19989APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
eulldin Pruect Identification
Building Address:
PERMTNO.
OP.. UP
one
CITY OF CUPERTINO, BUILDING DIVISION
APPLICATION /PERMIT
Contratur',N.me: Lac. N.
BUILDINGnECIRKALPLLTMBINC-MECHAMCAL
'
CATEGORY -
CONTROL It
Agect/Fsgi=e r. _ LIr Ngg
H Z b
Q ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add— (poq K iSS top t F
PERMITISSUANCE 2!�
❑ El L1LICENSED
CONTRACTOR'S DECLARATION
Ihereby affirm that l amllceneed underprovlsoroof0tapter9(commrnc
IngMth5e n7000)o(Diviilm3ofthegunrea,and PmfeWorrC andmy
11cons, b lofforndeffect.
APPLIANCES -RESIDENTIAL
JOBDESCRIPTION
PANELS
Lsoo.Ca$e.4
Date Contactor
UP TO 2DOAWS
1-0-
'
201 -IMO AMPS
AKCHITECPS DECLARATION
I understand my plana.hall be used as public reaordK
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
SICNS AL
Lloenaed Prof®bnal
ALE D
SI'FS:IAL CIRCUIT/MLSC
—
OWNER -BUILDER DECLARATION
Ihereby affirm hat l am exempt from the Contractor's Lf rue law for tM
following reamn.(Section 70'315, Busin®,rd Professions Code: My city or
countywhk requU aper ttowro c liter,Improv,de U3kormpair
anystm=mpr toltebsaame,alwrequlnitheapptantfmr &permltto
file a signed statement that he h provisions, licensed pursuant to the provbthe
ContnconA license Law (Chapter 9(commencing with Section 7000) of Divi-
ebn3 of the Busneeand Pro(eebro Code) orthat he V exempt Ehercfrom,M
1F�. I
/ /�
_—COMPUTE
TEMP. ME= OR POLE INSf.
POWER DEVICES
gWQ.17vBNCIWLELECTRIC
VALUATION
the bash for the alleged exemption. Any violation of Section 7MI5 by any
applicant fora permitsubjrct&the.ppBc.t to, civil penalty d nu mon than
Ol1TLETSSN77CI IESF7XIl1RIS
NEW RF�ENTLV' E- R
(wrwmdred dollars ( 5M.
L e owner of the property, or my employees employe"It wages a, their wile
STORIES
TYPE CONSTRUCTION
- 30
nmpeHmwworn
,dothe wk, and thervtnV rot
uIntended or offered for
saw
le Orc. 70K Buslwa.M Pro(®loms Cade: The Contractors License Law
-
doe not apply to a owner of property who bullde or improve thereon, and
who does suchwork himself orthrough his own employee, provided that such
OCC.GROUP
KFS. UNITS
Impnwemerds arc not Intended oroffered forsale. If, however, the Wilding or
Improvement L,sold wthlnorcyearofe onpletbn,tk owner-bullderMB have
TOTAL o30
H,,k.rden or proving that he did ret build or Improve for putpne dole.).
1 1 I, as weds of the property, ,m exchulvely contracting with Iberued
mntractore to mvtrua the pm}ect(See 70K Buslnea,M Prd®Torr Code:
QTY, PLUMBING PERMIT .FEE
FLOOD ZONE
AI'N
PERMIT ISSUANCE
The Coniractori Lberue Law don net apply to an owner d property who
bullds or Improve thereon, and who metn.ts for such pi njects with
�gp(f�ccc,$)licensed pnnu,nt to the Contractors License Law.
exempt under Sec B 6 P C for N6 recon
ALTER -DRAIN 6 VENT - WATER �V
-
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND.
F]%7L1REi PER TRAP
SANITARY Y_ N_
RC{Qpf g
Owner Date
WORKMAN COMPENSATIONDECLARATION
❑I hereby .Hired that 1 have a ¢tlflate of consent to self -insure, o •
certificate, of WorkerY Compensation Inwnnce o. mitlf ed copy thereof (See.
3800, Lab C.)
SCHOOL TAX Y N_
RECEIPT
GAS FA.SYSTEM-1 INC4 OUTLETS
PARKF-EE Y_ N_
policy a
RFCmT
GAS EA. SYSTEM-0VER 4 (FA)
y
BUILDING DIVISION FEES
CenlfEled copy. Ls heed withMed
�CenlOed appy V flied with the city IropMbn division.
CREASE/EVDUSIRI WASTE IINFUCEaTOR
PLANCHECK FEE
GREASE TRAP -
CERTIFICATE OF EXEMPTION FROM WORKERS
PAID
g}ypR SAMTAI2Y SIORIM EA.N�T.
COMPENSATION INSURANCE
TThlasetionneednottocmnpleted Ifthepem Isfmorchundmddollars
Dale Rexmi t#
WATERHEATERW/VENT'/ELEC R
ENERGYF'EE Y N
PAID
($100)or1erJ
Imouy had In orpioyhe perfo I.anfthewchkfor toohtMae, subps Issued,
I sora net empty any person In any manner at u to become subject Eo the
Worcant mpen.uEbn law, of Gldornh. Date
WATER SYSFIM/TREATING
Applicant
NOUCE APPLICANT: after mNng thio ttNate of Exemption, yw
should becoco me aubfect b thea Waaken' Compemenetbn pwxMloro of the Labor
Date Recti t#
NEW RES[DFNrI7AL PLk4B. ��..
TOTAL
st fmlhwRh mmpiy withwch provbbro orthfa permit ebill be
deemed
deemed rewked.
13UILDING FEE
SEISMIC FEE
CONSTRUCTION LDWING AGENCY
I hereby affirm Exit there L„ mnnrotlon kruling.geoay for the perf.mnF
,nceofthework for which this permit h lassoed (See 309'7,CIv.CJ
, TOTAL
ELECTRIC FEE D
PLUMBING FEE
Lender. Name
Lander.Add.
I matlfythatl have mad thbappllatbn erd a stethalthe.bove Inforr ration
bmrrect.I.grcero comply with alldty.M muntyordWnm and sate laws
QTY. MECHANICAL PERMIT' FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID
relating to building construction, and herebyne
authonare repsentetivof this
city to enterupon the above-mentioned property for Inspection purposes.
(We),gme to save, lMem fy.dkeeph.rml.theCfty.fC.pEnt
ALTERORADDTOMECK
Date Receipt#
SUBTOTAL-
agabuE WbWtks,judgments, mss.M ap<n,m which maylowy w-ayamue
agaWEWdCByi mnwquerc ofthegraNingdthls permit.
AIR BANDUNG UNIT( TO 10,00007M)
AIR I-IANIXING IR.Tf (OVER t0,00pCF111
CONSTRUCTION TAX
Signature of Apph.rt/Contncto Date
EXHAUST HOOD(W/DLCO
CONSTRUCTION TAX PAID:
HAZARDOUS MAI-ERULS DISCLOSURE
HEATH G UNIT DO IM,000 BTU)
Will the applicant orfuture building occupant nom or handle hacardous
rnaterbl a, defined by the Cupetioe Municipal Codc, Chapter 9.12, and the
Dale RLtief t#
HEATING UNIT (OVER IM,000 BTU)
TOTAL: Qtw
Ile.Rhand Safety Cade Section 75532(,)7
F❑� Ye No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
�QE
Will the applicant or sun building omnpant use equipment or devices
which emit lrrardous ab centambr N, as de0ned by the Bay Area Air
Quality Managerre.1IXndct7
Ye" ❑ No
BORFIF COMP OHPOR 100,000 BTU)
BOILER-COMP(OV M 100,000 BTU)
have mad the hovNousnwerlils requirements under Chapter 6.95 of
Ehc Califomia Heahh k Safety Cod, Sections 75505, 25513 and 25534. I
AP � � ����
NEW RESIDENTIAL ME01 SQFT.
and ern. cad that if the building dues not currently have a tenant, that It b my
responsibility to notify the o W d of the requirement, which mast be met
prior obsuanm da CeNOaleofOavpaney.
�l�t� l �'s—qo
Cit, � �le '
City C4
Owner er,uthmlred age Date
partrriyc►
ISSIIEDBY: Vu� rlclJ le/I.��GI'
TOTAL:
OFFICE COPY