19983APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm ed Ideni fkatlon
Building Address:
PERMIT NO.
o STO r
1998h,
ren � v Fl me:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BFRLDING-ELECIRICALPLUMBINGNf CHAMCAL
v
coni' '° oe Q Nm
CATEGORY
CONTROL
ArchHect/F gimer. LNce
k.
QTY ELECTRIC PERMIT .. FEE
BUILDING PERMIT INFO
Add. p �T b
PERMITI$IIANCE
® ❑ El ElLICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comme,
Ingwets In ionfomandeffx m3ofthegudmeand PmlesalomCda, and
Hoene V In . form and effect
APPIIANCMPTSIDENITAL
)uu mI lTON
PANELS
DateLiceClan CoedLte.UP
Date Coed dor
To 200 AM
/ i l C
C OTR YN D1�..j
7n, ) AMN
ARCHITECTS DECLARATION
]undantaM my plain ekBkueed npubllc recoNa
r¢ c _cL
OVERT W0 AMP5
RARER 5/SQ. Fr.
SIGNSF-LFCIRICAL
Licensed Prof.[..]
E�
l`a
OWNER -BUILDER DECLARATION
I hereby alRrm that[ am exempt from the Cordranor'a Lkenae lAw for the
following mum. (Section 70315, Buakm and Pmfmions Code: My city or
muntywhk�hmqu apert towroh MAkr,Impr e,dem h,ormpalr
anyatmctumpr Wibhauane,ah reqs theapptmntf¢auchpemd[to
file . signed fakment that he te Limned puraant to the provlebm of the
Contrauor.Lice. Law (Chapter 9(comncnctng with Seaton 700D)of Divi-
elon3 ofthe BuMmaMPmfmbm Code)orthNhebemnVtherdmmand—'�WLTIATIONI
the bah for the alleged e.emptinn. Any violation of Section 70015 by any
appll¢nt fora permit subjects the appikaot to a civil peruHy d n¢ m mothan
S17'C �+
m
ai Ui
C��LS
}�/f
b'
OQ 7 (6, ? e 60
LCIRCNT/bFLSC
+MEIFR OAI'OI.E INST.
DEVICES 07
S-yrggpNGIWLELECfRIC
OUTLXTSSWIR:I�FLX TURES
g1STORIES
(Iv -e hundred ddkn (¢BP). _
L I, uti, of the property, or employee° wtth wages u there °ole
TPECONMUCTION
mmpematlmEl dock work and theestmcturt bnM bderded or offered for
sale t5ec 7(144, Buelrcm and Profesebrm Code: Tk Comrtaofa IJ¢rae Law
does not applyban owrcrdpmperty wla ddlde orlmprvves thereon,and
Hot hrough wowne. a,pmvded
or
1
OCCCROUP
RES UNTIS
improwauc amnonlm
If,ho he MIng
impioveeroru artwtintended year ofred!¢sale. If, however, Beer 111 have
Improvemem L+.dd with in omyearofcompletlon,tk owner-buHderwW have
Z
XI.len of proving these k did not build or Improve fm purpose of sale.).
act owner of the property, am eacwWely �tracting with Licensed
oro to cn b d me project (Sec 7044, Bualnm are Profmbm Code:
QT-y.FEE'
IT ISSUANCE
FLOOD IDNE
APN
The Contractor'. Licer� Law does no apply to act owner of property who
Wildajea with a
or lmprow mon thereon, and who comfee such PPC
rynlf�ctor(a)Ikeosed punuant to the Contracts. Lleenae law.
LJ I am exempt.mer Sec B k P for mum
ALTER -DRAIN 4 VEM-WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOP, ARCA, GOND.
F0(TURES- PER TRAP
SANITARY Y_ N
RFLFlPI'I
Owner �� Date
WORKMAN COh ENSA71 AT1ON
❑I hereby affirm that I hart • ¢rH/i¢ c rot to aeH-Imam, or a
mrt1B¢ted/Workm'Compewtlmlmumn¢oa¢reified copythertof (gee.
3g W, abG
SCIR)OL TAX Y N_
RI'CFR'1' /
SGAF 4
SYSEA 1AC.41OU[LETS
PARK FF£ Y N
Pdlry I
GAS PA. SYSI1M. OVER 4 (FA)
Corr
ny
DING DI
BUILDING DIVISION FEE5
I ICenlRed copy is hedwithreby the eftyed.
LP�JI CerlNed ropy b (fled with lk city Ivpe Tion division.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFlCATE OF EXEMPTION FROM WORKERS'
PAID
SEWERSANITARYSIORM Fit. �r
COMPENSATION INSURANCE
(rhls°e«ionneednotkcompleted Hthepermitbfo ao hundreddollen
Date RCoei IN
tslomeeles..)
1 ¢s0fy mat b me pertarmnm of the work forwNrh tw penNt V trued,
WATER HEATFRW/VENT/ELFCTR
ENERGY FEE Y N_
I shag no employ any pemon In any manner w u to kco wbjm to the
Were 'Compenaatbnla.cfC°Womla. Date
WATER SYSTEM/TREATING
PAID
A UCEt agermakinglm Celon preofonsofthe Lyon
shouldb become
Chau become sfcmh to Um Worker: Comprovixeprovlsiomrmit
Date Recel tH
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL
slabor
Code,nned r neat lomwM comply with ouch pnMsbm ormfe permit shall k
deemed revoked.
13UILDING FEE
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iberebyefirm that them k a conatmctton leMingageny teethe perforin,
.. of the work for which rob permit b imred ISec- 3097, Cle. C)
TOTAL:
ELECTRIC FEE
Lender'°Name
lender's Addrtu
1 certify that l have mad tw ap pll¢lbn and .tate thLL the above ln(ormatlm
b mrren. l agree to comply withal city and county ordinances and late laws
QTY. MECHANICAL PERMIT - ITE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building mMmalon, aid hereby Authomm reprerntativn of this
city to enter u pon the above-memenned property for impectbn purpo¢C.
(We) agree to save, i demdkeep ty an d heed. the City of Cu pertlno
ALTFRORADDTOMECH.
Dale RCeel [N
SUBTOTAL:
agaWt liablBks, Frdgmems,00u and expenses which may in any way...
g teaid City mmequ ence of the gran" of this pemdt
�°-� a -F— A�/�
le [SiggnaWne
AIR HANDLING UNIT CFO l0,OrX1 CFM)
AIRr NDUNG UNIT (OVER 10," CFM)
CONSTRUCTION TAX
off`Apphezot/ — [)at.
FJ(HAUSr Flood tW/DLrn
CONSTRUCTION -TAX PAID:
FIAZA R DOUS MAT ERU DISCLOSURE
HFATHNGUNIT(rOlW,0l0glln
Will the applkam or fotumbuildingomrpant.tom°, handle hazard m°
material as defined by the Cupertino MuNctpal Code, Chapter 9.17, and the
�,�Datc RCCci t!f
HEATING UNIT (OVER 100,000 BTU)
-TOTAL:
health and Safety Cade SxHm 25537(.)7
Rill
VENTILATION FAN (ING.E RESID)
—} ISSUANC,E� DATE
(d a"G P�I y a ��
k?Pi1D;
the applbmorfuWm bullcingmeupant use equipment ¢devices
which emit emmmWm
it hanrd. er nta°as defined by the Bay Area Air
Quality wm
rugeerd Detrlct7
4Yes �° 6.95 of
kveread the mod,Sere..
N
BOMERMP OHP OR 100,0(011M
BORER COMP (OVER 100,000 BTU
the CelHomk llealth 6 Safety Code, Sectbm 25505, 25.533 and 75534. 1
2550nb5533 and
NEWRMDI1 TALMCCH. SQFT
understand that if the building dm rot mmently have a tenant, that it b my
respomibility to notify the omvpard&the requUcmentawhkh nerst be met
a
APRV IJDV
prior to L»uan¢ d a Cert ficaw do.,.ey.
L.
I` F r) •PA
ISSU EDB
Owner or authonred agent Date
TOTAL
OFFICE COPY