19976APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B011dl Project ldentifle d.
Build], Addma:19970
Iak7tMIT Nb.
_a:1,300 e-wi n� LEI U L I 2 C—
ame: cane
•L),
A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION it PERMIT
BUIIDNGPLELTRICALPLUMBIN&MECHANICAL
Q
G —� U�
can dW. N.me: � I IJc.N
I OL` T-aF�s
CATEGORY
CONTROLY
Archked/Engineer.
=� Z c r
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addres I '1 5T,�'
PERMIT ISSUANCE -
® El E] -LICENSED
El
CONTRACTORS DECLARATION
I hereby affirm that l en llceoe under provWons ofCMpter9(commenc
Ingwlth Sectin.7D=of DMaloo3ofthe Busiroeand Pru ealonsCode, and my,
APPIlANCES-RESIDEMTAL
JOBDF_SCRIPIION
Ieeroe is In full form and effect,
PANELS
Ll ClareLk. a
Date Cke. IF
AMPS
ARCHITECTS DECLARATION201-1000
I urdentard my phro shel be umd as public remnle.
OVERl000AMP5 I
/aaIaQ1"f,. FLSRIjl4N
VSQ. FT.
9GNSFT TRICAL
Lid Profebral
Licensed a
LV)
OWNER -BUILDER DECLARATION
Iherebyaffirmt tIamexemptfromthe ComractorblmeaeGth
Lwfae
SPECIALCItCU1T/M[K WP
T FrR
�+
TEMP METER OR POLE ASF.'
T'ralPOWER DEVICES
following remon. LSectlon 9015, Bueoua and Profmbv Code: Any city or
countywhichrequl aper tomrotmMdoer,Improve.demo h,orrepair
u
anyeudure prior to lb laaoc,aleo require the applicant fureah perMt to
file a signed Yatement that he b an
licensed pursuant to the provbbra of the
Conlndoh Liceve Law(Chepter 9(conrun log with Section 900) of Divi-
sion3 of the Buerem and Proa
febro Cade) or that he Is exempt therefromard
SWIMMING POOL ELECTRICC
VALUATION
by any
the Mab for the alleged exemption. Any Wdatbn of Section MIS room
If ountforspermReubfecb the applicant to dull penaltydnot more than
tiv undyed ddWa(S,AR).
u L ae owner of the property, empbym wages a thele sob
OImETSSW1ICHES—FDCFURES -
�o D . U•
NBWR2aDFN17ALELEICTR SQFf.
STORIES
TYPECONSIRUCTION
d i e
mi p0n 74k will Bothe" Pnofdthe CodurcbrotWcodedoroffered ..Lfor
ct
oan Ov,Ow and f Code: The Codndole Llceme Law
dale Ldoes
vim.
om apply t props ty
.hod. pplytoan Lw lfdt .gh who Wilda orim,p.Whercortand
wh hbown pmvdedthataitch
h.rkis
OCC.GROUP
RES. UMTS
rovenv amnolmse dedorough
Improvementaaa iwithindedoroftertd (oreale. If, however, the building m
e. If,h w
ImpmverrcnlbsoW wllhinoney<ardcomp Idlon, theowntt-WllderwlR Mve
try� rdenof pmdng that he did not Wldor Improve for purpose ofsee.).
IA Las owner of the Property, am essWalvely contracting with Ikensed
dap to mrolmdthe project (See n04{,Bvinea aM Prolmlov Cade:
TOTAL:
QTY. PLUMBING PER FEE
Q'7
PERMIT I%7JAIJCE
FLOOD ZONE
APN
The Comradore Lice. law doe not apply In an Owner d property who
builds or Improv theme, theme and who mmram for such ptojeces with ,
o9iEfadorW Ems pursuant to the Contndds Iaiae Gov. -
LI I am eamq under Sec B I P C ler fhb rtaaon
ALTER -DRAIN & VENT - WATER ffA)
FEE SUMMARY
Bn«FfAW P�TOCT. DEVICE
OUTS] OF, FEES
DRAINS FT•OORROOF, AREA, COND.
SANITARY Y N_
RECEIPT a
owner MA
WORKMAN COMP SATION RATIO
❑I'hembj •then that I Mve • mNllcat o co ant to seB-Iruurt, Or
mrtiflcate d Workeri Comperoadon Irounna as artilial ropy therm!(See
330, GbC.I
FD(.CURES PER TRAP
ScL;gOLTAX Y_ N_
RECE PT If
GAS FA. SYSTEM -1 AG4 OLrr S
PARK FEE Y_ IN
'F
GAS EA. SYMM-OVER4(EAI
Cama y
DING
BUILDING DIVISION FEES
Certltled ropybhercby (umlehed.
CertBled ropy ,!liedMth the city Iropedlon dldsion.
GREASE/INDUSFRL WASTE AT EPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXOA MON FROM WOR KERS
PAID '
SEWFR-SANFFARY-STORM EA_RDFT.
COMPENSATION INSURANCE
Cfhlese knu need out be cmnpleted If thepemdt b foram hundred dollen
Datc Recel t#
($100) Or lea.>
IaOut cop In the ppen r Ian thewak so whIch as tobUJrmsubjiCbsued,
I CMR net employ any person In any manner at as to become subject to the
Worken'Compen.utbn lACvs ofGWmnb. Date
WATER HEATER W/VENT/ELEM
ENERGYFEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICETOAPPLICANT. If, aftermatingfhb Certificatepruoof Exemption,you
to the Workeri ComperoeUan porthis a of the
Coded become su rt
Date .Recel t#
NEWR DFNRAL PLMB. SQFF.
TOTAL:
to
Code, You norat forthwith comply with each pmvbbro or this permX shall be
all
BUILDING FEE
60c
deemed re,oked.
SEISMIC FEE
CONSTRUCFIONI LENDING AGENCY
I hereby affix n that there is • mrolruetion lending agerry for the perfommELECTRIC
ance of the work for whkh thb permR b loved t5ec- 307/, Civ. G)
TOTAL
FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I<rderb Name
Lender. Adarcro
1 cedlfythY I heve read thb applatbn.M aatethat the above informtim
bmrmd.lagrcetocanplywithaU&yandcountyordbanoaandstatelaws
MECHANICAL FEE
PFRMTT ISSUANCE
FEES PAID:
rd"tobulMingmvtrudim,udhenbyauthab npremntatweofthh
dtytoenterupontheabwe-mambo<dpropertyforimpYlonpurpoee.
(We) agrm to nave, Wem fy an d keep ha m the Cby of Cupedlno
ALTERORADDTOMETH.
'
Date Recd f#
SUBTOTAL -
egaWtB bilti ., tdgmenb,m andexpevewh"A yin•nywayaame
against ova airy m,w.,egaettne grpi�d�(w^—
�%•City GLV a—�1I ��
AIR HANDLING UNIT (TO 10,000 CFM[)
ATRHANaINcuN•I'I'rovrxlo,(mcFM)
CONSI'RUC['[ONTAX
Signature of Applicant/C+artnemr
E)wnusr El000 nv/Duch
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA DISCLOSURE
HEATINGUNITOO10,0008TU)
WEIthe appleant Or Grum building oavpet Yore or MMle by uus
matertal as defined by the CupeMI. Munmpal code, Chapter 9.12,and the
Date RLCeI t#
HEATING UNIT (OVER 100,000 RM
TOT AL:
Elealtheai Safety Code Se on5532(e?
❑ Yrs No
Wlllthe applcallor cure building oavpam use equipment mdcv
which eno t Mardd, air mnlandrorus sa deflo d by the Bay Ana Mr
VENTILATION FAN (SINGLE RESID)
ISS,�drry^wy'C_E.DA'I'E
j j'
BOILER -COMP Ol6'OR 100,000 BTU)
Qu lty Mnragenrrd DLErld7
MYe earnvu No
4vcreadlheoEueabreglreb
mnunderCMperG95of
the California Health & Safety Code, Sodium 25-545,25533 and 5534. I
lir" PR
V
BO IX
GRCOMPOV1W,000BTU
NEW RESIDENTIAL MECH. SQ17.
un,!mtald that if the Wilding doe not arrently have. tenant, that it bmy
respoviblity, to notify the occupant of the onlubemente which oust be met
prior to fauarue da Certificate of Occaparcy.
�� yl "'+nor l/(IO
ISSUEDBY:
Owner or authodeed agent Date
-
TOTAL:
OFFICE COPY