19981APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
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19981
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRRALPLIIMBINGMECHANICAL
Contractors N.ore: I.U"N«
9(7-n
CATEGORY
CONIROLa
Aruhhea/Fsglnnr. LIe N.
_
^ 1�
QTY ELECTRIC PERMIT - FEE
BUILDING PERMIT INFO
Addrw: q S S d U _
PERMIT ISSUANCE
TrnL
1:1 F-1 D
LICF.NSEDCONTRACTOR'S DECLARATION
[hereby affirm thatlsm llcerued �rderprovlalonsa(Clupter9 (mmmmc
IngwlthS YIon700D)afDM9m3afthe BuNne»and PmfeatlmaCede, and
APPIIANCESRESIDENIAL
JOB DESCRIIrHON
II¢rmisle fu6rce
to. disci. -
lies. Ch: Lac. Y '
PANE75
P¢,vsa ylal c(3.re tic
Date Cortracior
UP TO 2DO ANUS
—
1-1000 AMPS
ARCNITEC'S DECLARATION
I understand ery plans shall be used as public records.
OVERIODOAMPS
SQ. FT. FLOOR AREA
$/SQ. FI.
SIGNS EIECTNCAL
Licensed Profmlorul
OWNER -BUILDER DECLARATION
IherebyafBrmth.tl.mnemptframthe ContmMrb Ll¢n Ue forthe
folbwbig... (Se[1im 70315, Budom asst professions Cade: Any city or
cowry which requbea perndt to construct. alter, Impmwe, demolbh, or replr
7
( Q 1
SPECIAL CBiCU1T/MLSC
TEMP.METFRORPOEINSf.
any strumare prier to Its lwan:e, also rcquim the applicant for such per -mut to
file a signed datement that he b licensed pursuant to the pro t tom of the
Canirx[ors License law (Chapter9 (mmmencing "Is SeNon 7000) of CIA.
s,on3ofthe Bualnm.rM Prdmloru Code) or that he b exempt thertfrom and
the ban for the alleged e.erep0on. Any violation of Section 7m1S by any
apphtforapemsub)n theappMk ttoadAlpe hydnommtMn
ROWER DEVICES
SWIMMING -
POOL ELECTRIC
OUTLEISSW7TCFIfSFTXTIIRES
VA/LUATIObasis�O r QO
O ` 7
�L
NEW RESIDFMIAL ELDZTR gQpT.
f to -1 n owner of property,0.
Lf ], u owrcr of the or my ernpbyen with wages ae their
STORIES
TYPECVNSIRUCDON
mmp'..70 ,wllldothew
worba cotImerdee oroffered for
fo
sib Qac. 706 Buslruv and Prafmbns Code: The Comnrmrs IJ¢rue Law
Profesthes Cede: h
don not apply to an owner of property who builds or improve theme, and
whodoessuchwork himself orthrough his. employee, provided that such
OCGGRO(Jp
RFS UNITS
improvemerds are not intended oroffered for nab. If, however, thebulldNg or
improvement haald within oneyearo(coerpletbn, the onwer-builelerwW have
TOTAL
IthTa�buben of pravl ng that he did not build or Improve f¢ purpose of sale.).
tt. owner of the property, am eubralvely mntracdng with Licensed
c reactors to mnstmet the project (See, 7DK Bustrum and Professions Code:
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The C."c ors License law does not apply to .n owner of property who
Wild. or Improve thereon, and who comnats for such pia" with a
�q 1orW Bmnsed pursuant to the Contractor's License Law.BAIX
U I ins evempt under Sec B & P C for thh reawn
ALTFR-DRAINTEA)
FIDW
FEE SUMMARY
DRAINS R
FD(TURFS PFR TRAP
AI2Y Y_N_
RBCIII'1'Y .
TAX Y_ N_
RECEIPT Y
q �� ��
Owner
WORKMANCOM ENSATIOt`ali RRATION
❑I hereby a(fl. that I ha e a ¢Mflca f consent to se -esu e, a a
certiBme of Workm'Compevatlm lraunnceora certl(IM copy <hrrtof (Sec
380Q C.)
CAS, EA.
ai
PARK Y N '
If
PedkYY
GAS FA. SYSTEM.OVER t (EA)
REIN
BUILDING DI VISION FE FS
y
Cenllled copybhereby (urNehM.
Cenlflod copy Is flied with the city InspectiondlvWon.
GREASE/INDUSIRL WASIE INTERCEPTOR
PLANCHECK FEE
.
GRE�TRAP
. CERTIFICATE OF EXFNPI'IO.N` MOM WORKERS'
COMpENSATI0NRJ5URANCE
ClNsaecilonneednail mmpinedlithe SURA Is(¢archundred dollar
PAID
Date Reeei tilt -
SEWER-SAM'fARYMRM Eh. 700FT
($Im)wles.)
1 certify that In the prde rmance e1the werk forwhich this permit is issued.
1.hall not employ any pennon In any manner no as to become subject to the
u
Worl,em'Corepention laws of Callfonla. Dine
WATER HEAroe w/vFxr/Fronk
ENERGY FEE Y N
PAID
wATFR SYS TWTREATTNG
ApplicanNOTICE
NOTICE ould co APPLICANT: M: a after making per CMat peo of Faempt the
ande,you me feath tot he Workers' Compruinbnprovhisp ofthe Lobe
Code, you corn fmhwlth comply with such provhlons or this perMt shall be
aeemea rewoked.
Date ROLei tk
NE:V RESIDENTIAL PLMB. SQ.FE
-
TOTAL
13VILDING EEE 7 Z2,msgI
ISMIC FE
cONSTRUn
cDN LENDING AGENCY
Ihercbyaffirenthattherse,mnstruction lending agency forthe perfomm
an¢ of the work for which thisa= Is Issued (Sec 3041, Civ. G)
- TOTAL
ELECT -RIG FEE
lardds Name
lcnaerb Addm,
I certify thatl have maul this appBratIonand inatethd theabe ve in(omWlon
Is mrren. I agree to complywtth au city and county, ordWnm and state laws
rotating to building construction, aM hereby autherbl repre,soutWn of thin
Qry.j MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
city on the
(We).9.nter to saw, Lodnmentiand property for Bmpection purposes.
(We) agm to mve, IMemNty and keep harmless the City d Cupertino
ALTERORADDTOMECH,
Date RCCCI tit
SUBTOTA
against llabWtlei, Fadgmems,cootsaod eapensetwhlch mayla anywayacvue,
.g.Wt said Cityl�n "sequence ofthe gent gofthh prink.
OraKn � 4
AIR HANDLING UNIT (170 10,000UW)
PIR HANDLING UMiIOVER 10,000 CFM)
CONSTRUCTION TAX
Slgnaturt of ApplHAZA D%-- to
FXHAI/Sf HOOD(W/DI1CD
CONSTRUCTION TAX
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (70100,000 BM
Will the applicant onfuture budding oavpnt store or handle havrdow
rnaterlal as defined by the CupertW Municipal Code, Chapter 9.17, and the
Da Reeel till (5�
HEATING UNIT (OVER 1W,OTD BTU)
TOTA
Health sodSafatyCode Section 2S537(.)7
n Y. r] Nw
VENTILATIONFAN(511 LERFSID)
ISSUANCE DATE-,
a.
'
.
0l the applicant or future building occupant use equipment or devim
hkhnMthaaNws.buntsnde0rkd by the Bay Arta Nr
larugaert District?
Idyhm
Iluvc mad the hamous materials requirt�nbunder Chapter G'Gd
BOILER -COMP OHP DR 100,000 BM
BOILER-COMP(OVER100,000 RR17 `
the California Health&Safety Code, SMions 25505, 533 and 75531. 1
understand that If the building dors rwt currently have. tenant, that it k my
rtsporuibBlty to notify the occupant tithe requirements which must be mat
p
1 /v,d 63
NEWRESIDFNTIALMECIL SQ.FT
prior to Leanne of a Certl(latc o/Oavpruy.
I hl Ter
'AV
ISSUED
Owner or authorlxd agent Date
TOTAL:
BY�
OFFICE COPY /