19993APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY,
Building Pm eel identification
Bulk ing Address:
350o cC2 iS12� p� e 2iTs �1 t 1 t S 1 t PF
PERMT NO.
9 9 9
1APPLICATION
CITY OF CUPERTINO, BUILDING DIVISION
APPLICATION / PERMIT
SUBMITTAL I
p_
IS ,Z Q3 -9q
Contractor's Name: Lk. N.
. BUILDINGELECTRICA1.17LUMBINGMECHANICAL
- -
CATEGORY
CONTROL
Architect/Engineer. Lk. a:
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
1 G'S3
Addreu �� b S
rIMMITISSUANCE a00
❑ El ❑
LICENSED CO.NTRACTOR'S DECLARATION
I herebyaffinnthat lamlkeneedunderpro Wb &Chapter9(omvml
Ingwlth Setbn7000)of DfArm3oftheBwlrcuand PnsfesdauCndeand
Been Is Infullfarceandeffeet.
APPLIANCES RESIDENIAL
JOB DESCRIPTION
.+C71 iii F— l
(����C,
PANELS
Dansc Cbm Lk.I
Dale
UP
y
/--1`
1-1 AMPS
ARCHITECTS DECLARATION -
I understand my pbm shall be used as public reovde
.OVERI000AMPS
SQ. FT. FLOOR AREA S/SQ. FT.
SIGNSELBCTRICAL
Llcenxd Pe f.tonal
• SPECIALCIRCUIT/M19C
OWNER -BUILDER DECLARATION
Ihergrason.keitemeu5,BusLessampt CorradoonsCnseLwfmthe
follmyl hit n,cf.iectlan 7mt5, Buslne�and l'mfewbon Code. Mytltyor
ntywh'eh requim a permit tommlmt, eller, Improve, demolish, arrtpalr
A L E D. 1
MP TE dC
TEMP METFRORPOLE INST.
any stmetum prierto its ivueee, also nNuinestheappliant fmsuch permit to
file a signed statement that he b licensemmed Pursuant to the provbbm of the
Contractor's Lc,.Law (Chapler9(mndng with Section 9000) of Divi-
sbn3ofthe%u mandProfem mCode)orthathebeumpttherefmmand
POWER DEVICES
Ze.a '
�(L
R�
SWIMMING POOL ELECTRIC - R/�
the basisfor the allegedesemptbn. Any v1cIsdon of Setbn 70JIS by any
.Ppllont fora permit subjects the applicant to a dull pemhy of sot =m than
OUTLETS -SWITCHES
rSQ,FC.
five hundred dollars ($500).
I, u owner of the property, or my employees with wages as their sob
NEW RESIDENTIAL FI tr7R
STORIES
TYPE CONSTRUCTION
ovnpenution, will do the work and the stmdure bmt bonded or uHeed for
vie (SK 700 BusbK•m and lin fewbns Code: The Cowradofs Value Law
dm not apply to an owner of Property who builds or improves thereon and
who does such work himself or through wows employees, provided that wdl
lmpmvemeMsart rot attended caro/tared fa ue. 1(hcwever,thebulldtngor
'
TOTAL O7
OCC. GROUP
RES UNITS
Improvement bsdd wfthlnorcyearofcampletloM tMaw<rbullderwW lave
'
tFVLIuraenofprovingthathcdld notbuudorlmprovefapurposeofule.).
LJ 4 as owner of the Property, am a Ius sly contracting with licensed
contractors to mrons
tct the pmjed(Sm 7(164, Businessand Profembns Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Comedo/. License Law does not apply to an owner of property who
builds or Improve thereon, and who mrrada for such PToje s wW a
ryalTacbr(s) Banned pursuant to the Contractor's License Law.
I_J 1 am eumpt ural r Sec B & P C for this reason
'
ALiFR-DRAIN& VENT - WATER (EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR AREA, ROOF, ARGOND.
SANITARY Y N
RECEIPT If
Owner Date
WOR KMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a erne fkate of ons of to a B -bore, or.
artiBote of Workenaa
'Cnperoamon Insurance a artlfied copy thereof (Sec.
MM, Lab CI -
FI)MIRESPER TRAP
SCHOOLTAX Y N_
RFLER'f
GAS E.A. SYSTEM -1 INC40[IDEIS -
PARK FEF , Y _ N
RECEIPT
PFIIFy
Com
a
ray
cos Fn. sysrFMovER 4 (FA)
BUILDING DI VISION FF. FS
I— certmed copy b hedwithreby tlh ha.
CetNed copy b fled with the dty Ivpc tion dhMlm.
GREASE/WDUSTRL WASTE NTIMCIPOR
PLANCHECK FEE
GRZ 'SE TRAP
CERTIHCATE OF B(FMIT[ON FROM WORKERS'
PAID
STORh1 EA. 2L()FT
COMPENSATION INSURANCEgglyFlygANITAgY
RNs xVm
lon need not be copleted B the permit b n
for onehundred dollars
Datta Recd (#
WATER HFATER W/VENT/E.ECTR
ENERGYFEE Y N —
61ID)alom.l
00)or1 ) In the pedorrtuna of the work farwNchtw Permitbb.,ed,
1 shall nM employ any person In any manner so as to become subject to the
Waken' Compensation Laws of OBfanb. Date
WATER SYSTEM/TREATING
PAID
Applicant
NEW RESIDENTIAL PLMB. SQFI'.
Date Re I t#
NOTICE TO APPLICANT. IL after making this Cerdfiate of Exemption, you
should become subject to the Workeri Compe.1cn provblom of the Floor
-
TOTAL
Code, youmost forthwith comply with such provbiom or this permit dull be
BUILDING FEE
deencd revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them Is. construction kndmgagemy for the perform
anon of the work for which this permit b hued (SK 3097, CW. C)
lender. N.me
Lencier'.Add.
I oetlfythrt I nava read thb.ppBatbn.rd natethat theabwe InfortuHan
bcortect. Iagrt wcouplywfthaUdtyandmuntyordb,ana.andkeehws
ELECTRIC FEE
QTY. MECHANICAL PERMIT - FEE
PLUMBING FEE
MECHANICAL FEE
PERMrtISUANCE -
FEES PAID
relating to building construction, ant hereby authafre representativesof this
efytoenteruponthc aboscmeMbrcd propertyfa bmpedbnparposea.
(We) agme to save, bdemrdly an d kap hsrmies the City of Cupertino
ALTERORADDTOME
Date Recci t#
AIR HANDLING UNIT (TO 10,000 CFAs)
SUBTOTAL:
against Ubilitkg)udgmeMs,cnksand eapenrs whkh ray in any way asvue
age W[ old City lo oanaequerce of the granting ot tw pemdt.
AIR HANDLING uNTr (OVER IB,oaocEAD
CONSTRUCTION TAX
Sigruture of ApplIant/Contractor Date
EXHAUST HOOD(W/DUC)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (70 I00,000 BTU)
-Date
RCCeI t#
Will the applicant orforum Wilding omupant store or handle hazardous
ma
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health aannd Safety CodeSSe cion 2S532(.)?11UW
es
Will the appllaM afv= bu0dingoc upant use equipment ordevlm
TG UNIT (OVER 100,0W BTU)
TOTAL:
VENTILATION FAN, (SINGLE RESID)
ISSUANCE DATE
whkh emit lurardous armnlanNUMea defteed by the Bay Area Mr
Quality ManageOILER-COMP
ment Dbtrke2
Ye, ❑j� No
p/��^
PAID
_
OHPOR I W," BTU)
BIW,"
BoaxACOMP(OVER IW,000BTU)
Thar ad the hazarneusmterlabregbemnbunderChapter 6.95of
the Caldomb Health&Safety Code, Sections 25505, M03 and 25536. 1
APR
NLWRESIDFNTIALMECH. SQ.FT
understand that lflhebulldingdoesem mrerntlyhaveatenant,tlat it bury
respombB4y to notify the accupard ofthe requlremems whkh mut be met
prior omueruoda CeNBateof PancY.
'e'd)
�,,,a�
City Tlf PIIPp,TfI1M
EE
-TOTAL
Ownerm aulhorlud age - Date
ISSUED BY:
OFFICE COPY