20008APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY /
Building Project Identification N'
Build^leg Addreu: e an a d o
PFRh11T NO.
O
`�'T� f�
O O O
sent 6_ me.
CITY OF CUPERTINO-BUILDINGDIVISIONQq
APPLICATION If PERMIT
BUR DIEL
NGECTRICA MP BINGMBCHAt.'I CAL
'2g �'v '
e d«. a �'I�ClQtiS / HC 3 LL.Na
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CATFLORY
CONCROL N
Amhkect/Englreer. I/y�.
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
1 �— 73� VNo:
�•
Address 0 C I-nS S
PERAI7T ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 (mrrmten
ingwlthSec1bn7000)ofDw1,1.3 oftheBuWwaand ProfeastonsCode, and
11¢nx Is In full and effect. . [ 'y
APPLIANCES -RESIDENTIAL
BDIX:RRTION
`
Tf�T -
PANELS
LlmrtcLk.I "/ L
Dale Contactor �^
Y„,w���ss
201'1000ANIPS
ARCHITECTS DECLARATION
I underabuml my plaro slug lx used! as Public temrda
•.
OVER IODO AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
SIGNS ELECTRICAL _
SPECIALCIRCUIT/MdC
Licensed Professional
OWNEReBUILDER DECLARATION
I hereby a(Orm that I n 7 exempt I.stye the d Profctori License LawAny for the
Pmlexbu Code: Mydtyvr
county, gmsaa�1J,req ices a peroUt to construct,
muntywhlch mryknapemat to mrmtruct, alter, improve, demolish, orrtpar
LED ' N
U T F Q
, a
TEMP. METER OR POLE INST.
anystm=mpdortotclmuame,aborequimtheappUotforauch,e to
file a algnM statement that he b Eaenaed pursuant to the provisions of the
BOWER DEVICES
%
SWAIMI(JG TOOL LECTRICWD ffE
Contractors Liceme Law (Chapter 9(mmmencing with Section 7000) of DM-
don 3 of the Bu sin. and Prdcespeu Code) or the he is esmpt therefrom and
/JR]s�
y
LUA
the bub for the alleged eserep ion, Any violation of Section 76)15 by any
append fora pemdt subject the applicant So • dull penaky d nal mo¢ Shun
OLl ILELSSWTTCEESFD7URES
NEW RESIDENTIAL ELEC[R 90FT.
FjI,uowner of the property, or my empbyee with wage as their mit
STORIES
TYPE CONSIRIK'1-ION
mmperuaion, will do the work, and the structure is ret Intended or offered for
sole bee 7061, Bua4a arta Pmfessbns Code,The Contndoh Lice. Law
'
,
don ret appy to an owner of property who builds or improves thereon,and
who don such work hlmselforthwgh Ms own emplryen, Provided that such
OCC. GROUT'
RFS UNITS
briprorcmew are, rot Ntended oroffered fwsale. If, hwwe mr, thebulHing a
Improveenof bmklwithin ldbM1thewfor
TOTAL:
ng that he thanotW old pur eou,ofsahave
lrLjL anafpro of thepoedu,a,eaorimy, conr¢pngwBhlwe.e.
LJ ; u owner tr the property, am es0K Boo,y contracting Pre wtth Mende
Code:
dot (See e0µ Bto
QTY, PLUMBING PERMIT FEE
PERMIT 'AU'11``CE
FLOOD ZONE
APN
The, Cetmetommirucl, Law apropert
The ContnGori Wmue Law dote h apply ct an owner d property who
an
bu0ds or Improve thertoR and who mnnm I¢ such w.o)em with a
anVor(a-Bnpt dEuratom to the Contnd«sLkerte Law.
LJ I am tempi under Sec - B k P C for this reason
ALTER DRAIN 6 VENT WATER TAI
.
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
DRAINS FTA DR ROOF, AREA, COND.
FIXNRFS PER TRAP
SANITARY Y_ N
RECEI T O
Owner Date
WORKMANCOMI' NSATIONDECLARATION
he eby afflim that 1 have • ¢di8nte d Consent to self-Iwrc, ora
¢rt cafe of Worke.'Canpewtl. Imuran¢ ora ¢rtl(led mpythermf(Sec.
3800, Lab J /
PdLLya S of/ l0 0O
1
$pi00L TAX Y_ N
RECFRTi
GASEA.SVBTEN-11NC10UTLEIS
PARKFER Y_ N_
RBCE!T0
Com ny
Certl0ed copy is fumLshed.
ertRled ropy Is filed'Mth the e ty inspection division.
GAS EA. -
BUI LDING DI VI SION F EES
GREASE/INIws1RL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXINIMON FROM WORKERS'
COMPENSATIONINSIIRANCE
(iNasction need nO beecomplpleted dthe permit b fa ore hundreddollars
PAID
Date Rcoel t#
SEWFR-SANTTARYSLORv( FA 2MFT -
(S10O)aka)
I¢nor that ch thioeemdtieissued,
_ WATER NEATER W/VENT/ELDCTR
ENERGYFEE Y N
employ anypeomun¢d<newek ac, as
I dell n¢ empty any.Lawn f any manners u to become subject to the
Worken'Compawdon Laws of Glifomla. Dae
WATER SYSTFAf/TRFA'lINO
PAID
-
ApplkaNOTICE
NOTICE co no,sub d to t H, after making thio Certificate Of iEacmptt s L bno o
Code, bemnr sforth it the Workm' Compewtbn provbiom of the Labor
Code, moat forthwith mmpy with such proalby orthb permLL shell be
Date ReceT t#
NEWRESIDESITLALPLMB. SCLFT.
TOTAL
BUILDING FEE'
di m
seemed revoked.
5EISMIC FE
CONSTRUCTION LENDING AGENCY
Iherebyaf0rm that then b a mrutroction lendleg agenry for the perform
ce of the work for which this pemtlt b breed bee 3097, CW. C.)
Lender's
TOTAL
ELECTRIC FEE
Name
Lenders Addreas
1 ¢rtify the have mad this application and state that the above informstlm
ismto, .l agrmtocomplywLLhaBtltyand muntyordwnaeand state lim
QTY. MECHANICAL PERMIT IBE
PLUMBING FEE
MECHANICAL FEE'
PERMIT ISSUANCE - 72sMW
FEES PAID:
relating to building mrutructlm, and hereby authorfv representatNn of this
city to enter upon the abovementpened property for Wb
pectn purpose.
(We) agree to cave demnly an P harmlem She City of Cupertiw
ALTERORADIOMEC
DH.
Date R20e1 t#
SUBTOTAL:
egalitttbiutln, g nt.,ma a eases whit y1nanywayacaue
egaliut ld n sryuen out ntingd frmk.
?
AIR HANDLING UNIT (TO 10,000 CFAs)
AIR HANDLING UNIT( OVER 10,11f10 CFM)
CONSTRUCTION TAX .
dor Date
Sigvturto App Date
FXFIAl15T HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZA
HAZARDOUS MATERIALS DISCLOSURE
HEATING [IMTCIO 100,000 BTU)
Will the apreiby teu¢WndingoM Mdpltstortor hhandlenuadthe
l lrreaterial ate defined odther5i. 2 5 Mu Ntlpal Coda Chapter 9.1 2, and the
l wan and SafetyCod Ion 2S532(a)7
Y.
Date Recelt#
HEATING IJMP'(OVFR 100,01.6711)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE •
Pglp
WIIl the appB¢ri-Iounant. oavpamus rye Bay A adevi¢s
which eMt hevoner" a mntaMunts as deRred by the Bay Arca Air
Quality Maragemerd
BOrlXR-COMP OIH' OR ]MOM BTU)
4Y.
have ma I"' moterfab mpulrcmenb under Chapter 495 of
the Califomh HeM fey Code, Sections E505, 25533 and 25531.]
'I(]()�
JUL � �
BORER-QOMP(OVIR 100,000 BM
s
NEW RESIDENTIAL MECCIL - SQF7.
unAmtandthatifth ildingd rrently hav atenantthatlthmy
isa77.9
resportibilkyto the orcu d e require swhic, oust be met
prior to luu CertiR wof Par -y
v
"^Tfinn µ0j
7SS11RD BY:]za f;Lta� i
authabed agent Doc
TOTAL: q6.
OFFICE COPY