19978APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY*
tluiidln Project laendfkatlon
Building Addm
PERMIT NO,
o Go PF Z
19 9 7 8
{ &V0 U8 me.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
BUILINNG-ELECTRICALPLUMBING-MECIIANICAL
VCm^
Lie. N.
o - n
CATEGORY
CONTROL /
AfcM1B—T O'.
� G 6
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addmss.�� F
PERMIT ISSUANCE
1�( ❑ ❑. _❑
�/�
LICENSED CONTRACTORS DECLARATION
I hereby.Hfrm that i am licensed under pmvblon. d Chapter 9(commeo
Ingwlth Sealon7000)of DIvWon3 ofthe Bu mu.nd ProfessionsCode, and
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
license Is N fed force and effeet.
PANELS
Date Cies it r
Date Clue Lontr
�1
-I AMPS
ARCHITECT'S DECLARATION
I urdcmUrd my phms)ull be used m public remrda
OVERIHIOAMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed! d
Pr®bnal
D IN
OWNER -BUILDER DECLARATION
I hereby affirm that l.m exempt from the Contractor'. Live Law fee the
C
SPECIALCIIICIIIT/MLSC
fodowing region. (Section 7MI1 ,Bush® and Profmbm Code: My aty or
county which requires a permit in mntrroo. alter, bnprow, dernolbh,or repair
TEMP M=OROR MICE INST.
G
anyshoaurc prior to Ba bsuance,alw rNuireithe applicant fee such permit to
Ole . signed Casement the he Is licensed Pu..rt to the provisions of the
Contractor's Lkeme law tChepter9(comreenrdng with Section 70W)of DNI-
ebn3 of the Business and PrdeebmCode)orthat he b exempt therefromaM
POWER DEVICES DATE
SWQ.(h1ING I'001, FL.ECTRIC
.VALUATION
the hexl. for the alleged exemption. My nidation of Seolon 70315 by any
.Ppli¢nt fora permit eubjeetstheappOcanttoa Wil penalty dent morethan
IRTIi�S5I17TCF�FLLr[SJRES
r-'� ^,
•
3Yor
NEWRESIDENTIALELECTR SQ1T
(Iva hundredner of hepr.
I, .s owner o/ the property, my ernplvym with wages there sole
STORIES
TYPECONSTRLCTION
d
comperwllon,wRldothe work udtheCmaurtbrotbderded or offered for
r
ole (Sec701y Law
Code:TMctr
,
V-
to.n ownerfpeoerty
imnotaPPlymuowrcrdproperty who bulkb ar improve thercoq and
impowm the.
lh.twdi
whodonsutt
Mm.eBothrough hbownemplgeeevemr
OCC.GROIIP
RES. UNITS
tiled
ancr
irepovementissoMtintendneyearfared (oreale. l(, however,the bulldingm
Mprovemantbwld wlthlnomyearo(XIetbMtheravner-bullderwlll love
rdenofprovingthxhedldnotWUorlmpeuvefmpurpoeeoft le.).
I, ae wvner of the property, am <xchuWely centracUng with Bren.ed
aae to cowruct the project (See 70K Rusin. and Pe f.tam Code:
TOTAL:
-
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD TONE
'VRI
The ConlnaoY. Linen Law dao not apply to a owner of property who
bu Ilia or Improvm , the e and who mntraas for such P jests whit •
erjo![+aor(O Brenmed pursuant to the Contread. Ll¢mse law.
r th4 re �n
LJ I .m exempt under Sec B 4 P C (DUTSID
ALTER -DRAIN 4 VENT - WATER (EA)
..
FEE SUMMARY
BACK FLOW PROTECT. DEVICE '
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY .Y N_
RECEIPT
Owner D e
WORKMANCOMPENSATIO 1? I ON
❑I hereby ,Bien the I have a ¢rtl(Int cat to .elf -Insure, a a
¢mitt-ofWorke Cmpem mImuran¢ascert kdmpythenofsec.
38W,Iab C.)
IR
FNTESS PER TRAP
SCI,lOOL TAX Y N
RECEIPT
GAS F.Y. SYSTEM -1 INC& OUTLET'S
PARK FIE Y_ N_
Iol{ryI
GASFA.SY OVER♦(FA)
CoEeny
DING DI
BUILDING DIVISION FEE9
ertffldmpybheebyfarwhea.
�CertNed copy b Ned Mth the tltyInspection dldSion.
CREASE/INDUs1RL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATEOFGX(eMPTIONFROM WORKERS'
PAID
SEWER-gANITARY STORM EA XI�-T
COMPENSATION INSURANCE
CE
(EMs aaabn needatbe mcompleted I(tk ppermit bfa ons hundred m
doda
Date Reoei 111
WATER HEATER W/VENT/EIXZFR .
rNERGYFEE Y N —
�OOJOf16a')
erodtbbo
I¢nor tmnner
so as tobecor
mpiy.np pe..Ian
1 orlo n¢ employ any pe. N any manner so m to become subject to the
the
WaApplicant mpewtbn laws of GBfamla. Dare
WATER S=ki/TRFATIIx
PAID
NOTICE
NOTICE co m, sob CAM:1L Sher making lith, C tion pr a int Exemption, you
shouldbecome to the Workers' Compematbnpnvdsbpeofthe "her
Date Remi N
NEW RESIDENTIAL PLMB. SQ T
TOTAL:
forth
Code, you moot forthwith comply with such provbbm orNb pemd.hall h
deemed rewkad. -
a1JILDING
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaferm that there ba construction leedingagency forthe Perform-
.naoftheworkforwhichthiopermitbb Ml5K3097,CW.C)
rorAi_
ELECTRIC FEB
Lender'.Name
leneer'..Adae..
I adify the I have read thbappButbnaM.tate thethe above Information
bconea.l.grceto<ompty avfth.Bdtyard manly ordWn¢s.nd C.telawe
QTY. MECHANICAL PERMIT FEE
PLUMBING FEB
jMECHANICAL
FEE
PFRMITDSUANCE
FEES PAID:
relating to building mnstrualon, mrd hereby authortre mprmentativn of thl.
city to enter upon the aboveemminred property farlmpealan purpose.
(we) agree lo.ave, indemnify an If keep hemlm the City d Cupertino
ALTER OR ADD TO MECR
Date Recelptk
SUBTOTAL:
against liabllitles,judgment.,"It.d e.pe. .which mayln anyw.y..c
against.afd Chyin con.equenaof the granting thi.1 remit.
r�r��p� art l9v
AIR HANDLING UNIT (TO 10,000CFW
AIR HANDLING UNIT (OVER MODOCEM)
CONSTRUCTION TAX
E7cFAU5T FRxlD (w/DECD
CONSTRUCTION TAX PAID:
_f�2
Slgmtureof Applicant/C'aerteaet�r1 IF,,—cote
HAZARDOUS MATERIALS DISCLOSURE
H ATINGUMT(MIM"BTU)
Will the applicant or future building occupant Mare or handle haunches
material m md defiby the Cupertlw Munili
cipal Code, Chapter 9.1 Z d the
Date ReCel I
HEATING UNIT (OVER 100,000 BTU)
Heaeh.w Safety code fiMion 2553x(.)7
Yee No
Wdlthe applicant m wrc building occvpantuee equlpmaM odevicm
TOTAL:
VENTILATION FAN (SINGLE RFSID)
ISSUANC6'DAT@j ""L)
which emit hanrdoue air mntare rants m defined by the Bay Arca Air
BOILER -COMP OHPOR 100,000 BTU)
Quality Marugement Db act]
4haYn veQNo
read F tau.reamililaregiiremenbunderChapmr69Sof
rs.eeW.�
u�•1rv^f��1L
BOILER -COMP (OVER 100,000 BTU
the Callf¢nie He&M & Safety Code, Sections 75505, 25573 and LSAT. I
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the budding don not currently have"ant, that it bmy
reeponsmdity to notify the occupantef the requirements which most be met
prior to hsuance of a Certificate of Occupancy.
OwnerorauthaladagentDate
TOTAL:
OFFICE COPY