20040APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bundle Pro Identuwtion
Banding Addme:
X ,500 C 50 U , fig`
PERMIT NO.
/ . 2 0 0 4
�.
• �y-QQIJ�
CITY OP CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Q
Comndoes Neox: Lk. No:
BIIILDINGFLECIRICALI'LUMBINGMECFUN7CAL
CATEGORY
'
CONTROL0
Archx /
gi rarr' Llc Ns
G —
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address �c ti —tss S
PEMITISSUANCE
�_ ❑ ❑
Lm CONTR RATION
by that Ia under ISDECIA
I herteefln.70tD).1Dmlkm.edhe Bu prov and Pre Clupler9(e, de
Ing hoe.I in fume anDldect. he BupneseandPro/nporu Code, and
Kava la In (ul fora and effect.
API'I.IANCFSRESm7iMTAL
/ �(��lO/B^
V /�
PANELS�y�
ls
Date Ctr# r
UP TO 2DO AMPS
MI-1000AMPS
ARCHITECTS DECLARATION
OVERIODOAMPS
SQ. Fr. FLOOR AREA
f/9Q. Fr.
Iunderstaed enyplanaahalbersed as publleremrds
SIGNS ELECTRICAL
Lkerse i Profeabrui
OWNER -BUILDER DECLARATION
1 hereby alRrenthe I am ctL
exampt from the Contraor'• Li row w for the
'
SPECIAL CIRCUIT/MBC
TEMP. METER OR TOLE INST.
following Mason. (SMtee MIS, Buelnvand lhofewlons Code:Mydryor
=nrywhkh requima permfttomatmct, alter, Improve, demvlbh, ormpalr
any prudare ppor to Its baance, abo require the appeont far ouch permu to
f� a p ed statement that he b Ix"o ea
gn punuant to the provbbro o! the
Contndori Lbemt Law (Chapter 9(mmmmcing with Section 7000) of Divi-
alon 3 ofthe Business and Profms wCode) orNp he b exempt(herefromand
Iti7WFR DEVICES
,
SWE✓.MING POOL ELECTRIC
VALUATION -
the basis for the alleged eaemtp(lon. Any ,loiadoo of Section 701,5 by any
applicant for a permR sub)tt1s the applicant to a civil peruhy of not more than
five , as undred dollan,
pro
I, as owner of the Property, or my employee with wage a th<U sale
O(TD.EISSWIICFffSEJCIUREs
.
NEW RESIDENTIAL sQFr.
SIOWEs
TYPE CONSIR(1CTION
camper curio n,wnl do the work and the strumae is, not Intended or offered for
sale (Sec 7014, BoMnoe and Pmfeabm Codr: The Contractor. Uaee Law
does not apply to an owner of property, who builds or lmpmvn themes, and
whodoe.uchwork lbm lfmthmve
gh hleown employe, provided that wa
OCC. GROUP
RFS. UNITS
ImprovemeNa, am out Intended oroffered for vale. Il, hoverer, the brlknng ce
impm�ememub dwflhlnomy rofcomplel Nthcowner MerwWFuve
TOTAL: Q
-
_
the burden of pmwor ng the he did nbunmv
d or lmpe for purpose of sale.&
LJ I, an owner of the property, en exchuh,ely oaitrxct ng with Monad
euntndms to melruct the pmj Y(See 7044, Busing and Pmfeabm Cade
QTy. PLUMBING PERMIT FEE
PFRKUT ISSUANCE
FLOOD ZONIi
A PN
The Contr ctor'a Lianas Law don not apply to an owner of property who
Wilds or Improve thereon; .,b who cont. taw such plojem whit
cgWr �or(s Bmru%ed pursuant to the Cuntnctori Line. Law.
LJ I am exempt under Sec B & P C for tbia reason
ALTER -DRAIN& VENT- WATER (EA)
RAIX FLOW PROTECT. DEVICE
FEE SUMMARY
DRUNS-FL0ORR0OP,AREA,ODND.
pIX.M2ES PER TRAP
SANITARY Y_ N_
RECEIPT
Owner Dale
WORK MAN COMP E re"ifiee DECLARATION
❑f hereby affirm that I Farr • Ino mn of consent m bpythcrre, m
ami, Lab of Workani Compemallon Ieunna a •omitted ropy therco((Sec.
]800, Lb C.)
SCHOOL TAX Y_N_
RECEPT
GAS IA. SYSTEM -1 INCL OITH.EfS
PARK E'FE Y_ NPol_
4
RECEIPT If
Cpm Y
AS
GEA. SYSCFM-OVER 4 (EA)
BUILDING DIVISION FEES
cerUned ropy b furnished.
�Certlned ropy I, filed filed'Md, the city Impectlon division.
GREASE/INDU5M1, WASTE INTERCEPTOR
PLANCHECK FEE
GRF/SETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mead not be compided R the pemdt b fmorc Fundred dollen
(or
PAID
Date Recd ted
SEINER-SANTTARYSTORM EA 3%IT
ledbn
atmtalerd
]l]out that lnthe performanceofthe work for to bthis comemdtlabored,
I shag nor employ en any P. b any manner at n to become ubjea to the
Waken'Comperwtbn LaMtof G.lBomb. DoraM=QPAID
WATER
TR
ERGYFEE Y N
'
WATER SY
NOTICE
NOAppTICE MI'LICANT:I,after making thio CenBimh of Exemption, you
should beerme.ubjm to the Wmio,m' Compensation provlabm of the Labor
Code, you mane fort hwLLA comply with such provbba or this Permit abet be
deemed revoked.
CONSTRUCTION LENDING AGENCY I
NEW Raw
Date Recei t✓y
nATF
TOTAL
-
-
SEISMIC FEE
I hereby afnrmthe there b a mmtmmm on lending agency for the perform,
nor of the work for whish thio pemdt b Issued Sec 30Y7, CN. G0
TOTAL:
ELECTRIC FEE
Q Q
Lenderb mm ,
I<eder.Addre.
I enn flythat I have read thbapplotbn •M Informationate the the above Information
qmi MECHANICAL PERMIT IEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID
Is corn>i.I agree to comply with all city and mu ny ondmanae and pate laws
PERMIT ISSUANCE
relating to building mmlmmon, and hereby authorlu repnnentalNLa olthb
city to enter upon the above-mentioned property fm inrpeNon purpmea.
(We).&me to save, hdemNfy an d kmp harrNes the City of Cupartlro
ALTTRORADDTOMECH.
Date Reeei NI
P
SUBTOTAL:
."Ane llabWtln, jadgmaw, mstsaM npenrs wbkh may in any w.y..e
ago Lpt said City N mnsequeme of the granting of this ,sold.
AIR HANDLING UNIT (TO 10,000 CF'hU
AIR FiwNlwtNc unTr (OVER lg000CFM)
CONSTRUCTION TAX
Signature of Appllmnt/Contractor Date
M(HAUSr HOOD(W/DUCT
CONSTRUCTION TAX PAID:
HATAR DOUS MATERIALS DISCLOSURE
HEATING UNIT CIO 100,000 BTU)
Will the a ppllo of ce future balding occupant store or ha ed le handous
material as defined by the Cupertino MunbripaI Code, Chapter 9.17, and the
Date RMeI t#
HEATING UNIT (OVER 10D,OW BTU)
TOTAL:
I Iealth ami Safety Code Section 25537(a)?
RRIBTu No
nl the appuranta tare Wilding occupant use equipment or devices
whish emit havrdouv air comenlrant. a. defined by (be Bay Arta Al,
Quality Management District?
Yes No
VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
���
BOI,ER-OMP QHPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
have read the hanamous mnedals nquirrments under Chapter 05 of
the California Health&Safety Code, Srdlom 75505, ES33 and 25534. 1
understand that if the building doe rout mnently have a tenant that it bnry
APR .J. TogU
A R J
NEW RFSIDENTIAL MECH. SQFL
rmponiblfty to notify the oceapan of the noct bement. whldn must be met
rimfadrum daC<dlnatedOavl! � �f-9D
Ownerero�ut odd agent Date
LIrof (TnAp.4"
i�l`o/Lr,l
ISSUED BY: D
TOTAL
OFFICE COPY