20200APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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Owner's Name: me: ff0l?—Utt '�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
d
CwtnRor's Name: Ik, N.
BUILDINGfl,ECTRICALPLUMBINGMECHANICAL
CATEGORY.
Archhect/Fsglver. Lle No:
QTy ELECTRIC PERMIT - FEE
BUILDING PERMIT INFO
Add.
PERMITISSUANCE
❑ I�/� E] El
-,�j
EO CONTRACTORS DECLARATION
Ihereby affirm that l am licensed under provWov of Chapter 9(commenc
ingwih SecUon70 )0)of DIV Wm3 ofthe Bu,d..rdPmfeeloraCc dc,a^d my''
homse b In full force and effect.
APPIJANCES-RESIDFMIAL
)OBD UCRFMN
' lam � � (-�
♦j'��+I tr~
PANELS
Llanse Clan Lk.a
Dae GOMradar
�)u P�^�
2II-1000
ARCHITECTS DECLARATION
IuMentard my plan Juebe used as public r ads.
OVERIOWAMPS
SQ. FT. FLOOR AREA
5/SQ, FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIXCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby afRrmthat l am exempt fmm the Coaacior'. Live TAw for the
following ... (S.abnMIS, Business and Profeanns Code: Any city or
c ntywhishrequbesapen tocoro Malter,Improve,dernlbh,orrepass
hl8 METER OR POLE INST,
anyswcturt prb to lb Wun�a,abo raqubesthe appBantfa such pemdtm
Rte • signed statement that he is licensed purwant to the provisbv of the
LOWER DEVICES
'
SWIMMING IA7IX, ELECTRIC
Contractor's Licerne Law (Chapter 9 (commencing with S etlo^ 7000) of Divi-
ebn3ofthe Bugneaand Prdmbro therefrom and
A A
Myraioth.nofSecmpt
thebaan for thermic jecmptiou.t,ap Mytt.. ciiof Sedbn7m15 byany
the appOcanttoa ctdl pevity dn,ea mare than
OIIILEISSWITCIi6FU1TIRF5
OEM
�(�C-
NEW RESIDENFEAL EI.FLTR '�'�'��'
five hundred dd of the p0).
fivehuntforapsmdt$W.
❑I, as owrar o(tk property, or my employees with wagesutheir sole
cnmpevation,willdothe work, and the shucture fs wt LueMed or offered for
vie (Sec 701C Business aM Prof®bro Cadr. The Condractols IJanse IAw
J [I NSIRIiCHON
+/ N/ 9 �
LIN
don rdspply to an owner d property who builds orimprwesthereov,and
whodoouchwark himself or through hlsownemploym, provided that such
Ur'•,.-- _RE4 UNIS
impmvemwarcnwfbtended'orofferedfmuk. FLhowever,thebuildingor
impmvemedbwWwlthinomyearofcompldbn,theav^er-bulldar shave
TOTAL: fZ
tl�kurden o(pmving thakdW r,ot wild or improve for purpose o(nle.I.
U S as cors of the property, am erchuivehy mnu-aeing with Ikm:d
contractors to construct the project (See 7066, Business aM Prdessbro Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
1'T.00D ZONE APN
The Contractor's Lkeve Taw does not apply to an owner d property who
Wilds or improves thereon, and who comram for such p(ojeN with a
"WIP"tor(O licensed pursuant to the Contractela License law.
U I am exempt under Sec B k P C for this reason
ALTER -DRAIN k VFM-WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE
IXUINS FLOC)R, ROOF, AREA, GOND.
FIXTURES- PER TRAP
SANITARY Y N _
RECER a
Owner Date
WOR "AN COMPENSATION DECLARATION 01
❑1 hereby affirm that I hhave• certificate of consent to seIf.inurr, a a
ceni0oteofWorhers'Compevatlon l... ma aNlled copy thereof (See.
3800, Lab cI
TAI( Y _ N
GAS F.A. SYSIT]d-1 INGd OlJllf75
PARK FEEY N
policy,
by a
RDCEI T a
GAS F.A.SYSII]T1-0VFR d (F.9)
y
BUILDING DIVISION FEES
[('inNed ropy 'ah henebyluMshM.
eNfled ropy billed with the dry IropMbn dlvblm.
GREASE/INDUSIRL WASTE INTF]KEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
PAID
� S NTTARY_�RME ST
COMPENSATION OURA
ISNCE
(fhb sectbn need kcompleted Bt he URAisfara ohundred des
oBa
Date Re i t#
WATFRHEATERW/VENT/ElXCM
ENERGY FEE Y N
PAID
M00)alese)
anp person in
noremploy
1 ahe0 rat employ any pennon in any rtanvr at es to berome ubjea to the
murnek(o as to heorpertnitbbo the
TVmken'Canpenvtlan [Awn of GBlomb. Date
WATER SYSTEM/TREATING
r(ppllant
NOTICE TO
wbjecAMWung�fhebn
,Wsoarnkt
Date Revel t#
NEW RESIDENfIAI, PLMB. SQ.ET.
TOTAL:
become the emna' vCtion provisions
sh�ulro visovnempHtOMayboour
coa, you must forthwithcomply with suchpuWbroorthbpermishalk
decmQ evoked.
CONSTRURION LENDING AGENCY
BUILDING FEE
SEISMIC FEE
I herei7afBrm that there b a mvsuNan lending ageruy for the perfmmr
ince of the work for which this permit b Issued (See 309/, CW. CJ
TOTAL
ELECTRIC FEE
a
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Larders blame
Larder's Adder
MECHANICAL FEE
1 xmifyllut]Juwe rod this appll florard state tlatthe above Information
benne .1agreeto comply wlthW city.M county oNbunces and state laws
relating to wlWinam'stuNm, and hereby authorfae repemantattves of this
cfty to rmerupoo tl=ab°ve'n^entbrrd Property for Lupectbn purposes.
(We) agree to vy4 indemnity an d keep harm. the City of Cupediro
.gat Wt liabWtb,}rdg�amta, mstsa'd expeses which may b.^yway.roRe
agelvt said City U, con \eros of the grarding of tints permit.
PERMIT I%IIANCE
FEES PAID:
ALTFRORADDTOMEC11
AIR HANDLING UNIT (TO 10,000 CFA()
Date Reeei t#
. SUBTOTAL:
AIR HANDLING UNIT (OVER 10,0)0 CIM)
CONSTRUCTION TAX
Signature of Appgant/Conti wtes Dae
FIAURDO MATERIALS DISCLOSURE
WWthe.ppuoMafuturt Beams oaopant gore or handle havndous
macrlalasdcHned bytM Cu onaNcipal Code, Chapter 9AZ and the
1@alth.rd Safety Code Stolon 31007
❑ Yes No
Will the apptlaMm fuwm buildl,08 occupant use equipment ordevim
which emit harnrdous At eentan renis as defined by the Bay Mea Ale
O..11ty Mavgcmerd Dalrinl
4Yn ❑ No
havereadIheIh Nousmgeriala qu ^^buodcrChapIcr6.95of
EXHAUST HOOD (W/DLrn
CONSTRUCTION TAX PAID:
HEATING UNIT (IO 100,000 BTU)
Date Revel t#
HEATING UNIT (OVER 10,001) BTU)
TOTAL:
Z
VENTILATION TAN(SIN'= RF ID)
ISSUANCE DATE
�Y
BDILF CDMP OFIP OR 100,000 BTU)
BOILER-COMP(OVER Iffl,"BTU)
the Caltfomb Health A Sat fety Code, Sectbroc'0i• ISSM.025534.1
teM that if the building does not have a levni that it is my
u idennot m
Mporuibilfty to realty the oaupard Of the requ4*vb whieh const be met
p Lauanceofaartifbteofonti y, ��,
Ownerm.uthortrN age^ ate
r nor? !i J ����
`
ISSUED BY: Ju`V�
NEW RESIDENTIAL MECH. SQ.FT.
TOTAL:
/ OFFICE COPY