19979APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pmect ldemlfkelvn
B,u1MIng Addieve
Z 3S00 G r tTO
PERMIT NO.
19979 V9n
ane:
CITY OF CUPERTINO-BUILDLNGDIVISION
APPLICATION / PERMIT
BUIIDINGd�'IRICALI'LIIMBINGME{HAMCAL
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cAmORY
CONTROLI
ArNrea/Eng/rce Llc No:
C
Qr, ELECTRICPERMIT. FEE
BUILDING PERMIT INFO
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Add. `Q N
}F�a
PERMIT ISSUANCE
LICENSED CONTRACTORS DECIARATION
I Fereby offinn Thal lam l4....M order prwftlons of Gaplcr9 (mmmaic
IngvmhSection7000)of Dlddon3 ofthe Budrcuand Professions Cod, and my
Ikenm binfull fome.nd le.
Cb. L1
Date mnice
Date Goctor
Ate,3IHECTsedaspARATION
[udesetand my puns WBbe used upubecremda
Li¢esed Profe®bvl
OWNER-RUILDER DECLARATION
I hereby a/Brm that I aai exempt from the Cordrelora Llarue IA W f¢ the
folbwing Hawn. (Se m 70315, Bwtln a" lhofeubv Cody. My dty or
mrntywhkhrtqulreeapem tommwd,aw4 Unpm de=lWh,orrepalr
any structure prier to Its buarc, also requbes thea ppB¢nt for such pomr to
flit a signed statement that he b leemed pursuant to the provisions of the
Centreco/eLkerm Law (Chapter9(.reing with SeWon 7000) of pW-
Nonaofthe Badnessand Prdcebv Cock)orthehebc mptthmfromand
the bash for the alleged exemption. Any violation of Section 7MIS by e,
sppBant for. pemm ubjectetheapplicant toatldl pevlty dna monthan
Bee hundred dollars (SE.
❑ 7, as owner of the property, or my i mpk ym with wages u lh<b sok
mmpen,70K wllldoss,and rofcssheshutlumbwt Wedel oroflend(w
vie (Ser- apply to a nm.rd Prdesbv Cade: The or Improves m s Eoeon,ue Taw
and
don teatapply torn owner orProughroperty whonernporvided that
who does such work MmeBerthmngh hbowne. If,
provided illi gor
improvements; am not Wended oro«erect (er nit. If, havcver, the building er
Wprovemem broil wNhinovyearofcompleb,thewvner-W Ilderwl0 haveER
IygJa,racoon of proving that he did rod wad or Wpro.x!¢ pose urpof sab.).
I, .s owner of the property, am euhWveiy, contracting with IteenseItd
t uis to nstruct the project (Sec. 70K Bu linead aPrdenlom Code:
The Contractor's Lkerue Law don no, apply to an owner of property who
Wild. or Improves Outten, a d who mmncts for such p�jem with a
c7allacto W Ileemsed punwnttothe Contnnds Ll¢ruelaw.
LJ I am exempt undo Sec B & P C for this renin
APPDANCFS-RESIDENTIAL
JOB DESCRiPCI N
� �
ravC~ GQVt�
PANELS
OVER 1000 AMPS
OVER0000AM
SQ.FT. FLOOR ARTA
5/sQ. FT.
.
SIGNS E.DCTRICAL
5[PECIALCIRCUIT/MLSC
TEMP. METER OR RICE INST.
POWER DEVICES
Sy�pyptgNG POOL ELECTRIC
OUTLETSS•WITOIIISHXTURFS
VALUATION
OQ
2 31 761 'f-3
NEW RESIDENTIAL E EC R SQ'FT'
STO
'
TYPE CONSTRUC71ON
T
QTY. PLUMBING aM5 V I!
lUP
RES UNITS _
ZONE
G/
7�
APN
PERh1H 156UANCE
ALTER -DRAIN& VENT -WART
FEE SUMMARY
BACK HAW PROTECT. DEVICE
OUTSI OF TEES
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N
RECFITT
Avner matt
WOR]C,1AN COMPENSOFTION DECLARATION
❑1 hereby affirm ¢u wm that I have . ¢rti«d consent to seR-insure, .
teo(Workeri Compew«onlvunn¢¢a¢rt«ied copytherro(6ec.
3800�bCJ
38 r
s
.
FIXTURESPER TRAP
SCI{OOL TAX Y_ N
RIGS. 0
GA. SYSTEM -1 G4 OUTLETS
S EAW,1
PARKFE: - Y N
RECG s
GAS FA. SYSTEM -OVER 4 (EA)
GoFCertlBed
BUILUINC Of DI VISION FF. FS
Miffedcopy, b hereby furnished.
Ctri111ed ropy b filed with the tlty Ivptt[bn division.
CERTIFICATE OF EXEIMON FROM WORKERS'
COMPENSATTONINSURANCE
CTlds ..) need Hatbcrm�pieted «the ptmdt bferorc hundred dollen
�401orIyth
1¢rtifythrt In perfomun¢oHhe work Wspermrbbaaad,
I shall nm employ any perwn in any runner n as to become ub*d to the
Wmkns'Compensatbnla.mCal«omb. Dee
Appb.t
NOTICETO APPLICANT: If, after mldngthb Certicateof Exemption,you
should be mm subkct to the Workers' Compewtlmi pmdebv of the Irbor
Code,youmustfmthwlthcomplywlthsuchprovbbvorthbperndlshallbe
revoked.
CONSTRUCTION LENDING AGENCY
Ihrt
ebyafBmthatthere bamvbuctiw)edm ingagerruuyy fmthepidor
an¢ olthe work for which thispermit b hued (sec 30YI,CW.G)
IeMer'a N.
Ieder's Addnm
1 ¢kifythe I Huvc rted ehbappliotbnad tlatethe the above inforrtutlm
e...iagree to comply with all dty and county, ordinances and state laws
relating to building mvtruction, and hereby authW nprnentatives ofthis
cry to enter upon the abovcmentbrud Property for Wpectlon purposes.
(We) agree to save, ind emmly an d keep harmlem the City of Cu pertbo
against Liabilities, Iudgments, mets a rd experues which may in any, way acvue
agaivtsaid CBylmmmseque�tbegrant gdthbpemdt.
/li%Uh ft,70
GREASE/INDUSIRI. WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recd t#
GREASE TRAP
SEWERSANTTARY-STORM FA. 711FT.
WATER HEATER W/VENT/E.FLTR
ENERGY FEE Y 'N
PAID
Date Recel t#
WATER SYSIEN/IRFATENG
NEW RESIDENTIAL. PLMB. SQFT.
TOTAL
B use so,deemed
173
-
SEISMICFEE 12V r $7
TOTAL
-I
EI-ECiRIG FEE
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Date Receipt#
ALTER OR ADD TO MECR
AIR HANDUNG UNIT CTO 10,000 CFM)
SUBTOTA • O
AIR HANDENGUNTr(OVER I0,W0CFM)
CONSTRUCIIONTAX
Sgrutumof AppBont/C 6"f Dat'
HAZARDOUS MAT . IALS DISCLOSURE
Will the applicant orfuturebuBdingomrpet store orhadle hazardous
mterbl as defined by the Cupertlro MunidNI Code, Chapter 9.12, and the
IOl ,a ndl Safety Cade Seim 2553701?
WWiheappllom¢gt mWfldbg¢cupanluuequlpmeN devim
which enut hanrdow er mnnmlrams as de«red by the Bay Area Ab
Quality Mavgemrn District?
YnNo
Tuve read the harms materials requirements under Chapter &95 of
the UI«omb Health & Safety Code, Seetbv 25505,25S33 and 25530. 1
udendaM that lithe building does neat eurnently have.tenanL that It Is my
respovibuty to omlfy the oavpam dthe requWmrdewhich mut be met
prlorto eausne, da Colifloteof Ooeupancy.
EXHAUST HOOD(W/DUCT)
CONSIRUCi1 AX PAI .
C Recel t#
HEATING UNIT CIO IW,(XO BTU)
HEATING UNIT (OVER 10Q000 BTU)
IOTA
VENTILATION FAN (SINGLE RFSID)
-T,D ISSUANCE DATE
��%
CPl�l4/ "/ ?.yw/
PI`1/!I
D
'
h�
ly R 3JV
ISSUEDB1!,
BOMZR-COMPHPOR100,0(0EU)
O
BOILER-COMP(OVER IOD,000 BN)
NEW RESIDENTIAL MECII. SQFr.
O.vnermaulhodredagent Dale
TOTAL
OFFICE COPY