19990APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
B.Ildi.S Project ldentifbadon
Building Add.:'
PERMIT NO.
k 19 99
U G QpV�
CITY OF CUPERTINO-BUILDING DIVISION,
APPLICATION'/ PERMIT
OO
_[
Contract«.Name: Lk. No:
CATEGORY
COMAOL Y
y- ti.eUfLDINGdF]C'IRIGL.I'LUMBINGMCCFUMGL
A It / lU 3l 1�
QTY .ELECFRIC PERMIT' FEE
BUILDING PERMIT INFO .
Add— e5q- - � � 5,F
PERNIT74UANCE � oo
� E=I 1:1 ❑
X
LICENSED CONTRACTORS DECLARATION
I hereby .HlrmNtlam Wl ie duMerprovbbnsof Chapter9(mmmm
ingwIth5eetbn 7000)of Dlvlmon3ofthe Buelreaaandlhofea Coda and my
licerae Ita in full forand effect.
APPLIANCES-RMDEN11AL
JOB DESCRIPTION
PANELS
License Clan Lle'I
Date Contactor
-
Imo✓—A�-'a�k l
-1000
ARCHITECTS DECLARATION
I understand my plan shall be uzd u public remda
OVER1000AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
Licensed Prn(evbral
SIGNBEIECAI,
ALE D
OWNER-RNLDER DECLARATION
I a
I hereby affirm tlutlam memptfrumthe Comanoes Lkenmlrwforthe
A
,Y' T
TEMP.SPEDHALCIRCUIT/MISC
TEMP. METER ORPOLE INST.
following recon. (tlua
70115, Buairiu and Pnfeslom Cod<: My ctty or
cvrntywhkhmquWaper tomwmMOter,Impmv,demolbh,orrepair
enymmcture statementExc ryi pursuantto the (oreucraeof tto
/Be . dgned tatement that k b 8ansed pursuant to the proWbro of the
■
Q
I �a 91
IOWQI DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Uw (Chapter 9 (mmmnnctng with Section 70M of DM -
.b.3 of the Bu sin. and ProfesbmCode)car that he Is exempt therefrom. M
VALUATION
the balls for the alleged exemption. Any violation of Section 70115 by any
applicant for a permit subjema the appllrant to a tlWl penalty of not moa than
�J-�E.ISST1'TILIiFSFLYfI1RE5
NEW RFSIDQJTIAL ELA_7R SQ'FT.
five hundred dollars MM.
❑ I, a owrar of the property, or my employers with wagon v the wle
SIORIGS
TYPE CONSTRUCTION
mmpensatlon,will do the work and the stmctum is wt Wended or offered for
vie Lee 7014, Buslros and Proferbro Code: The Contactor. U.. Law
TOTAL (?CL -A'6
does not apply to an owner of property who Wilde or Improves thereon,and
whodosuch woM
m rkmseBorthrough Ms own .mpl yeas providedthatsuch
bnprovememsare retWemoclorofferect fonsale. If,however,the Wildinga
OCC.GROUP
RFS UNTIS
-
me
Impnverd is sold witMln oneyear ofcompletbrA the owner -0W MerwW have
t reienofprovingthat hedld rot WBd orunprove forpurpmaefule.).
ed
Li L u owner of the property, am exclusively contracting wlkeneed
mntnctms to mrotsuct the project (Sm 70K BusinesaM Profesbm Code:'
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
The Contactors Warne Uw dm ma apply to an owner d property who
WBdv s or Improthereon and who contracts for such pA" with a
cqritpecmrW Barged pur.uant to the Contactor. License Law.
LJ I am exempt under Sec. B 4 P C for this renin
ALTER-DRAINA VFM-WATER ffN
FEE SUMMARY
BAOC FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINSFT.00K ROOF, ARFA, COND.
SANITARY Y_ N_
RECEIPT I
Owner Dal.
WORIONANCOMPFNSATIONDECLARATION
MIhere affirm that I have • aerti0ate of caamt to ulf-tmun, or
certificate of Workea'ComperuaHmlwrana as certifled ropy therref(S..
3f100, Iib G
Policy- I
FD(77/RFS PER TRAP
SCIBOOL TAX Y_ N_
RECEIPT I
GAS EA. SYSTEM -1 WCIOUTI.EIS
PARK FEE Y N
RECEIPT I
GAS EA. SYSTEM -ova I (FTA)
Ca ray
BUILDING DIVISION FEES
ECemlfled copy is MunLhed.
E]Certl/1ed ropy V filmherefiled witth the city inspection division.
GREASE/ iNDUSIW, WASTE INTERCEPTOR
PLANCFIECK FEE
GREASE TRAP
CERTIFlGTE OF O(e MON FROM WOR K ERS'
PAID
SEWFRSANTTARY-SfOE(M EA. 2](R-1'. -
COMPENSATION INSURANCE
(TMsaectbn need neat ecompleted Bthe permit lafmomhundred dollar
DRIC RCCCI IN
WATER HEATER w/vlxr/EucrR
ENERGY FEE Y N_
( Meeles.)
I artBy that In the perfornwanf the work forwhlch thl. pemdt V Ia.Wed,
WATFRSYS MA/TRFATINC
I shall not employ any person lo any manner ro as to become subject to the
Workero Caenperaation laws of C.Womla. Date
PAID
-
Applicant
Date Recel t#
NEW RISIDEMIAI, PLMB. SOFT.
NOTICE TO APPUCAMmaking
: If, after this CMifi ate of Exemption you
should become subject to the Workers Compensation provisions of the Labor
TOTAL:
Cod, you most furthwhh comply with such provisions or this permit shall be
BUILDING FEE
deemed revoked.
SE15MIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending.gency for the perform
onhi
once of the work for which thio h permit Laxom Lac 3097, Cie. C.)
Irnders Name
I1nder. Add.
Iartfl!J at I have read thisapp0atbn and rtatethatthe above Infomxtlon
N correct. I agree to comply with all cityaM county ordb.nm and rote lawn
TOTAL -
EI -EL FRIG FEE
o
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
-
PERMIT ISSUANCE
FEES PAID:
relating to building construction and hereby authorize repreeentatWa of this
city to enter upon the above-mentioned property fee WpMbn purposes
(We) agree to save, imemrdfy an d keep harmles the City of Cupertino
,,.Wt BabWtim,judgments, costsand exper. wMch may lnanywayacvue
.g.Wu said City I. mnuqe, uenof the granting of W. permit.
ALTER OR ADD TO MICH. '
Date Receipt#
AIR HANDLING UNIT CIO 10,OW CFM)
SUBTOTAL
AIR HANDLING UNIT(OVER I(LODO CFM)
CONSTRUCTION TAX
Sigvtum of Applicant/Contractor Dote
t7(HAUSf IIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
HEATING UNIT CTO IW,000 BTU)
Date Reaei t#
Will the app0ard or future building occupant more or laMk havrdoua
material as defirad by the Cupertino MtWdpal Code, Chapter 9.1 Z and the
Fleaith and Safety Cade Section 25537(a)?
Yo No
qilitheeppllarda tore WBdingaccupvuueeequipmmwdevlas
HEATING UMT(OVER 100,00) BFU)
TOTAL:
G
Z�13�
VENTILATION FAN LWGLE RFSID)
ISSUANJ.%at {�
which emit baardous.ir conambams as de0ned by the Bay Arca Air
V�J�
BOILFR.COMP OHP OR IMM BTU)
Quality MarugemeM Detrkt7
❑Yes Na
API?
IIOILE100,"MP(OVIR 100,BTU)
. Ihave mad the havr�.1m.tert.Ls requirements under Chapter 6.95 of
_ �
5 oat
98U
the CAhbma Hc&h k Safety Code, SMbro 75.50$, 25533 and 75534. I
NEW RESIDENTIAL MECT I. SQpT
understand that lfthe building does not currently have a tenant, that It is my
rexporesmRlty to ratify the occupant of the requirements which must be men
P olar l8uaroc ofacertificatcofoav
as 90
M
ISSUED TOF
neer or authorized age Date
7O'fAL
BY:
OFFICE COPY