20041APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY 1
Building Project IdenOflodon
Bmid2-255-00
PERMITNO.
CR -i5 0 �Nx S FF
20041.
te r( 6_(2.01„)P are:
CITY OF CUPERTIN&BUILDING DIVISION
APPLICATION/ PERMIT .
pQ
Coatador's Name: Lie. Nm
BUTT.DINGELDZTRICALPLUMBINGMECHANICM,
CATFCORY
CONTROL M
.
Archlt p/Fitglnee . o.
If TL _7_T G —
QTr ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add. `
q
PERMITISSUANC'E 66
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
-
Ihereby affirm 700G)oDh,isle.edunder pmvWomof ChaonsCode,andm
Barn 1Secbon71X0)ofDevffect. ttheBuslmeadPm/melonsCode,andmy
Barn la In (uB forte and died.
APPLIANCES -RESIDENTIAL
purer-v�U� �
6'"'"""�•"
PANELS
Llame Clare
Dal�Cooau, wador
UP TO 2DOAMPS
FLr't/T
201-1WORM
ARCHITECT'S DECLARATION
I uMudand my plaru.hall be, used as public remrda
OVER 1000 AMPS
SQ. FT. FLOOR AREA
5/SQ. Fr.
SIGNSELECTRICAL I KILED
Llanud Professional
IN
SPECIALCIRC TIT/MISC
OWNER -BUILDER DECLARATION
I hembyafflrtnthat l am exempt (nwnlhe Camador.Lioen.eliwfm the
E R
TIME. METER OR LE INST.
ID CADN
POWER DEVICES
SWIMMING POOL ELECTRIC
followleAreawn. LSectlm 7(DIS, Bu.Iriea and Pm(mloru Codr. Mydty or
muntywhkhrequbeaper wmmtmct,alter,Impmvs,demolish,ormpdr
ay.tmdumprbrtolb Ls. ma ab m-qul theappBantfmaudiper to
Be, a dgm i statement that he a becnmd pursuant to the pmv ions of the
Contradori Ikeree Law (Chapter 9 (mmmeneing with Sedlon 7000) of D(Vi-
tlon3ofthe Buelne»and Pmfeelam Code) mthat het exempt themRomard
P U T
1
VALUATION
the baa for the dleged exemption. Any Violation AT Scalen 70315 by any
apphant fora permit abject the appllant to a dull penalty d not mamthan
OUTI.EISSWITCFIFS FIXIl11tES
NEW R6IDFN71'V' El'}7. [R SQ'FI''
rive hundnea dollars CkW.
Ql, as owner of the property, or my empty... wite a h wagtheir sole
S(ORIF9
TYPE CONSTRUCTION
C
compensation, wW do the work, and the atmdu'r, b not intended or offered for
sale (Sec. 7034, Bus aev and Pdulom Code.. The Contractor. LI¢roe Law
'
'dos not apply to a t owner of property who build& or improves thereon, and
who dm such work himself mthmgh his own employee, provided that such
OCC.GROUP
RES. UNITS
ImprovrmeNaamrwt Intended oroHereci toraale. If, ho,x ver,thebuikllngm
Impmvamedbaldg o
TOTAL; fl
that mime a for pbullderwWhive
t en ofner of tepraperty,abuddorvely mpurlao.edWeJ.
dWnot tbuild or
Lj I, a t owner of the property, am er0K Bcn.l mnand Pr with ns Cocie-
mnttdon to ronslmctthe pmjM(Sec 70th, Bu.lneas and l'rafeasbm Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISST1ANCE
FLOOD 70NE
APN
The CoNndor'.1,1¢03. Law doe sod apply to an owner of property who
builds or Improve thereon, and who mmada far suet pSojems with a
m;NT.etArW Hamed pua.uant to the Contractor'. Llan Law.
IJ I am exempt order Sec B k P C for this neon
ALTER -DRAM& VENT -WATER(EN
-
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONI).
SANITARY Y_ N_
RE=4
Owner Date
WORKMAN COMPENSATION DECLARATION
F-11 hereby aRirre that I hove s aNRate of cmmnt to self-lwre, a .
anlfiWeofWorkem'CompensadanImuran¢macertifiedmpythen f&c.
3RO, Lab G)
FIXTURES. PER TRAP
SCHOOL TAX Y_ N_
RECEIPT If
-
GAS EA.SYSTEM-1 INC4 OUTIE15
FAR ELL Y_ N_Pal.
CAS E.A.SYSTEM-0VER4(FA)
Cama
DING DIVISION
BUILDING DI VISION FEES
Cedified ropy b hembyfuMahed.
enNed copy afBed with the city lnsptttbn division. -
'®Cy
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKUS'
PAID
SFWFR-SANITARY-STORM FA L'1LFT.
COMPENSATION INSURANCE
(I need nbt be complcied Bthe pemNt l9fmorc hundred dollars
Date RCC¢I t#
WATERHEATERW/VENC/ELFLTR
ENERGY FEE Y N
arlestbn
aI ImAticmd
I¢nor
Ntettoth,
emplhat oy .hypo Isanfthewmk so as tobnones
1 slue) not empty any lAwt� f any manner a a to become subject to the
l�.v.dUWorna. Date
WAEFR SYSTEM/TRLATTNC
PAID
Appli.'Cmnpenvtbn
NOTICE
NOTICE TOne sub CANT: ll, cher meriting thiotation pro es Exemphe Labor
Tall on
shoedbecome abjecttothe Wonkem'Cuch
Date Recel t#
NEW RESIDENTIAL PLMB. 9Q.FT.
TOTAL:
pna inprovbbmofthe
Code, you must forthwith comply with such pmVisbm ortha permX .hall be
-
13UILDING FEE_
deemedrevoked.
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby aff— that then b a rominudlon lendingage7Z forth. pedorm
as of the work far whish thisperma a �ed (Sec.307/, Clv. C.)
TOTAL
ELECTRIC FEE
Lenderi ovate
PLUMBING FEE
Lender. Add.
I oen ify sluHve
t omad thisappllatten a M .aov
state that the abe informaUan
I, rorrmt.I agree to comply with.11 cityand muatyordlnamand date Laws
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PFRMHISSUANCE
FEES PAID ,
Mating to building ronstmedon, and hereby authorize mpnznatisv of this
city to enter upon the above-mentbnod property for WpMlon pu rpmes.
(We) agree to ave, bdemedly an d keep hamaea the City of Cupertino
ALTERORADDTOMECTL
Date Receipt#
SUBTOTAL'
agaLut OabWtlea, YdgmeMs, coat.. M uprettiest which may in any wayamme
agaimt said City le mn.yuence of the grant Ing of tha permit.
AIR HANDLING UNIT (I010,ODO CFM)
AIR HA NDLINO UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
Sigmtumof Appgant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
BEATING UNIT(TO 100,00) BTU)
WW the applicant a future bu0dleg F..t An. or handle hazardou.
nutenal a deBmd by the Cupertino Municipal Cade, Chapter 9TZ and the
Date ReC'el t#
BEATING UNIT (OVER 100,00) BTU)
TOTAL:
d,
kQ vQ Safety Code, svo 2M32Wt
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
��a
WWtheapplamarfummbuildingoavpantusampip�m mde
hitteMthavN airs ui mrnsasdenrcdbyted Bay Ara Mr4
�u Ilty Mavaemem IXstrkt7
BOILER -NMP PI-Q'OR 100,000 BTU)
L� Ye ❑ No
Thaw read theta Rus materials rqulrcmcnb underChapter E95 of
Ap_p gT
APR
BOILER.NMP(OVER IDLM BTI!)
theunderstand] Calffoma Health k Safety Code, Sections 25505,25533 and 25534. 1
(.e cs 19(10
NEW RESIDENTIAL MECH. SQFT
understand] that if the building dm rot mrmntly have a tenant, that It b my
- J
reponsm0ity to natlfy the occupant of the requlmment. whkh must be and
P rior to hsua Am daG tcdOmrpa
C rev) y as yp
//tt�
Py of
I�%D�
f ,• k,
(� /44/�� y y p
ISSUED BY:DL�(�TV.I�Y"`t-e/Is'
Pv�erwmth rbed.grm I- Date
TOTAL
OFFICE COPY