20042APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY -
Building Protect identification -�
Building Address
0 e-1 buy s7 ss 6
PERMIT NO.
20042
not
CITY OF CUPERTINO-BUILDING DIVISION
, APPLICATION / PERMIT
BUILDIW—ELECI1UCAI-PLUMBING-MECHANICAL
CSI
CATEGORY
CONTROLI
Amhl /F nerr No:
Q ELECTRIC PERMIT FEE
BUILDING PERMITINFO
Add— j � 5
PERhUTISSUANCE � t i�
❑ I�
❑ ❑
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LICENSED CONTRACTOR'S DECLARATION
Iherebyaffbmthat l.mlten uMerpro Wm.of Chapter9(mmmnenc
ingwithSection7000)ofDlvWon3oftheBumnmsandPr.iW.,Cede,and.y
Bmnse Is In full form and effm.
Difle hss Lk.1
Date Cit,11 or
ARCHITECT'S DECLARATION
Iundtestardmy, phrsahll be used As public records.
Llmns.d Promsloral
OWNER -BUILDER DECLARATION
I hereby affirenthat lam exemptfrumthe Contractor's Lkamse Law foe the
followleg ream, (Snnd ilon 70715, Business aPrefmmbCode: Any eity or
muntywhi requk apemdttommtmd,alter,Improve,demolbkorrepair
anymmeure prbrtolts Lvuaaealso mqubnthe.ppl)ont for aueh permit, to
Ne a signed statement that he h Bocn.ed pursuant to the provhmtaof the
Contraofe Lkeme IAw(Chapter 9 (mmnendng with Section 7000)of Divi.
sian3 of the Busla®and Profmbra Cade)arthm he Is exempt therefmmand
the bash for the Ateged exemption. Any,ioWion of Seebn 70315 by any
appftvnt for a permit sub*ds the applicant to. dull peialty d not more than
By l,as droit 500).
L as awrcr o(lhe property, or my employers with oiled as their sole
mm(SL, 70 n, B.Ine ha wvh5 andthe stratum h of ntended or awned for
vie son 7011, to A nc a er f property Cade: The Conhaeofa t1mme IA d
dos not apply to an vwisrdproperty who Wilds orlmprovn therms,and
whodonwchem Mein Bmthraughhlsowd for It crw provdeuildi Rn or
ImpmvemeM°arcMfthbs ed earcfttmpledisale. the o ne r -b tlkierwdingm
Improvamed basad within orc yeardcampldbm the ownerkullder will have
L"ben of proving that he did not build or improve for purpose .(.Le.).
LJ L as roma of the property, am t.dusWehy contracting with ti ensed
mntr.cton to mrotnae the pm)eet(Sm 70K Business and Profmbns Cade.
The Contractor's Lkerse IAw dm not apply to an owner d property who
Wilda or Improve thereon, and who mmnt4 for such pt,okcn with a
rytfadarWBmnsedpursoanttotheCondo:. Limwe Law.BACK
LJ I am exempt uMer Sec o
B 6 P C for this mn
APPI.IANCESIE4DENT1AL
I �f7f JO
PANELS
— UP TO 2DUAK25
M-10DO AMPS
OVER ]ODD AMPS
SQ. FT. HOOR AREA
i ISI .
T E R
p0..
f/SQ. FF.
s
SIGNSELECTRICAL
SPECIALCEICUIT/A LCFIN
TyA(p.MER7(ORPOLEWSP.
]OW'F'R DEVICES
DATE
yyyp/MING NOT. ELECTRICC
VALUATION
OUTLETSSWRCtFIXTURFS
NEW RESIDENTIAL E.ECTR SQFT.
STORIES
TYPECONSIRLCUON
D
TOTAL: D
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN k VENT - WATER (FA)
OCCGROUT,
vcc UMTS
FLOOD ZONE
AI'N
-
FEE SUMMARY
FLOW PRO]FLT. DEVICE -
OUTSIDE FEES
DRAINSFIOOR ROOF, AREA, CONT).
FO(-NRF_S PER TRAP
SANITARY Y N_
RECEIPT a
Owner Date
WORKMAN COMPENSATION DECLARATION
1`71I heraffirm that affirthat I have a certlft,dm of consent to "ll-iwm, m a
cerHBate of WorkmaH
en'Cnpereon lrunnlf
unoe or a mkd copy thenof(5a.
3800, Ub CJ
pdiCom a
SCHOOL TAX Y_ N_
RNA, ft
GAS FA.SY51'FM-1 ING401-17ILE15
PARK FEE Y N
RECEIPT.
GAS EA. SYSTFh1-0VFRd(FA)
Y
BUILDWG DIVISION FEES
Certlned mpy b herby fumlahed.
CtnHled ropy b Toed Mth the dty Irupectbn dlvlsim.
CERTIFICATE OF EXOvIMON FROM WORKERS
SATATIONINSURANCE
Ca becompleted
OTbsectbn need nilbm ed Brmit
lithe ohundred dallan
R1I mmfyss.)
I mrtdy emplhat oy
I.haB not empby any pawn f xL rronner so +s b become wb)M to ti;
tany ptrhe d. Is an thework so As I. b come sok h bo ti;
Workeiv'Comptvatbn lAays or Gllfomh. Date
Apphant
NOTICETOAPPLICANT:IL.ftermakingthioCer "teofExemption,yw
should become.ub}at to the Wodars' Comperumion prevhbns of the Labor
Cade, you rout forthwith comply with wch provbiom or thb permit sha11 be
deemed revoked.
CONSTRICTION LENDING AGENCY
I hereby offim"hat them Is a mmtmdtm lending agency for the perform
anmofth.workforwhkhthbpemt,ls Wued(See3097,CIv.C.)
IAMee. Name
Leech.Addmsa
I mrtlrythml have mad thio Application aril •ntethal the Above Information
Is mace.] dgme, to comply with all dty and county ordinances and state laws
relating to W I lding mmtru"Ion, and hereby authodae representative of thio
city to enter upon the abovt-mentbned property for Wpeetbn purposes.
(We) agree to save, Indemnify an d keep harmlm the City of CupeKUm
against liabWtis,pcigmerds, ooniard expense which may In anywayacvue
against said City in consequence of the grunting of this permit.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel t#
GREASE TRAP
SEWER-SMTfARYSTORMEA700FT
WATTRHEATIRRw/VENT/FILCTR -
ENERGY FEE Y N'
PAID '
Date Reoei t#
WATER SYSTDA/TRPATING
NEW R19DENITAL PLM a. SQA.
_
TOTAL
WILDING
..
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. I MECHANICAL PERMIT 'FEE
PLUMBING FEE
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
,
ALTER OR ADD TO MECH. '
Date Rmci t#
AIR 14ANDLINC UNIT(TO 10,000 GEM)
SUBTOTAL:
AIR HANDLING UNIT( OVER 10,000 CEM)
CONSTRUCTION TAX
Signature of Appear/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appltamorfuture Wilding occupant mom or haM k haaandous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Hr..Bh.nd Safety Code Sectio 75537(a)r
Y. N
W tithe appBanior tum Wilding oacvp.M..equipment ordevlm
ha
whkh tout nrdaus air rentamloada A. defirad by the Bay Arca Ab
Quality?A..Stmed District?
YnI�I No
havemad the h rosmaterialsrequbemcntsunderChapler695of
the California Health h Safety Code, Sedbrm 25505,2553,3..d 25534. 1
uidcmd,uM that if the Wilding dms not curmntty have. tenant, that It b my
responsioBlty, to notify the oavpard d the requirements which must be net
pdw LssuarcedaC.niflate f may.
17 /�h2//�i"�r� 5' -
T
D(RAUST HOOD (V/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recti t#
HEAHPf G UNIT (OVER 100," BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISa� ATE
/�T�!�25i990
APR
n'F. t ln�
City of rl
ISSUED BY R
BOMER{OMP (3HP OR lOQOW BTU)
BOILFRODMP(OVER 1W,=IIU)
NEW RESIDENTIAL MECH. SQFf.
PvnerorwthmU.dagent%ry Dale
v
TOTAL:
OFFICE COPY