20035APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY A/
Building Pet Identlf relmt
PERMITNO.
B.Mirg Address:
�4zsbc cR.�'M OF, Vu, l6 1? PS
20035*
rs ame: one
-j'-t P
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
Contndor'aName, Lk; Nee
BUILDINGELECTRICAL-PLUMBINGMECHAMCAL
GWWRY
CONTROL R
Archhed/Fs ,.. �. {- No:
1
QTY ELECTRICPERMIT PEE
BUILDING PERMIT INFO
`�
1 C`
Add— 6 0 1--CAS
�J S -Ft
pERMITISiUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyeflrm that 1 am 11cen ed.rd, Provtionsof Ch.Pler 9 (oommenc,
Ingwlth5eedon 7000)of Dlvlslon3ofthe Budrramm
and Pre eselGode,and
APPLIANCES -RESIDENTIAL -
g
•7r]j_'�✓+�//
LRRg_
Ilm�tln tuff roan and dreg
PANELS
Love Gla»lca
L
Date CIc.r -
UP TO 2DO AMPS
GL cT'I .
x)1-1000 AM
ARCITMCT'SDECLARATION
" I urderwM my plans dull be used as public records
JOVERI030AMTS
SQ. FT. FLOOR AREA 5/9Z. FE
SIGNS ELECTRICAL
Emoted Pmf.ional
ALE D IN
OWNER -BUILDER DECLARATION'
I hercbyalflrmthat lam ezempt framlhe Comratlor'albevelaw fa the
foL'owing reason. �edlai 7(D15, Bu.iw and Profeaebm Code: Mydty or
ntywhlchrequi apem tomrutrud,alter,improse,der h,ormpatr,
anyetrunumprlatoitaba,erre,abomaqulro eappeantfma apem to
file a Jgned anterrent that he, t Bernard punuant to the provenres of the
CoretntlortIke. Lxw(Clupler9(mmrendng with Sedbn 7000).! D1v1-
olthe BuJne dPr.fembmCode)orthmhebe.empltheW.m .M
SPECIALCIRCUFF/MIS
TFMP.METFRORPOLEINSEco
SER DEVICES
M P ER
Aaa
II
SWIMMING POOL ELECTRICebn3
VALUATION -
the basisfor the allegedexemptbn. My vloIecm of Sedbn 7QT15 by any
appLoni fora pared! subjects the appBcant to a dull pemhy.f nit mom than
flu hundreddroft(.500).
of the property, or my euctureem wRh wage there sole
I, e.m,
OUTLETSSWRFS
CHFD(TURES
NEW RF9DINIIALELRC1R SQ.Fi,
STORIES
TYPE CONSTRUCTION
Q
will
c le (Sm 70K BusBothe wak and thestaaurc t rut bteoded L offered for
r
uk nee. alnm and Prdmbro Code:Wid. Cawatlots Th.,Lawl
to
doe such torn awvr property who Wild. .,pr v lhemoMand
ot apply and
.he doosuchwork M1lmseBalhmngh Nevwnemply/en, pr.vided that such
OCG GROUP
RES UNTIS
Improvements are not Intended or offered for sale It however, the building or
Improvements wW within ora earofcomplelbn, the avner-bullder wHl have
TOTALOOCI,72
t Menof proving that he aid not build or improve for purpose of sale.).
Lf L as owner of the property, am exelue,a:y mntncdng with lirenand
onetractun to romtrutl the projeet(See. 7064 BusNm and Pro(e Tom Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD7DNE
APN
The C.dndor. Lice. Law dm net apply to an owner a property who
or Imv prothereon and who eontratla fee such p�jed, "ha
cgaf;+ or(.)llmrand pursuant to the Contractor'• Limna, Law.
L, I am exempt under Sec B k P C for th6 mason
ALTER -DRAIN 4 VENT WATER MAI
BAIX FLOW PROTFLT. DEVICE
FEE SUMMARY
FLOOR, ROOF, AREA, COND.
SANITARY Y N_
RECER'T a
OwnerDRAINS
�e
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certifiale of consent b w
.elf -Ire, a •
aeofWorkers Canpumatlonlvunnmaladlfled mpythertof pec.
m00,Lab
bG)
FIXNRFS I'FR.s'
$p-fpOI, TAX Y_ N_ '
RECEIPT a
GAS FA. SYSTEM -I WC4 OUTLJ=
PARK FEE Y N
Polk
- T 0
GASEA.SYSIFM-OVER4(EAA)
Cam, y
DING DIV
BUILDING DIVISION HES
d.
Cenlfled ropy t herebyfumthety
rtlfied ropy t flied with the tlty Wpettbn division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thos I..) need nm trca�ldedIfthe pemd tfaom hundred dallan
R1 IOJa Lea.)
thewok fors to b co pesub Is toted,
Ione thatbthe pedorm to
Wu,), rx' empty any pew N any manner at n to become .ubjed to the
Waken' Compevatbn iAw. of Glifomla. Date
PAID
Dale Recei til
SEWER -SANITARY -STORM FAA 700FT
WATER HEATER w/VENT/ELECTR
ENERGYFEE Y N —
PAID
WATERSYSTEM/TREATING
ApplleaNOTICE
NOTICE TOnw, sub n t tote, after mating this Ction pr a of nes of Exemption, L you
aLabor
Code,�oxtlbecome sub}anrothe Workers' Compematbnprovhis permit
Code, you role facthwdh comply with such provl.bns or this permh .hJl ba
Date Recei til
NEW RESIDENTIAL PLMB. SO.FE
TOTAL:
deemed revoked.
TOTAL
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them 6arommctlen lending agency for the Perform
Anm of the work for which this permit t i.ated (Sec 3097, CW, C.)
ELECTRIC FEE
a
I'Merb Name
Iroder's Addns,
I mntfythat I have rtadthtapplladonaM nate thdthe above Infornutlm
QTY. MECHANICAL PERMIT- FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
tmr .lagrc toccmplyw haBeLLyaMm tyord4 noaandnatelawa
PERMITLSUANCE
rtlaling to bulWing mvtrotllbn, and hereby authorlu rcpnyentlhea of this
cu CW0aeree to theabndemify and propenyfl Wpe Cit of Cups.
(We) agree to axe, Indemnify and keep harmless the City of Cupertino
agaremt BabWtle, ydgmew,mst.sod opevn which may In any way a¢rue
aga Inst said City N con.cquenm of the grant Ing a this permit.
ALTER ORADD TO M0."7 -I.
AIR HANDLING UNIT CFO 10,ODO CFA)
Date "Recei oil
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
Signature of Appliant/Conrado Date
E)(HAUST HOOD (W/DUM
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
- HEATING UNIT (TO 100,000 BTU)
Will the a ppUmnt or future W13ding occupant store or ha ed le hmmicu.
rrutrd l as defiead by the Cupertino MuNdpal Cede, C oupler 9.1 Z and the
Dale Recei tk
HEATING UNIT (OVER IOD,000 BTU)
TOTAL:
O
Hearth and Safety Code Section 75532(m)r
❑ Y. No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
pmol ��t
/'11
Will the appllent a tune building occupant use equipment or dcvicca
wh leh emit) rd.. air c.nla mivnts as defined by the Bay Area Are
Quality Afarogemeat DttrM7
Yea ❑ No
BORER -NMP DHPOR IK000 BTU)
BOILER-COMP(OVER100,000 BTU)
have read the bauNmu nutcrlat mryiremencs under Chapter G95 of
the Ulif= Health 6 Sf BCode Sections 25.5(tS 75533 and 25534. 1 ^'Y
undentaod that if the W Ildin doe not amens have a tenantthat itis
Ad17
I J
NEW RESIDENIIALMECH. .FT
roponsBtO ity to not By the oceupert a the requirement whidi must be met
PA Ewttanm LftCertlfcate.f Oc'mpaoc2y0
�G�e n
llla A
SSIUEDBY:
ammo
uihodad.gentDate
TOTAL:
OFFICE COPY