20016APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY \
Bwld] Pr. tct Identifica0on
PERMIT NO.
Building Address
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�-�SOo URiSto REQ p2 �uitS 7 P c
G 0 O
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
qr
6 _2�e
/
Contra'e.Name: Lic.N.
BULUENGEDCTR1CALPLUMBINC-MTCHAMCAL
CATEGORY I
CONTROLI
Arch Rect/G '..1� �3II,1No:
/C
QTY ELECTRIC PERMIT,
BUILDING PERMIT INFO
Acid— &0 �� T SF
PERMITISUANCE
O � El 1-1
LICENSED CONTRACTOR'S DECLARATION
IherebyaHlrmthatlamlkeruedurdoprwWma of Chapmr9(commerh
IngwRhSMbn force effeon3oftheguelnesaand Pro(esalouCode,and my
Lienee la In fail for¢ and effect.
APPLIANCE-RFSIDEMTAL
JOB DFSCRITI ON
LF�-RgF- IuP�-�iX
PANELS
Claes Lie♦
C�
DateLim
Date Goo
[T
ARfECEC
CTd pTS DECLARATION
]uMerNaM rtry phu.lu0 be uxd republic nemds
OVER
OVER 1000W AMAM PS�rj$�(3
r✓l
5/SQ. ET.
SIGNSELECTRICAL
Licensed Profesbnal
�IT,(sU$
E �
OWNEReBUILDER DECLARATION
I hereby asorm that I exempt fawn the Con License Law f¢ the
NI P U T E
SPECIALCItCUR/M1SC
TEMP. METER OR POLE INST.
-POy DEVICES
001
reason. n 7
f ntywgretScNoe7 toe css ard Propu , eo le h,ytltyor
dens loo
aounty mmpe tour a toa rorequ,ilter,appose,tfvn h,or rep o
any strunurepatements the he is t the prosuhmaof to
!Ile • actoM statement that he b B¢nsod pricing to the provWoro of the
Coni of the LkeBusiness
Law (Cluplom (croCodrrcntlngwMxMbnherefom and
Ymin. Code)sxemptectio. therefrom and
SIVRAMINGPOOLFLECIRIC
VALUATION
the hues the Allegede yvi lhatheb
of SeatbnMIS reany
thehob for the ilbgedjectsE .p Myvtos lo.civil
a permit subjects the appBrant to a eWl realty d nor more than
five hundred
five Wndnddollars
rofthe pro
❑ I, a owner of the property, or my employees whh wages there dole
OUTLETS-SWfTCHSFIXTURFS
NEW RESIDENTIAL ELECTR SQYr
STORIES
TYPECONSTRLCTION
_ 6
in
dam(Soc.7 on, Bu.trewill do tM.d Pof theomnurebnot Weeded. ice.offered for
r
ale (Sec. B and Prdesbro Code: The
nws Il¢me Law
car, ow
dm ret apply loan owner of property who bunds or Impmvn thereon, and
apply or imp
who does such work hlmaeUwthrough Nsownemploleen, provided that such
OCC. GROUP
RES UNTIE
aprovemenb an nct Intended oroHered forsale. If, however, the Wllding w
lorprwemcnt baod with ooneyearofcornpinbn,thewvne,buMerwRI have
TOTAL:
Q
t"Iden of proving the he did rmt baud or improve for purpose ofaee.).
LJ L as ownu m of the property, at-hod sly mn'ractiog with licensed
concretion to mrotrun the Project (Sec. 9014, Busines and Prudminro Code:
QTY, PLUMBINCPERMIT
PERMIT ISSUANCE
FEE
FLOOD MINE
APN
TTe Contractor'. License Law don nor apply to u owner d property who
builds or Improws thereon, and who mvinna for such Moots with s
Tchar(Qlumaed p. or to the Cantona'. License law.
yl am e.emp order Sec B ! P C for this reasonQUISIDE
ALTER-DRAINk VENT -WATER MA)
BACK FLOW PROTECT. DEVICE
SUMMARY
HES
DRAINS FLOOR ROOF, AREA CONI. -
SANITARY - Y N _
RECEIPT 0
Owner Date
WORKMAN COMP ENSATION DECLARATION
❑ 1 hereby •Htrm thathe I have y
TEXTURES. PER TRAP
SCITOOL TAX Y N_
• ¢mBate of consent to o -i¢, ora
certificate o(Workenro
'C¢npeawu¢¢N
danllrceaffed copy thereof 6te
3800, Lab CJ
RECFRT 0
GAS FA.SYSI'FM-1 INC-40LITLM
PARK FEE Y N
RECEIPT
GAS EA. SYSTEM-0VER4(EA)
Com0 y
BUILDING DIVISION FEES
CenNed ropybhereby fumlahed.
C.d" copy b f=
with the''hY W(xnbn dlvlYon.
GREASE/INDUSIRL WASTE INTERCEPTOR -
PLANCHECKFEE
GRFASETRAP -
. CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(f Ma section and nn he complcted lithe permit h!¢care hundred do1Wa
PAID
Date Rcoel t#
SEWER-SAMTARYSTORM EA 700FT
cal m)¢Iy thatwork Wdpemdtbbo
]llnot
WATER HEATERW/VENT/ELECTR
ENERGY FEE Y N —
anyhe solwNdh
Peron inan numnerhe
employ theed,
I shag not empby any perewr N any rtnnner n u to bcaome subject to the
W
Workers Laws o/Ullfomla. Date
WATERSYSDM/TREATING
PAID
ApplicaNOTICE
Date Recei til
NEW �DENTIAL �. SQA..
after rs'Comiialdripe action procatte isoof ncmpte Lyon
.WTICETOAPPLICt to
should you fort et to tco Worker' sumpere ilio provisions of the Labor
Cade, you nvrt forthwith Damply with such pmWbro or this Permit eSill be
deemed revoked.
TOTAL:
BL11LI21NG FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby aPorm slut then b a mrotmnlon kMing ageray for the perform
[n¢.nhe work for whin rob permR b tvoaed (Sec. 3097, Ctv. C�
TOTAL;
ELECTRIC FEE
p
ender. Name
Ledet's Address
¢ntfy that I have read this appBuWn and oatethe thesWw infomwion
bmrmct.lagrte toccmplywithaetltyani muntyoNinancesand sunelaws
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE1
PERMIT ISSUANCE
FEES PAID:
rclat c m, and rcppQnnthm of thio
o enteru uponhe abov d prop"horlu
city TWO agme to the ,indemnify ap d property WpecC t porno
(We) agnec to RdcmNty u d keep harmless, the City of Cu pert W
ALTER OR ADD 7O MTCFL
Date Recel tM
SUBTOTAL:
judg
agaButllabWtln,�hpdgmew, mosard eapew whkA may in any way accrue
mwhit
agilut tied City in consequence of the grant Ing N this pemdt.
AIR HANDLING UNIT (!010,000 CFM)
AIR HANDLING UNIT (OVER ]o,DDDCEM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST H30O(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATENG UNIT CTO IOg00O BTU)
Will the applicant w future building occupant store or handle hmardcus
material as dcOrnd by the Cupertino MuNtlpe Code, Chapter 91Z and the
Date RCCei f#
HEATING UNIT (OVER 10D,000 BTU)
TOTAL:
30
Itrahh aid Silety Code Section 95537(x)7
❑ Yea No No
VENTI LATION FAN (SINGLE RESID)
ISSUANCE DATE
PAID
Will theappllcandturc W Eding«eupant use equipment or civ
which tout hazirdws air mnta mi,nts as defined by the Bay Area Are
Meugemtrd Derkt7
Ye" E-1 NO.
BOILER -CAMP QHP OR 100,000 BTU)
BOTI.ERCOMP(OVH IT)OX(0BTU)
Ihave nadtheharedcusmaterials requirements under Chapter 695of
the California Health 4 Safety Code, Sectloro 75505,75533 and 25534. I
understand that tithe Wilding dm not currently have a tenant, that It b my
_ r�
NEW RESIDENTIAL MECIL SQ.FT
msporolbUity, to notify the occupant d the requirement. which must be met
'prriiorW Iowan of. Ce�rtjifi/cate.(O/ccupy a/ �/
!_I� �7 iYJM ( �/L�) / Ste__. �I�
4:k¢a'"h
City .,,.off�!� infI.(tIUyt,)
ISSUED BY. �aV�� L:I`r'a k -J` -L- --(63 L
agent Date
TOTAL.
OFFICE COPY