19975APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
ewldin Project Identification
Bulldtng Add.:
PEQATNO. -
19975
o e:
A
FO�CTt t
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
GL+q
Cunt a=: No:
-T�Lk.
BUILDING-F].g'tRICAL-PLUMBING-MECFIAMCAL
G7FL'ORY
CONTROL 4
Arch
ect/Fsglreer. Lic N.
1 G—
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add— G� l vo ♦ S
PERMITLAUANCE
I[],' ❑ ❑ ❑
lfjl
LICENSED CONTRACTORS DECLARATION
Iherebyafifrmtfutlam Ucrosedurderpr msof Chapter9(mmnm
Ingwlth Section 7000)of Dfvlatoo3 ofthe Rualraa.and Pro/mtlons Code, and my
APPLIANCES -RESIDENTIAL
]OBD, N
It. Is In full force and effect.
PANELS
License Cls. - Lk.1
,
Date Contractor
ARCHITECTS DECLARATION
Iuodentand my plansshaB be used u pubilcmmrds.
I-1 AMPS
OVERIODDAMPS
SQ FT. AREA
S/SQ. FT.
SIGNS ELECTRICAL
Lkenzd Profmlorol
TE
'
OWNER -BUILDER DECLARATION
the bya/flmthatlameaemptfromthe ComnRor's Lberuefrtwfor the
V
SPECIALCBRCIIITn,115O
TEMP. METER OR POLE INST.
following reason. (Sectlen 7QI15, Bminem and Proferbns Cade: Any dtyor
muntywhich requires aPerrot tomrotruMalter, bnprovgderrolhh,orrepair
i
./
any alrocturttatermlbhsu he bt almosed pennutnt t the pmsuchpemdte
the
Ole. tlgned ke.Law tthathehr 9 n.c(nocrunrocing pursuantitthepon 7(1 f LIM-
Cn.3oftr. Licerue end Proapter Code)orthad a is Ser1bn90W)omand
of the Butlnw and Cade) onllut he h eampt
POWER DEVICES
.
SWIMMING POOL ELECIWC
VALUATION
the b exemption.
thebash for theallegedjeemtheap Myt to albndnaltoion 7m 1Sneany
7MI,5 by my
appUont/ora permit subjeeb the appllcanttoa tivll penalty dna norcthan
OITTLETSSW[TCHESID(TURFS
(JO
nBW RE5IDEMIAL ELFLTR SORE.
Ell6ndted ddws (SM.
1,aowner of the property, or my employees with wages as their a ole
f
STORIES
TYPE CONSTRUCTION
comp..., will do the work, and the structure besot intended or offered for
.L a -c 70K Bu,I, and Prefabm Code: The Contractor. Urcme law
-
dm not apply to an owror d property who builds or imprvvm thereon, and
who dom much work himself m through hb o
own mployeesid , proved that such
OCC.GROUP
.
RFS UNITS -
Improvememsart not Intended ort/erect (m.ule. If, however, thebuilding «
bnprownrent Is" wlthinomyearofcample mthewvner-bullderwiU have
TOTAL
3
T,,of proving that he did not build orlmpmve f« purpose ofuLe.).
as owner of the Property, am <xct..bwIy contracting with Licensed
me to contract tk Project (See 7064, Buelnem aM lsrof�ro Cade
QTY, PLUMBING PERMIT FEE
IrEU.1R ISSUANCE _
FLOOD TONE
AI 'N
The C-otra—e. Llocme Law dna not apply to an owner of property who
buBda or Improves thereon, end who contracts for m& iupje . with a
rynl�dortillicen.edpurauant to the Contractor'• Lice. Law.
LJ I am nempt under Sec B & P C (o th teawnOUTSIDE
ALTER -DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DLYfCE
FEES
DRAINS FLOOR, ROOF, AREA, ODND.
SAMTARY Y N_ ,
RECEPI a
Avner
WORKMAN COM E.r Mot a RA 1 N
01 hereby affirm Wt I have o «rtlliat o rent to opyt emof(or a
3800,L eofWorkm'Compewtlanlwran «.aNfkd eopytheteof(Bee.
ab CJ
FD(TURES-PER TRAP
SCHOOL, TAX Y_ N_
RECEPTI
GAS EA. SYSTEM -1 INC40UTI.ETS
PARK FEE Y_ N
Policya
It
GAS EA. SYSTEM -OVER 4(FA)
Coo y
DING DT
BUILDING DIVISION FEES
Centlfled copy is hereby ed!wfurdshed.
CertNed copy h filed with the sty WpMbn dlvltlm.
GREASE/TNDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GRFASETBAP
CERTIFICATE OF IXEMPTION FROM WORKERS
PAID
EA 700FI'
ON INSURANCE
COMPENSATIgEIVFR-SANRARY-SIl7RM
(Tinaaectbn neM stat be <ompl TI Uthe h(more Fundrtd dollen
Date Recei t#
p100)mfe�J
Ictally that loran pet/o the wank for
WATER HEATER w/VENT/ELECTR
ENERGY FEE Y N
irm n
tobeco.aubjhhsued,
L -11uhall not employ any pe. f any manner o u to become arbjea to the
W Compcnsatbn lasva o/GUfomb. Dale
W,A,� S,91�/TREATING
PAID
PAID
Applicant
NOTICE
NOTICE ca ne,subCAM:IL aftermakingOMs ut for pro is Exemption, y,o
shouldbecome subjecttothe Worken'Compeovislo prwbbruof the Lb or
-
Date Reeei t#
NEW RESIDENTIAL PIMB. SQFT.
'TOTAL:
Code, yea rause forthwith comply with each pcovhbro or thh pend shall be
deemed rewked.
EUILDING
SEISMIC 'E
CONSTItUCFION LENDING AGENCY
I herebyaf nor"he there be corotroction lending agency for the per/orn,
rt of the work for which m
thla pertt b Weed (Sec 3097, CN. C.)
TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
'
Lender'. Name
Leoder.Addrees
I «lfythstl rthave read thb applloatbnard elate that thee we lNmdon
ou
bmrrm.Iagreetoromplywith.B rny.nd countyordlnanmand date laws
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authorom repre.enatNm of this
my to enter upon the abos rwntbnedproperty for lmpe ioopurpos.
(We) agree to save, IMewdfy an d keep harrrim the City of Cupertino
ALTER OR ADD TOMIOII.
Date Rene t#
SUBTOTAL:
agaimt llabLiHea, pcigments,costs.M e.penam which Troy In.nywayamue
egairot said City in consequence of Ve& rruaig/9¢f tide Permit
�QYL�g, �a/ �NG/ /�
AIR HANDLING UNTT(TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Sigof Appaont/G�hfLIR�/ A I DShe
EXI IAUST f I00D (W /DLCO
CONSTRUCTION TAX PAID:
HATAR DOUS MATER LLS DISCLOSURE
I EATTNG UNIT CTO 100,000 BM
Will the epplicam orfutu re bu0ding occa pant store or ha rd le harardous
,nateriaF1e.hhlact by the Cupertino Chapter9.1Z and the
Date Recei t#
FffAnnG 11nTT (OVER 100,000 Blip
TOTAL:
S.f,Iy .2S5MudtlpalCode,
iieahhes safety Codo Semon 15532Wt
RI�jj Ya �] No
VENTILATION FAN (SINGLE RESID)
—4
ISSUANCE DATE
�VlRrhe luranl u..(cortbullding oaupnedi by equipmec.Air a
which emitrogerdoua ab cvnamW rte as deRnsd by lM Bay Arte Air
BOR.ER.COMP(3M'GR 100,000 BTI.
Quality Alawgement Dbtrlct7
PAID,
•J �. '
4 Yes j1 No
Tuve read the hoes our material, requiremenb under Chapter&%of
the Gldamh Health&SafL4y CWd,sectb 505,25533and]55M. 1
, 199U ,
(-?
BOILER-COMP(OVER 1W," BTU)
NEW RESIDENTIAL MECH. SQ.FT
urdmuMt tlfthebuildingdoc.ro ova nttyhawatenant,twtlt L.my
rospomibUfly to notify the occupant of the requirements which must be rrct
prior to ane of a Cettifcate of Occupancy.
13
�Y6
.,,C-Ity 6Cf ,C�ttine�Tti�no a�
ISSUED BY: `y %
Owner m euthorlved agent Date
.
TOTAL:
OFFICE COPY