19991APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Fminet identification
Building Addma:
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PFR.WTNO.
1'9991
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINC [ELDTRRICALPLUMBINGMFLHANICAL
APPLICA HON SLJH.Mri IAL DAM
P
6
C.metor'. Name: Lk. N.
CATEGORY
CONTROL ♦
Arehhttt G mer.
Z
Q ELECTRIC PERMIT �
BUILDING PERMIT INFO
/' �G+'(�
Address (704 Q�--T JI t F/
PFRMITKbUANCE 11,00
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrmthat l am lkensed under pmvlelomof Chapter9
IngDlafthe Buelweand PmleWana Code, and
RaossialnLullforceand effect.
License ClassWe/F-[_riTl
Date Cordnctor
ARCHITECTS DECLARATION
I understand my plane shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
y.lRmn �tiFecrio meaemptframmeCmanMrsLbnd: Lewfmthe
owing14
f ntylwh. rqua aan70 WRualneaa[dr,ops e, sod h,ycityor
counrywhkh mequknapermittommMmuct, viten knprove, denv0shor.palr
anyetructu. prbrto its beuarcGal.omequlro NeappBcant for ouch pemdt to
file a Mitred statement that he as licensed puesuant to the pruvleloro of the
Contractor'. Lice. L w(Chapler9(commend.gwlth Section 7000)of Divi-
don3 of the Businem and Professions Code) orthat he h e.empl therefromand
the basic for the alleged exemption. Any violation of Section MIS by any
applicant fora permit subjects the applicant to a civil penalty a not moat than
By hundiedddiarn(f500.
N1, as owmr of the Property, or my employees v It wall. as thio sole
compnnsrion, wSl doth wrrk, and Ne slructurt isnot IHIended or offered for
sale ♦See 7014, Bush and Pmfenebns Code: The Contractors U.. Taw
don not apply to an owner of property who be llda or Imp. t hereon,and
who dressuch work himself orahro igh hlaawn employees, provided Nat such
improvemmnteamnotintendedorofferedfwule. It,howcvegthebuldingor
impmvementlawldwlthinomyearofcompldWn,theownerbullderw have
tlgjZu.den of proving that he did not baud or improve for purpose of gala.).
4 as ow,,., of the Property, .m excWdvely contracting with Ikmsed
contnctmrs to construct the project (Sec 7014, Busin® and Professions Cad,.
The Contractor's License Lew does not apply to an owner, of property who
Wads or Improves Naean, and who contr.m for such pkojnts with a
onalfactor(s) Ikxnsed pursuant to the Cort.cior's License Law.BACK
L j I am exempt under Sec B k P C for this reason
APPLIANC6RESDENf1AL
)OB Rp
`Tj +f—�r..D�ESC
PANELS
UPT02DOA PS
1-1 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
g L E D l
M P,�a1 T E
` //
rE-Qr /�
.
SIGNSELECIRICAL
9'ECLILCU(CUIT/MLSL
TFAIP.ME717ROR1'Oi,C♦NST.AM
_
' POWER DEVICES
S1VA1MiNG POIX.EECIRIC '
OUTI.EISSWTICF�rT FIXTURES
NEW RESIDENTIAL EI.ECTR SQx7.
STORIES
'
TYPECONSIRUCTION
O
TOTAL O
QTy. PLUMBING PERMIT FEE
OCG GROUT'
RM UI 715
PERMIT ISSUANCE
ALIElt-DRAIN& VENT- WATER (EA)
FT-OODZDNE
APN
' FEE SUMMARY
PIDWPROTECT. DEVICE
00TSIM FEES
DRAINS FLOOR, ROOF, AREA, COND.
FOCIl1RES PER TRAP
SANITARY Y_ N_
RECEB'T.
Owner Date
WOR "AN COMPENSATION DECLARATION
❑I hereby affirm have. that I haa .mHOmaconve
te of nt to self-iw m s, a
mni0ole of Wor"'Comperoatlon lnxuru or a certified copythe.of(Sec.
3SOO,Leb G)
PolCom 4
SCHOOLTAX Y_ N _
. RFLkE I .
GAS FA. SYSTEM -1 ING4017f1.EfB
PARK FEE Y N
RECEPT a
GAS FA. SYSTEM-0VER 4 (EA) _
y
BUILDING DIVISION FEES
CertNed copy rumlaned.
GentBed copy b filed with the city inspection division.
CERTIFICATE OF F](EMPIION EROM WORKERS
CAONINSURANCE(IhleeMbn need er- bac-npletd Bthe Imult
Mo orc hundred dollars
at I onnifess.)
♦cant thatln arypehe ormt In nce the work so as to which eemdtlabo theed,
I alae not employ any person In any winner n d to becvrmr subject to the
Workers Compensation lawn of Glffornla. Date
Applicant I
NOTICE TOAPPLICANT:APPLICA: IL rm
after king Ledm
o Certificate of Exemption, You
should become subj ct to the Workers' Compemadon provisions of the Labor
Code, you mwr forthwith comply with such provisions or this permit shill be
dern el revoked.
CONSTRUCTION LENDING AGENCY
Inerebyamrm tbat the. Is. mmmitruction lending.gela issued � my for thpenbom,
ante of the work for which this pert ise30YI, Cly. C.)
Lender: Naim
Lender'.Addreae
I rertlfythal l have mad thlaappliatbn ant sutethat the above informa lon
la conect.lag.e to comply wttb.0 cty.M.."retwnm.nd rate lows
relating to building eomtroalon, and hrcby authortze repreaentrWes of this
city to enter upon the above-mentbred property for Wpmat opurposes.
(We) agree to save, indemnify an d keep harmless Ne City of CW
agaWtlhbWtfes, jrdgments,cors.nd expenseewhkh meyln anywayamue
agaBut Bald City in consequen. of the granting of W e perms.
GRFAGF/A'DUSTW,wMTEIMEtCE'lOR
PLANCHECKFEE
PAID
EUtC Reoel ttt'
GRFASEIRAP -
gEWER-SAM'IARY SHAM EA 71%FT
WATERT TER W/VENT/ELIK17R
ENERGY FEE Y_ N
PAID
Date Recd til
'
WAIF]t SYSIII.1lIRFAlINL
NEW RESIDENTIAL PIMB. SQ.FT.
TOTAL
FEE
-BUILDING
SEI IC FEE
TOTAL:
ELECTRIC FEE
O O
QTY. MECHANICAL PERMIT FEE -MECHANICAL
PLUMBING FEE
FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
AUR FIANDLING UNIT IT010,"CFM)
Date Recei tq
Puped
SUBTOTAL:
AIR HANDLING UNTT(OVER I(),000CFM)
CONSMUCFION TAX
Signature of Appgont/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
WBI Ne applluntmfutu. building oavpant oto. or handle hazardous
material as deRrud by the Cupertino Mu Mdpal Code, Chapter 9.17, and the
hMalth end Safety Code Section 25531(a)7
❑ Yen No
W01 Iheapplkaor or to x building occupant use equlpnv,rt or da
whkb eMl haamdou. W contaminants asdeRmd by the Bay Area Air
Quality Management District?
Y. ❑❑ No
iE�lhaveread the hardousmaterialsrciluUcmenmunderChapter6.95of
v
the California Health k Safety Cade, Sections 75505, 75513 and 25534. I
undemtaM tht if the building does rent aumrntly lune. tenant that it Lamy
responsibility to orally the ocapant &the rryuUemeMs which mwr he met
prbrtobeuan.o(a Cent undo.
.��� �PJ y-as�o
EGLAI THOOD(W/DUcn
CONSTRUCTION TAX PAID:
11E1TING UNIT (TO 100,0DO BTf1) -
Datc RCtiei ted
HEATING fIMT (OVER 100," BTll)
TOTAL:
VENTILATION FAN (SINGLE RFc )
I$$UF�C, _DATE
M
APR 4 yUUca
'� IJsaU
-- Mr'In?rtIIM
� '
ISSUED BYN1L1co'--i�xLJrs.SI�I'
BORER -COMP OHP OR 100,0410 BTU)
BOILERCOMP(OVER 100,p0OBTU)
NEW RESIDEJTIALMEIN. SQ.F7
Owner or auth agent Dole
TOTAL:
OFFICE COPY