19995APPLICANT TO FILL IN INFORMATION WITHIN RED LINES= USE BALL POINT PEN ONLY
Building Proert Identification
PERMIT NO.
Building Address:
'z3 Soo �2�s� e, uu 5� Ss 6
199
ra ams: one.AFTLICK=
tr-(�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
SL)umii IAL UA IL
Contactors Name: Ix. Nc:
IN
BUILNGLI'
ELECTRICALUMBING-MECHANICAL
CATEGORY
CONTROL#
Aea/lsgireen k. Na
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO '
Add— e� l ST• S
PERMJUISSUANCE t
❑ F-1_ ❑
LKF.NSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed under provldons of Chapter 9(mmmm
Ing with Salon Nm g
00)of Divld3 ofthe Buresand ProfW
eonsCode, and
have Is In full form and effect.
APPLIANCES-RESIDENT/AL
O
B Rll'110N
�r�
PANELS
Cks Lin #
Date
Date - - k,or
101-1000 AMPS
ARCHITECPS DECLARATION
I understand my phnsshatl be used as public remrda
OVER1000AMPS
SU. Fr. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed professional
OWNER -BUILDER DECLARATION.
Inbya(Orm thetlamexemptfinessthe Comrasors License lawfor the
IN
ALE
SPECIALCE(CUIT/h115O
TEMPMEERORPOLEINSP.
following ntyaaon.(S apEion to Rusin®alt P, fpetbvCnde ,orrepor
musty which rtvryLicsa pemdt to mvtruct, alt,, Improve, demolleh,or nepalr
H G
R
anystmctum prim to is bgsrce,abo requbesthe appBcantfa ouch permkm
file a signed statement that he b Licensed pursuant to the provisions of the
POWER DEVICES
UTE
POOL ELECTRIC
Contractor's Lcense Law (Chapter9(mmenendng with Section 7000)of DM -SWIMMING
Bug me dProfesbm Cade)orthO hebexempttherefromand
U N
the bans for the alleged exemption. Any violation of Section 70315 by anyOLTILE.ISSWI.ICI
applicant fora perrtJt subjects the applicant to a civil pershy dna mom than
E;SFLCCURFS
'
NEW RESIDENTIAL ELECTR SQF .
five hundred dot" (SM.
❑I, as owner of the property, or my employees with wage as their sok
STOKES
TYPECDNSIRUCiION
mmpevatlon,"I do the vork.andthe structure isnot lotended or offered for
axle (Sec 70K SusOees and Pmfesbm cev
Code: The Contractor's LJe Law
does rut apply to an owner of property who builds or Improvs, thereon, and
who doosuch work himself ce through his own employer, provided that such
OCG GROUP
RIS. UNITS.
Improvemen s are wt iatended oroffered for eak, I( however, thebullding or
impmvemedbsotdwlthnomyearofcompleti n theavner-buBderwllllove
TOTAL
t nofpmAngtat dldw ddorlmpmvefmpurpoaeofrak.).
exclusively
as owner of the property, am excaively contracting with licensedPERMIT
mn
ntranoto comlmci the project (Sec 70K Bushes b
and PrVfessnsCode:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
ApN
ISSUANCE
The Contnnor'a Liceme Law does not apply to an owner of property who
Wads or Improves themon, and who contracts for such P,jects with a
9➢1lacta(O Licensed puraumt to the Coruncta'. Lfrenslaw.
Lj I am exempt under Sec B & P C for thin reason
ALTER -DRAIN &VENT- WATER TA)
FEE SUMMARY
BAIX FIDWPItOTCCT. DEVICE
DRAINS FLOOR, ROOF, AREA, OOND.
SANITARY Y_ N_
RECEIPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION d nm
F-11 hereby aRlrm that I have • artl c Gamest to self-Iwm, IS i
certificateWorka'Comperton
llw.nnm macertlfled copy thereo(LSec.
polo, Tab CJ
polT
F7CTURFS. PER TRAP
5(71001, TAX .Y_ N
REY'EIPf j
GAS FA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
0
CAS-OVER4(EA)
Cam#
DING IV
BUILDING DIVISION FEES
CertNed copy b hereby filedw ibthec .
�y
CertlBed mpybfBcd with the citylnspectbn dlvlstm.
GREASE/WDUSRL WASTE INTERCEPTOR
PLANCHECK FEE '
GREA' TRAJs
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -MRM EA. pOI; T.
COMPENSATION INSURANCE
(fhb salon need not M compined Lithe permit b forom hundred dollars
DRte Rcecf t#
WATER ]iFATI]Z W/VENT/H,ECTR
ENERGYFEE Y N —
($100)crles0
I¢rtlfy Hutlntheperfomunaofthew forwMl Hdspemdtbbwned,
I ,half not employ any person In any mann, w as to become subject to the
Workers Compensation laws of Callfmnb. Date
WATERSYSITM/TREATING
PAID
Applicant
NOTICE TO APPLICANT:E, after mak( ng this ficad Certite Exemption,you
Date Rloei t#
NEW RESIDENTIAL PL.MB. SQ.FT.
TOTAL:
should become sub)eet to the Worken' Compereatbn provisions of the Labor
Code, you ower fort hwhh comply with such pr"kme or this permit shall be
deemed mocked.
13UILDING FEE
5EISMIC FE
CONSTRUCTION LENDING AGENCY
I hembyaffirmthet thea is a comtsuctlon lending agency for the perform-
ens of the work for which this permit b Wued (Sec. 3097, CW. C.)
TO'rAl:
ELECTRIC FEE
Q
PLUMBING FEE
Lender'• Name
Lender', Add mv
I certi"at I have mad thbappliestbnand state thrtthe above Infamutlon
b rormot. I agreetocomplywhh all city and muntyordmanmand gate laws
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
rdatlog to building rowmNon, and hemby authorlve mp em marines cf thls
'
city to enter upon the abovo-mentbmd property for lvpecilon purposes
(We) -&—to save, i denudfy an d keep harmless the CBy d Cu pertUio
ALTERORADDTOMECH.
Date Recel t#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
egalmt habWtk�,judgment+, costs and,.perm which mey In any vayamue
against said City In com qu eros of the gra mg of this Permit
AIR IIANDWN'G UNIT (OVER 10,000 CIM)
CONSTRUCTION TAX
Sgrstum of Applicant/Contractor Date
IXyIAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNFT(TO 100,0DO BTU)
Will the applicant« futum building occupant goer or handle haciodous
material as defined by the Cupertino Municipal Code, Chapter 9.11, and the
lkahh and Safetycme Semon 25531(a)r
�Yen No
Wthe applicant« tun bullding orcupntum equlpmerd ordevim
Date Recei t#
FWATNGUN17(OVER100,00)BTU)
TOTAL:
O a
VENTILATION FAN (SINGLE RESTD)
DATE
which erot hwrdous alamntamW nb as defined by the Bay Area Air
_ �la`►� j�
BOiLFR-COMP MIP OR 100,00D
Quality Management Distrkt7 -
4 Yes �a
have mad the Fav smstertile mqukerrcnb under Chapter of
APR 2 Tg r1
BOEER-COMP(OVfR 100,000 B,
the Gll(a& Safety Cods S 75505, and 25531. I
NEW RESIDENTIAL MECH. SQ-n./�}}
undusd that fifthe buBdNg does non carrmntly hayratenanL thetltbmy
mspombBBy to notify the oaupani d the requirements which must be mot
P or heuanacofa CerifkutcofOam ancy.
City Of rfl!l'rflR eT
ISSUED BY: %lF�
ser or aut horlud agent Date
TOTAL
OFFICE COPY