19971APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY I 1Ir/
Building Pm eet Identification
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19971
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUII.DINGELEC'1RICALPLUMBINGhpECHAMCAL
C.tr m .1N1ame:
CATEGORY _
CONTROLa
,
ArchBed/Engineer: Llo.
QTY ELECFRICPERMIT FEE
BUILDING 'PERMITINFO
PERFfC[ISS[IANCE
I�T O ❑ ❑
�I
LICENSED CONTRACTOR'S DECLARATION
I hereby SecUon70 that Dfv[aJato en3 ofthe erpessandu dChapler9(luno
lnenseISection oftha Buslvessand lRolerlonaCodeand rrTy
APl'UANCFSRISIDEMTAL
JOB DESCRIPTION
license � N full fora and effe2
Force and
PANELS
Canoe Char Co tl
Dime Codndor
_
fa�UPI—F—X . -
201-1000XMPS
ARCHITIC'PSDECLARATION
I understand my plareehall be used as pubkc neo da
Lloneaed Professional
111'--�r11 1V
OVFRIODUAMPS
- SQ. Fr. FLOOR AREA
D IN
$/SQ. FT.
SGNS ELECTRICAL
OWNEReBUILDER DECLARATION
I heng tuna ,fS et l am 31,5, B fmmthe Cor Professions
Garue law (a the county gref, req ics a peurD15, onatrrand Propine, Code:Mycity or
requbesa alter, Improve, dernlish, or
TER
,
SPECIAL CIRCUIT/MISC
�gp MEER OR POLEWcountywMrh
DEVICES'
Vi\
banar ccoastruct,
emirepair
to anyatsigne eprbrtolteLmarce,alsnaod r rauaot to the or such of toPOWER
Me • signed mens eLa that h b Brenaed pwsuant the the
monprovisions007)of
Contractor's the LitemsTaw(Chapter9(commencingeR Sedbn7000)ofDIVi-
t
sbn3af the Businer and PrderbaCode)orNrt heberempttherrhvmand
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. My Violation of Section 7m15 by any
applicant for a permft aubjeRc the appllcant to a civil penalty of nor more than than
OUTLRTS-SWHII
CESFDlTURFS
0�
NEW RESIDFM7AL FI ,.rR SQ FT.
five hundred dollars ($S00). t
I, as owrcr of the property, or eny employees with wages u their sole
STORIES
TYPE CONSTRL'CHON
mmp.tfon,will do the work, and the structure brat Wended or offered for
.vie (Bet apply f Code: The Contractors Lianas I�w
V -N
to owner
does oessurot y to owner dp rou,h who bdrnpllds y prwmted that and
property
rope
whodoeeuch workhlmxBathuugh hlsownenrplgen, pravded that such
'
OCC. GROUP
RES UNITS
bmprovements are not intended or offered for sale. If, however, the building or
Improvement is sold: fthln mi
one yearofe pletbn, the owner, Wer will have
TOTAL
(�
t?Kdenofpmvingthathedid no bul]d.rinpmv fcrpurp..f.le.).
�jfj 1, as owner of the Property, am eslueively contracting with Beer d
cont tas to mnMrud the pmjeet (Sec 7044, Business and Prderbro Code:
QTY. PLUMBING PERMIT FEE
bT�DD ZONE
APN
PFRhUT ISSUANCE
The Contractor's Lcenae Law does not apply to an owner of property who
or Imp. Merton, and who contracts for such p(ojeda with a
cjpscWr(n) uarsed pursuant to the Comrade. Lirerse Law.
U I am exempt order Sec B k P C ffoo�r fldiireason
ALTER DRAW 4 VENT - WA]IIt (EA)buids
- - -
_ FEE SUMMARY
"
MIX FIDW PROTECT. DEVICEQU`Tq
I DE FEES
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY _ Y_ N_
1ZECEETR
Owrar w %t—C� 1' 1� Date �rJ J--/�
WORKMAN COMPENSATIO TION -
MI hereby affirm the I have a ca lc int( Q to mi!-Iwrc, or •
aniRcatc of Workers'Compewtion lesurrarannravhhce aa mnffW unity thereof( Sec.
3900, Lab C.)
Polky /
��5� TRAP
SCHOOL TAX Y_ N_
REfFEC9
-
GAS FA. SYSTEM -1 INC.40U]I.EIS
PARK FEE Y_ N_
RECEIPT a
GAS FA. SYSTEM -OVER 4 (FA)
Com ray
BUILDING DIVISION FEES
CertNN copy (umished.
Certified copy is filed with the dty inspection dlvis on.
GREASE/t1uDUsrRL WASTE W'fFFCFPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF D(EM PITON FROM WORKERS
PAID
SEINER -SANITARY -STORM FA Ilt(IFI.
COMPENSATION INSURANCE
(this sessionwmb
need nor be cnpleted if the peJt for one hundred dollars
Date Reed [#
wATFR [-�ATFR W/v¢vr/FzEcrR
ENERGY FEE Y_ N_
(s Mull®.)
I artily that In the perfornana d the wait per
emit whieh thin pedt hu
is ed,
I shall net employ any p mon N any manner u as to become ubje d to the
Wakme'Compensation Lawsd Calfomh. Date
WATFASYS FM/1RFA IN
PAID
AppNOTICE
NOTICE TO ager mki.n1Ne Certificate Ens ,you
Date Remi t#
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
cons sub)CAM: e
is cd the Lab
shaildbecomeforth
the Wlywit Cuch
it
Code, you mlued. with comply with such provbbv orchis pemdt shall be
provisionsorthionaredt s be
deemed revoked.
BUILDING
i
SEISMIC FEE
y CONSTRUCTION LE'NDIN AGENCY
I hereby affirm that there ha construction lending spray for the perform sere
sere of the work for whdch this pemdt is oa,ed (Sec. 3097, Civ. C.)
Tender4Name
Ienders Add
I ovAi that I have read thin application and statethat theabove In(omutlon
b correct.I agree to comply with all city and county ordinances and late lawn
ELECTRIC FEE
-
QTY. _ MECHANICAL PERMIT 'FEE
PLUMBING FEE
'
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authodre representatives of this
-
eltytoenterupontheibove-mentioned property for Inspection purposes.
(We) agree to ease, Indemnify an d keep harMea the CLLy of Cupedlw
ALTER OR ADD TO MECH.
Date RCCeI [#
AIR HANDLING UNIT GO 10,00 CFM)
SUBTOTAL:
against LiabWties,}adgrrenby ousts and expenses whir, may in anywayaceme
aga Wtnald CRyir con��rvry �- aftk grantingdtMs rmit.
�ffv�Z�G/^ 4,,/� ,o
ZVWM
AIR EUNDUNC UNrrroVER 101000CFW
CONSTRUCTION TAX
E)(HAUSC HOOD (W/DUCT
CONSTRUCTION TAX PA ID:
Signature of Appllantf/J/a(iwMW'to
HA2ARDOUS MATERIALS DI OSURE
HEATING UNIT (TO 1W,WO BTU),
Will the appBrant orfuture building occupant Mare or handle havrdous
nud
aterial as de0rby the Cupertino Municipal Code, Chapter 9.17, and the
z
Dale RLCCI t#
[EATING UNIT (OVER 100," BTU)
TOTAL:
Heahh and Safety Code Seatlon 25532(a)7
f 1 Yee I`l No
tienuth rdou i curerollding a. ocrupant equiprrBay A or devices
whir, eMt haarreed Di trier? lruntaae defied by the Bay Arta Nr
Quality AlavgemeN Dslrhd7 •^
4Ye No
have reedtheb.: smaterielsrequimmnbunderChapter6.95of
the California Health Safety Code, Seniors 25505, 75513 and 25531. I
VENTILATION FAN (SINGLE RESD)
ISSUANCEDATE
n
BOILER-Wh11P PIEOR 100,000 BTU)
BOILER.COMP(OVFRIM,"BTUA
NEWRESIDFNIIALMECH. SQFf.
understand that lfthe building does rad cumetly have a tenant, that it is my
respomibihty to ndifythe oceupant d the requinerents which runt be met
,a�
aiaJ car C
prlorto Lcwnarcoda Certiflateof Oeeupamy.,
P
IT..}l0,rf1[I!}
ISSUEDBY. Rf fy''r'�4
Owner a auchorbod agent Date
, TOTAL
OFFICE COPY