bcome.ub)eet to the Worken' Campevatlon provbbru of the labor
Code, you rant forthwith nonply with such provbbv arthis permit ah.II be
deemed invoked.
CONSTRICTION LENDING AGENCY
1 hereby affirm that then b a covtmelon lording.gcrcy far the p,rform
a ntdtheworkforwh hthiopermkbLeaned(Sec3091,Civ.CJ
TOTAL
lender. Name
1<ndor.Addm.a -
QTY. MECHANICAL PERMIT FEE
.ntotooltheabovedn
1ant.
Ihavemplyh ppBcayao
lag teldon
b mrrm.l.greeto comply ankh all city and countyordlnanmand state law.
d
PERMIT ISSUANCE
dthb
Wdolingmvnuelenamiherebyrtyor
eity to enterd property,forlmpe
Inspection
etytoentgee
theabovemnify
ALTER OR ADD TO MECEL
fWe) agree to save, an d keep hamdes the City d Cupertino
Cit of Cupar
ema ern(y.n
agaWtllabWtb, pdgranb, coetsaM enpew whkh may ln any wayamme
,
ago Bald City In m99��N /thegra Mingdtl/IapemW.'
/I"4 /�
AIR HANDLING UNIT UO t0,030 CFM)
AIR HANDLING UNIT(OVER lq"CFYO
EXHAUST HOOD(W/DUCT)
Signaturtof AppBanVVt/Qr,—al •a. Date
HAlARDOUSMATERIALS I URE
HEATING UNIT(M 100,ODO BTU)
Will the applkantorfuture WOding a aupant tom orhardle h-ardous
material ore defined by the Cupeniw Mudepal Cod, Chapter 9.1 Z and the
HEATING UNIT (OVER 100,000 BTU)
Health and Safety Code Section 25532 W7
RY. No
ill the appllont arum building oovpant use equipment or de"
VENTILATION FAN (SINGLE RESID)
which emit havrdow W nontamlruds as de0vd by the Bay Area Nr
BORER -COMP QH POR 100,000 BTU)
Iky Mavgcmcnt Dbtne"f
Yea ❑ No
HOLLER-COMP(OVER IW," BTU)
11 ve mad theh rdwarvtenab mqulmmente under Clupter 6.Ai of
the Cawomla Health h Safety Cod, Section, 75505, 75533 and 25536. 1
NEW RESIDENTIAL MECH. SQ.FT
uMcmtand that if the building don not currently have. tenant, that it b my
reeporulbilty to notify the occupant d the mqubemenb whkh must be met
prior to bwaece d a CeelBotc c1Omrparcy.
Owner or authorie agent Date
TOTAL
OFFICE COPY
19 9'6'3
CATEGORY I CONTROL
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FEE SUMMARY
OIITBIDE FEES
SANITARY Y_ N_
RECELPI I
SMOOL TAX Y N
RECEIPT
PARK FFR Y_ N
RECE'T i
BUILDING DI VISION FEES
PLANCHECK FEE
PAID
Date Reoei t#
ENERGYFEE Y_ N_
PAID
Date Receipt#
'SUBTOTAL:
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
TOTAL:
ISSUANCE DATE
PAID"
'City 0 Cenertino