20119APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY \
BulldlnA Project Identificatlm
Buid.rngAdd�.35'o
PFRMITNO.
2011
P . t'ot'( C-p—QU-1� tee:
CITY OF CUPERTINO-BUILDING DIVISION-
APPLICATION I PERMIT
BUILDINGFlEC7WCA4RUMBINGMECHAMCAL
'.t__
14 f 40
Contnctor'e Name:
��� ITS S�`t N ��l
CATEGORY
CONTROL
Architect/lsglrim: Lie N¢
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Adder
I'IXAUTI.AUANCE Ll_c3
❑ ❑ ❑
LICENSED a CONTRACTORS DECLARATION
I hereecdonhy that ieteonueduMest nese anofCWpler9de, and s
Ing with Section force of d effi on3tithe Bue.ssaM Pmfesslon-CMe, and roy
Lhce�lce. b In foil force and d.N
Llano Class LILY
Dar
Date Corador
ARCNITECT'SDECLARATION
IuMe Mmyplam.WUheumdnpubUcnmrda
Licensed Professional
OWNER-BUILOFR DECLARATION
IherebyafB that Iamexemptfnvnthe Come eaLianas Lewfmthe
following reason.(5ea1m7MIS, BuesessaM Pufmb.CMe:Anydtyor
any -soden tatamelbhe he is abongd ursuanppUwt(rewchpermt a
anyoy hfmpr totb a at ,alwred,abr,lmp U=tf wdipr tto
file a signed RabmeLa the he b Uaru rr pursuant to the provhbn d the
aeroftheusloes Ucerse Taw (CWssionscom)ortheonneing witeis secten mptthe00)of Divi-
elan 3 ofthe BuslnessaM Prdmlon Code) orthat he b eumpt thenfwmaM
the Web for the alleged e.emptlon. My in abon of Stolon 7m1S by any
apPBant fora perodt subjects the applicant toss d,l penalty of nal rron than
five hundred dollars (5500).
❑ I, as owner of the property, or my enryloyen with wages as their win
ocenpenalon,wUldo the work, and the nructun an not Intended or offend for
.sale &1 7044, Business and Prv1®lo. Cade: The Contractor. Wane Law
don not apply to an owes dproperty who builds or lmprwes thereon, and
who d..suchwork hfrn<Uathrough hisown employees, provWed that sea
Improamew arerot intended ,,.ffercd for sale. If, hewe.er, thcbulldbg or
Improvement eseld withir .rayearofcoommppletlon, the oweer-bdlderwW ha e
t rden of proving the he did not buddor Improve fee purpose of sale.).
L as owner of the property, en escW-Wely omNg
traRwith lleenxd
cont.ctme to construct the pmjeet(Sm 7064, Business and Professions Code:
The Cent.ctor. License Lew dose net apply to an ower of property who
Wilds or Improves themon, and who contract- fee such piojeda with a
cel erfi.) Umfued pursuant to the Contractors Lice. Law.
U 1 am e.empt under Sec. B h P C for this comm
APflIANCESRESmFNf1AL
JOB KUMON
F t-• yf
1 �jy`t` ♦ tJ[yC./� -
PANELS
Ml -1000
OVER 1000 AMPS - -
SQ. FT. FLOOR AREA
a
$/SQ. FT.
'
SIGNS ELEti TRICOT.
SPECIAL CIRCNT/MISC
TFMP.METFRORIOI.EINSf. 1o•(i)
IVIVER DEVICES
SWIMMING POOL ELECTRIC
OU7LEISSWITC HIF l=FIXTURES
-
ATION
_
NEW RESIDENTW, ELECTR SQFT.
STORIES
TYPE CONSTRUCTION
_
'IOI'AL C�
`a .
QTY. PLUMBING PERMIT FEE
OCC. GROUP
RES. UNITS
PERMIT ISSUANCE
ALTER -DRAIN& VENT-WATE (EN
FLOOD ZONE
APN
.
- FEE SUMMARY
BACI( FLOW PROTECT. DEVICE'
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_ '
RECEIPT I
JewDae _ _
mer OR O TION DECLA RAT N
❑t hereby alflrtn the I hes • aklfiate of cormnt to .el( -Ino
nertlflate of Wor),en'Comper sa ton Imranm a a mnUbd copy themN (Sec.
3800, Lab
r
-
��$� TRAP
SCIiOOL TAX Y N ,
RECEUef'
GAS FA. SYSTEM -1 INC4 OUTLETS
PAWL F -FE Y_ N_ .
g
GAS FA. SYSITM-0VER 4 (EA)
Cootry
y
DING
BUILUINC DI VISION FT:ES
Certified copy b herebydwith the city
CertWed espy b filed with the dry InpeNon dlvlMon.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need nor be cmnpleted If the permit is free. hundred della.
alD)ata')
0orI the Ushe pedomanadthi sums WrwWch thio permit lebsued,
1 shall nm employ any Peron In any ...en w as to became subject to the
Workm'eompensatlnn lewa ofGWornb. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become sub}ctw the Workm' Comperuetion pmMaWna of the Labor
Cade, you mut forthwith comply with such provision or this permit shall he
dnmed reroked.
CONSTRUCTION LENDING AGENCY
I henbleaffirmthet then b a construction leMingagenry forthe perform
ansa of the work for which thb penmB b issued 5a. 3097, CW. C.)
Lender's Name
Lender.Add,ea -
I mKilytlutI hew read than appiketonand este thrtthe-lawsInfomrutlm
bourrect. Iagneetocornply wdh ail chyaM mrnty ordWnm and rtatebwe
Mating to building com anuctlon, and hereby eathortu representathes of this
city to enter upon the abw entoned property for bbpectbn purpose.
(We) ague to save, IMm
cNarms
fy an d keep hthe City of Cupcdlre
against liabNtiies,judgments, cost. aM expense- which may In anywayeeee
against sed City in mnsequn. oI the grating of thio permU.
GREASE/IN SML WASTE INTERCEPTOR -
PLANCHECK FEE
PND
Date Reoei t#
GREASE TRAP
SEWER -SANITARY STORM E.A. 2(X)FT
WATER HEATER W/VENT/o-ECTR
ENERGY FEE Y N
PAID
Dale Rece6 tlf
-
wAlT7t SYSCEM/TREATING
NEW RESIDENTIALIP[ALB. �F(.
TOTAL:
BUILDING
SEISMIC FEE
TOTAL.:
-
ELECTRIC FEE
a�
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID.
-
ALTERORADDTOMECK
AIR HANDLING UNIT (TO 10,0)0 CFM)
-
Date ReCel t#
- SUBTOTAL:
AIRI-wnvuNC UNIT (OVER looao CFM)
CONSTRUCTION TAX
Slgnatun of Appuant/Cent.ctor Date
HAZARDOUS MATERIALS DISCLOSURE
WUItheappliarre/utumbufidingocmpant atom or handle hmardous
material as deO.W by the Cu penal. Mu rdpal Code, Chapter 9.1 7, and the
EicahhsndSafety Code Salon25532b)7
F1 Yn M No
(VWtheapplicant orluturebdldingeccupante,seequipr.est mdeviees
which curt W urdous air contaminants as defined by the Bay Area Air
Quality Mangcmcnl Dbtrlct7
171 Yes No
have read the h�va� • materlds requirements under Chapter 6.95 of
the Californiaode,niHealth k Safety Ce, Sections; 75505, 75533 and 25536. I
understand that lithe building does not camrly have a tenant, that It is my
mmponbil Uy to nnlfy the occupant of the requirements which rmea be met
to da Certifiat m
fOrpancy.
EkI-uoBTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
'
IMATING MIT(TO 100,0(XBTT)
Date Rttc] In,
HEATING UNIT 100,000 BTU)
TOTAL:
1
^a se -i6
VENTILATION FAN(SINGLERFM I
ISEUANCE DATE
APR 11 1990
cityprim
of om"M
ISSUED BY:�(_Ql�/�W`V
BOILER -COMP OHP OR 1W,= BTT.
BOILER-COMP(OVEt 1fU,0W RTU)
NEW RESIDENTIAL MECH. SQFT
;
n wined est Dat
TOTAL
OFFICE COPY