19987APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Projed Idemlf don
PLMT NO.
Building rms:O pv. uru L,- B
- 1.998
con.
FQ UQ
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
QQ
—•O
centrad«.Name: Lk. N.
BUILDINCE] DE MCALML BIN'GMECHANI AL
CATEGORY.
CONTROL '# .
A ect/Fs neer.
�—
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/ ^
Address S I —
PERMITISSUANCE �tcc
❑ CJ ❑ 1:1'
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm 700D)o DivilicensedoftheBunder pmv and Pru Shaper ode and me
fthe BusircaaandlhofaslauCode,and
l]ance fintill] forte and A(ed.
Iles th5edbn 700W of DeLicense
APPUANCFSRESIDPNf7AL
JOB DFSCRRrCI
-
PANELS
Classflect.
Date Coerador
UP TO 2DOANIPS1.
201-100() AMPS
ARCHITECTS DECLARATION
I understand my plaroalaB be used as public records
OVER 1000 AM1'B
AX. WIN
$/SQ.Ff.
SIGNS ELE
S>DC1AL CIRCL;Ii/MISS COMPUTER,
Licensed Professional
OWNER-BNLDER DECLARATION
I hereby asonn that I am exempt from the d Pmfesslo Lkceroe ]caw for the
cou'owing yWhicasm.(SeRbn7Qit to Bualnm and Pmteasbns Code: Mytltyir
ountywhkhreq wiup a t am reqt,alter,lmpmve,demolbh, or repair
any atruaWreprt.ment Lwaroe licensed pursuant to ont(aatme, of t e
floe a aigned aUtemeLa that he (Chapter 9 nerve pursuant to Se prodsbro d the
Contractor's LicenseLawawrofess9(commerMg a Is SeNnn70W)of and
don3dthe Businwand lidubn. Code) or and
��'//�,
��
�,(p,MEfFR OR POLE INST.
POWER DEVICES
SWB•SN.ING POOL ELECTRIC
VALUATION
Any violhrtheb Section
the basis for the alleged jeetathe. Any violation of SMIon nor m by any
7MI-5therefromby
fora permit subjemtheapplbant to a tlWlpenalty d nor rrore than
OC`r=SW[TCFNSFDKTURES
'
NEW RESIDFNIIALELECTR SQ.FI'.
fl, hundred
Ilve hundred dollenAOI.
�I,nowrcro/thehe Property, or my employees With wages; mtheir Bole
STORIES
TYPE CONSTRUCTION
comperoadon, wl]ldo the work, and the atrucrom latest intended or offered for
sale (Sec 70K Buslress and PmfeWore, Code: The Contractor's License Law
don not apply to an owner of property who builds or dmprovn thereon, and
whodoesauehworkhlmaelf erlhmugh his.nemployen, provided that such
OCC. GROUP
RFS. UN FS
briptovemenb are nest Intended oro/!<rtd for ills. ILhownw lhebulldinga
Improverrctdbaddwhhlnomyeardcompletb theowner-bullderwWlave
TOTAL
-
t rden ofprodngthx he did net build or improve for purpose ofaale.).
Lj T, as Avner of the property, am eshulwly contacting with liceroeal
ormaclon to construct the project (See 701/, Bu,lnrm and Professions Code:
QTY. PLUMBING PERMIT FEE
PFRMITISSUANCE
FLOOD ZONE
A PN
'
The Conmctoes license Law don nor apply to ao owner of property who
Wilda or lmipmvm thmon, and who contracts for such projects with a
cgat(+cter(N lbrnaed pursuant to the Cmtntl«s License law.
ae B k P C for this
LJ1 am emp order Sec this re
TER -DRAW 4 VENT- WATER (EA)
FEE SUMMARY
BAIX PLOW PROTECT. DEVICE
-
DRAINSFIOORROOF,AREA,CYDND.
Fp(nFRRS PER TRAP
SANITARY Y_ N_
RFOEEPT If
Owner Dale
WORgNAN COMPENSATION DECO
❑1 herebide.f car that I have
5CI XYL TAX Y_ N_
a cemiRtats of Consena.nift to apythe re, ora
38Wceri,alcofWorkem'Cempensa0m irourance as artlfled oapy lhereot(Sec.
CJ
RECE]I'1' Y
GAS F.A. SYSI'Ehl-1 INCA OUTLETS
PARK FEE Y N
Policy N
�,
GAS FA. SYSIT]H-OVER l (FA)
y
DING Of
BUILDING DI VISI ON FTi L9
Certified copy Is hercbytumWed.
❑ Certified copy b Bled With the dry Inspection dlvWaL
GREASE/INDIIS[RL WASTE INTERCEPTOR
PLANCHECKFEE
GRFASETRAP
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATIONWSUmit laf C
(Th la sedbn need not bc<ompided lithe permit morc hundred n
dolle
PAID -'
Date Reuel til
gh pR-SANITARYSIORM FA fiOFT
(rOD) wIesaJ
I¢n hat In the pemdllaweed,
WATER HEATER W/VENT/ELECIR
ENERGY FEE Y N
-
of employ pe.Iadthewark sorweobeco
In any canner n n to become subject to the
I steal] not employ any pea Laws
Workers Camperartbra lawsd California. Date
PAID
WATER SYSIYM/TREATING
ApplicanNOTICE
NOTICE ce APPLICANT: the
rruklnm ea Certificate o/ Exemption,Labor
emm a InOt et towit] the Worker' such p Compensation pmvhis es per it s Labbe
Code,shoulYou
Cede, d re nvkR bthwW comply with such ptvvisloro orlhla permit shell be
deemed mroketl.
Date Recei t#
NEW RESIDFNRAL PLMB. SQF.
TOTAL:
BUILDING FEE
EISMIC
CONSTRt1CTION LENDING AGENCY
Iberebya/Brm thatthmaamnslmMmkndbgagem fortheperform
ce of the work for which that permit Is Issued sec 309'/, Clv. C.)
� ender'sName
' TOTAL
ELECTRIC FEE OL30
-
PLUMBING FEE
Lender. Addrms
I cedlylhat I lave mad thlsappliatbnard Ystethat theabove Infomalim
Is ginned. Iagree to empty withal] dlyand county ordinanraa and state laws
QTY. MECHANICAL PERMIT FEE
PERMIT LcSIJANCE
MECHANICAL FEE
FEES PAID:
orin apmonpurpoadthat
citytoeto uponnter to above- enandherebyrtyfor
pmpeharmlinspe Cit pu
dtyWeimttsaw,
(We)agree to
4M,entyan dkeepmwhiitthe Coy of Cupedlw
ALhR OR ADD TO MECH.
Date Receit#
SUBTOTAL•
judg
ag, Wtl]ablWies,ydgmew, metasnd espensn white may In anyweyacvu<
against sold City In mnseverem of the granting d this permit.
AIR HANDLING UNIT TIO 10,W0 CFhT)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
D(HAUSTHOOD(w/DU" -
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the appReant orfutune building occupant store or handle hazardous
meterlal m detircd by Ik Cupemim Mumtlpal Code, Chapter 9.17, and the
Date RCCeI IN
FWATNG UNrT (OVER 100,00(HTU)
TOTAL: ICIORIO
health andSafetyCade SeGlm 25531(.)7
I—I ye,M No
VENTILATION rAN(SINGLE REsw)
ISSUANCE DATE
TY III the applicant m future building occupant usecqulpmerd ordevlm
Which enth haardms air contaminants as defined by the Bay Arca Air
BOILER -CAMP DHP OR 100,010 BTU)
Quality Mawgemerut Dlatrhl7
Yes IF��No
have mad the havudous materials requirements under Chapter 6.95 of
IM Cslitomn Health&Safety Code, Sections 15505,75533 and 25531. 1 .
V
qP�j
BOILER-COMP(OVWt 100,000 BTC)
NEW RFSIDENT1ALMECH. SQFr
understand that lithe building don not mrmntly lave a tenant that It b ray
reaponsbIlRytonalify the oo rpard d the requlrcmemswhkh mast be met
proem LauanneofaCertifiateofOrcu
S
all
/
city
,
ISSUEDBY: �[Jh—r7�f\LDwv—SII
Owner or aulharlrad agent Date
,.
TOTAL:
OFFICE COPY
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