20069APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Frojet Identification
Building Address:
�3 !-oo LS 0 rye ►—
PERMIT NO.
2006
rens a
con:
U PSV
CITY OF CUPERTINO- BUIL DING DIVISION(^�Q
APPLICATION I PERMIT
BUIIDING-ELECTRICAL-PLUMBINGNiDL' MCMI.
_
Q
Coatarmr' N.lae. f� D (/ �.N.
f (
CATEGORY
.
CONTROL 4
ArchBact/Englneen IJc. No
�T
QTY ELECTRIC PERMIT - FEE
BUILDING PERMIT INFO
Add. 6 ePCf=M l•� Sl va
PERMT17ISSUANCE
f�1 ❑ ❑ ❑
LKENSED CONTRAR RS DECLARATION
I hereby affbm that l am Bcensed under provW...fChpter9(.c
ingwith Senbn70D0)of DivLdm3ofthe BuMnesand Profesdoru Code,and
License b to.In full foand effeet
License Clara _LJ`, N_ -
Date Cowador
ARCHITECTS DECLARATION
]undcataM my plaruehal be used as publeremrds.
LlaruM Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt frocn the Contractor's License Lw fee the
foPnwing reason. 6edbn 70315, BuMnesa and Prolmbv Cede: Any dtyor
ceatywhichrequireapermit tocomltud,Miner, imprwe,deetolsh.orrepair
any structure prior to lb borance, alw requires 0. applicant for tach permit to
fib a signed mlement that he, is ficensed pu.t to the prwhlom a the
Cort actor's Lkeeae law (Chapter 9 (commencing with SeNon 7000) of Dlvl-
Mona of the Budnes and Profesbne Cade) ortlut he b exempt therefromaM
the basis for the alleged exemption. Any Wolatlon of SaHon 7(1315 by any
applant for a permit subjeM the applkant to a dvll penalty of net more than
five hundred dollars (550,.
F1I, as owner of the Property, or my employees with wage u theb sole
mmpewtlon,willdothe work and the structure ee Plat Intended or offered for
sale(Sec 7044, Rusi, and Profeselore, Code: The Cordadots]JameLaw
does not apply to an owner of property who builds or Improve thereon,and
who doesuchworkhbrueB orthragh wownemployee, Provided that uch
Impmvemew arc notlntrnded oroflcred for u4. 14 hmwevec the Wlldln8a
Improveme i bsold withinoreyearofcompletlon, the ownerbuIlderwll have
Xt n of proving that k did net build or improve for perp. of sale.).
4 as owner of the property, am rxcwWely mntncnng wkh Licensed
t on 10 mnebud the project (Sec 7014, Bushes am Profession, Cade:
The Contactors L emse Lw does not apply to an owner of property who
builds or Improves theneon, and who mmnes for such Mjecb with a
cria(ra.dWs) rued puauaot to the Conse L
LJ I lia nador's License
am exempt under See. B 4 P C for this reason
APPLIANCESKF9DENTIAL
)OB UES DON
C,OVi Vatp� Sl�
` •� — L n A
d ddD,
- PANELS
UP TO 2DO AMPSVa
-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
f/SQ.Fr. -
,
SKINS ELECTRICAL
SPFLIALCIXCUIT/MISC
TEMP. METER ORPOI.RINST.
POWER DMCFS
SWIMMING POD[. ELECTRIC
VALUATION
OUTLETS -SWITCHES .
NEW RESIDENTIAL ELE(7TR SQFr.
SIORIES
TYPECONSTRIICTION
TOTAL
QTY. PLUMBING PERMIT FEE
OCC.GROUP
R6.UMT5
PERMIT ISSUANCE
ALTER -DRAIN& VENT- WATER (EA)
HOOD EINE
AI'N
FEE SUMMARY
BAER FLOW PROTECT. DEVICE _
DRAINS FLOOR, ROOF, AREA, GOND.
gpTLURES IPE[7RAP
SANITARY Y_ N_
RECEIPT]
Owner - a
WORKMANC . PENSA O D CLARATION
r—affirmve
I hereby affirm Wt 1 haa nerHflaco
te of nbwa
sent to self -re, a
ceN weofWorkers Compm im InaunncemaceAY"mPy Ihened(Sec.
380, lab C.)
� a
SCIKJDL TAX Y_ N_
RECEIPTa
GAS F.A. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N
RLCID'T Y
GAS E.A.SYSIFM-0VER 4 (EA)
CCeto
y
- BUILDING DIVISION FEES
Cartlfled ropy is herebytarnished.the lty -
CedNed copy b filed with the dty Ivpectbn division.
CERTIFICATE OF IXEMPTION FROM WORKERS'
COMPENSATION INSIBIANCE
(Tide ettYbn orad net be completed dthe permt b fe ane hundred dollen
(f100)mlas.)
Icertifythat Nthe pedomunceof the work for which this pemmtblwed,
T anal fiat empty any peramt b any manner m u 10 become anbjrd to the
Workeri Cmnpenvtbn Iaw•a d GEomia. Date
Applant
WTlCE 70 e, subjCANC:e, after malag Certifteate of Exemption, eLabo
should bemma subject he Workers' Cush pnwi tan prvvbbnermit of shabor
Code, tfmthwhh mm I with such rovbbra arthb
Yo�+maPs PY P permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
lhembyaffirm tut then bamviructlonkMingageuy forthe pedarm
anceo(the work(orwhkhlhb permitbbared (See 3097,CIv.CJ
Leadero Name
1<naer:Mame.
I¢rtt/ytharI have rtalthioappllat and
remingt Dagreing."tlywlth anckyand mu oriie lnan¢eand sta(elasys
rtlatoenterupong mmtrudbn,and hertby Pty orl rtpresntaHvn of thio
city (We) to see,he d property for the tion Cfty.f Cupertino
(eM agar ts, save, bdemudfy an d keep which the City of Cupenbo
which permit. wayacvue
aga4ut said City jndgmequencetof th era ting
age Wt sale atybmn.egae�fir the gra tbgatw permit.
�-JGfir
GREASE/INDUSTRL WASTE INTERCEPTOR
P NCHECKFEE
PAID
Date Recei li!
GREASETRAP
SEWER -SANITARY -STORM FA 2IXET
WATER HEATER WryINT/EFCTR
n
WATER SYSTEM/TREMT1140 ry — _
ENERGY Y N
I
1 t�
OTAL:
NEW R®DFNRAI. PLM 9QFT.•
P \ P} r, �,,7
� r 1J L �
TE
ELECTRIC FE•
TOTAL
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING E
MECHANI LFEE
FEES PA
'
ALTER OR ADD70MECH.
D e Recei
AIR HANDLING UNIT OO 10,000 CFM)
SUBTOTA
AIR HANDLING UNIT (OVER 10,00)CF%I
CO STRUCIION TAX
_��1•a+(j✓Otl�.%
Sigratureof Applant Date
HAZARDOUSMAT RIALS DISCLOSURE
Will the app0ant orfutum building occupant More or handle havnddus
ma
material as defined by the Cupertino MuNdpal Code, Chapter 9.17, and the
alt
Heh ant SafetyCode bn 8
Sert532G)7
n Yn
Iltheappliamorntrcrebuildingarvpint..equipmentordevku .
which ermt lunrdoue air contaminants as defined by the Bay Area Air
Quality Management District?
Ye j� No
have read the Inas .ornalcrlab requtrements under Chapter&95 of
the California Health & SafetyCode, Sectbm 8505,25.533 and 25534. 1
uMe MthatiltheNtldingdoer mnentiyhavea tenant, that It b my
respommlhy, to nmttly the onvpam of the requirements which must be met
prior to issuance ole CartBlnreol Oct paruy.
EXHAUST HOOD fW/DUCT)
C NSTRUCTION TAX PAID:
HEATING UNIT (JO 100,ODO BTL)
Date ReCei IN
HrATING UNIT (OVER 100,000 BTU)
TOTAL:
VFNTILATIONFAN(SINGLERE37D)
ISSUANCE DATE
P
����
APR
-'"199�II
�J
ISSUED BY.1j
BOILER -COMP OHP OR 100,0(9 BTEO
BOILER-ODMP(OVER 10D,OW BTU)
NEW RESIDFN'llAI. MECIL SQFT
Owner or awhorived agent Data
TOTAL
OFFICE COPY