19969APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
H-uilding Pro' et Identification
Building Add Arms:
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PE MITN'O.
Phone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
LAICAL
A
canlnearm Narne: Lk. N.
CcQ `�G b Ll�qlBUIL.DINGnECTRICALPLITIBINGML
CATEGORY
CONTROL ,I
Amh /Fsgtru�er. Lk. N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/
Address: hk'SSL�VJ Is F,
FERMITISSUANCE
� ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
Thereby afllrmtlutlam llcenaed urWer provWoru ofChapter9 (amunm
Ingwilh Section 7000)of Division 3 ofthe Budram. and PmfamoroCode, and al
llmnse b In full force and effect
Llmnm Clam onbr
e Gic#
DatOr
ARCHITECT'S DECLARATION
I undenbrd AT pbra shall be timed u public record..
LkeraN Professional
OWNER -BUILDER BUILDETT DECLARATION
Iherebyaffirm HutIamexemptfrom Ne DECLARATION
LlmroeLawlm the
Following A,.. (Section 70315, Bushes and Prufembra Code: Any city or
ceuntywhkhrequl apemlh Wmru d,alter,Improve,den h,orrepalr
anystm=mprbrto Ibbs ,abortbq.6.app0eantformuchpemdtto
Rte a signed ebtement the k he llnrued pursuant to the proviebro of the
Contractor's Llcerue Law (Chapter 9(cd n ncing with Section 7000) of DM_
sion3 of the Buelnemaand PmfeaW.Code) orlhmt helm exempt therefromaM
The hub for the alleged eumptfm. Any violation of Section 70115 by any
applicant form permit urbjecb the applicant to a civil penahy At not more than
0vffundred dollem%5W.
LJ I, am owner of the property, or AT empbym with wage am their sob
comperoadan,"I do the work. and the.tructum ie not Intended or offered for
mm le 5ac 7064, ILkneu.AdProfessions Code: The Contractor.llama. law
doe not apply loan owner of property who blies orlmpmvnthertoR and
whodoaauchworkhimaelfor .ghhi o.n pley.,pmvldedth.tmrch
Improvcmoimartretiotendedorofferedforsee. ILhowever,thebulWWger
Improvemem beokl wllhinomyearofcampletbn,tkwvner-bullderwlll have
X.. of pmving that he did not build or improve for ofmale.).
p(I L .. owner of the property, am esshuNely mnlraning withlkxwed
ctms to construct the project(Sec 7044, Businea, and Prdesloro Code:
The Comnctar'A Llicerue Law dm neat apply to an owner d property who
b.Od. or Improv. thertoM1 and who contnrn fee much p,)eRwithm wa
cgatpetoa(m)Banard pursuant to the Ceeb totem Llmrue law.
UI am exemp under Sec B & P C for this recon
Avner
APPI3ANCESRE�ENML
JOB ON
Y
PANES '
— =.lQ00 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
L ED r^I N
P }J T }.m R
'a /
...+++!!!
S/SQ. FT.
SIG NS ELECTRICAL
SpEC1ALCIRCUIT/MISE
TEMP. METER OR POLE INST.
POWER DEVICES
SWLMh17NG POOL ELECTRIC
OCILETS53VHCHESFIXTURES
VALUATION
t
NEW RESIDENTIAL FT FLTR .FT.
`"�
SIUKIES
TYPE CONSIRUC ON
TOTAL:
QTY. PLUMBING' PERMIT FEE-
PERMIT I4'l1ANCE
,Q .�g.DRAIN k VENT WATER (EA)
OCC. GROUT'
�]
1t '3
RFS UNITS
FLOOD 7DNE
AMpurpome
FEE SUMMARY
BACK FLOW PRO],ECL DEVICE
DRAINS FLOG ROOF,
R AREA.
SANITARY Y N
Rf�Ellrl'I '
WORIGHAN CO 1PFNSATI RATION
❑I hereby affirm that I love • mrtlgate sent to self-bwrt, or a
certificate of Worlo, •Comperonlon lruuranae or. mrtifled copy thereof tSec
3800, Lab - -
Polky Y
�REe'�T�r
-
SCIiOOL —TAX
N_
RF EIPfI
GAS FiA.SYSITM-1 INC4OU LE15
PARK FEE Y_ N
RECEIPT I
CAS EA. SYSfa1-0VER 4 (FA)
Cam any
BUILDING DIVISION FEES
9Certlflea ropy b hertbyt],the M.
Certified copy b feed y hi The city inspection dlvWm.
CF.RTIE CATE OF E(EM MON FROM WOR K ER S'
COMPENSATION INSURANCE
Cfhl. arctbn need not be completed if the perndt b far ora hWundred don
(A00)ary th)WATER
I snot that W the pe erven t a any
h. nnanner for t obe,con wbd ec bo the
1 ork not employ en any person W any manner so u to become mrbjcct to the
Warkers'Comperoatlon law. of California. Date
Apphant
NOTICE TO APPLICANT: R, aper making thio Cnrtff"te of Exemption, you
mhculd become subject to theWorkers'Comperuathm provbbro afthe labor
Code, yeti num forthwith comply with such provbloro or thio permlt.hei he
deemed revoked.
CONSTRICTION LENDING AGENCY
I henebyafHrrn that then 13amrotructlon leMing agency for the perform
anon of the work for which thio perodt Is bead ( 3097, Civ. C.)
Lender. Name
Lenders Addres
. 1 mnlfythat I have madthlmappilalbn and matethat Iheabovelnfomutlon
bcom'R. lagrte to coereply with all city and county ordinancesL'S
and Bate lawn
relaling to building eorotructlon, and hereby mutharted reprem,ntaHvn of thio
sty to enter upon the abomcmentbned property for WpMlonpurpoma
(We) agree to cave, Wdemmty an d kM
keep harew the CRY of Pentre
,,.trot 11ab01ties,pdgmemm, command e.p.. which nuy In anyw.y..e
agalrotsald City In mnaequera of the grunting of pemJt.
AepjAl M�/lb
Signeurrof Applicant/^-. C
HASARDOUS MATERIALSI SURE
WHl the applicant or fiWm bu Oding occupant store or handle has sous
matcrlal a. defir ci N
by the Cupertlro Mutlpsi Code, Chapter 9.17, and the
Health and Safety Cade Section25532(a)?
Ry"M No
illtheappilcant or Wm build Wgacccpantua<egtiipmem ordevlm
which emll hazardous air mntaMvnt. u defined by the Bay Arta At,
Qualftynagcnr wDWr�
have read the huajr�-jour matrrlala rcqulmmencv underCHpter G95 of
The California Health & Safety Code, Sections 25505, 25533 and 255M. I
undMndtktiflhebrlldingdce.mtarrnntlyhaveatenanLtlutltbmy
r ponmm0lty to notify the occupant of the requinmenls which retial be met
prior tot uanco N a Ceiiflwe of Omrpai my.
GREASE/INDUSIRL WASTE INTERCEPTOR '
PLANCHECK FEE
PAID
Date RCLY'1 t#
GREASE TRAP
C; •m SANI.I.ARY SNIL1f EA. xID..1.
HEATER W/VENT/ELIZTR
ENERGYFEE Y N
PAID '
Date Recei t#
WATER SYSTEM/TREATING
NE'WRESIDE-rHALF[]dB. SFT.
-
TOTAL:
1
-
SEISMIC FEE
T07AL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT UANCE
FEES PAID:
'' ALTERORADDTOMECK
Date ACCCI t#
AIR HANDLING UNH' CFO 10,= CFM)
SUBTOTAL:
A)RHANDLINGLRTT(OVER1400(iCIM)
CONSTRUCTION TAX
EXHAUSTFUm0D(W/DUCD
CONSTRUCTION TAX PAID:
HEATING UNIT(TO 10D,000 BTU)
Date Rccci t#
HEATING UNIT (OVER 100," BM
'
VEJHIATIONFANt51NGLE RES'ID)
= 'ISSUANCE DATE
4 O IUyu
/. .L
�l Cune"IFifv
-f,�/I{^. (�s �{s��•y p�R l/nM
ISSUED BY: v`' �iM/ ��.'�"'�(W V•''
BORFA C0MPOM'OR100,=BTU)
BOILER -COMP 100,000 BTU)
NEW RESIDENTIAL MECH. SQ}T.
Owner or aulhmtr d agent Date
TOTAL:
OFFICE COPY