20559APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
22 Sco G7_..1 To aF--f 0 RFi Pf;CZTr1 F Ts 'oe ll-�.�
POINT NO.
Z D V
name: - one.
Tf0IT3U59rrFAI7=
1-Dp_u%A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION If PERMIT
�� Q
Con cto/sName: Lac. N.
BIAI1XNGELECTRICMLPLUN1BINGMECI UNICAL
CATEGORY
CON MOLY
Archffea7Enlfueeo Lr. W.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
❑ ❑ _ ❑
PERFRTISSUANCE
LICENSED CONTRACTORS DECLARATION
'
IhthSed n7")fDirm a Wm3oftheerprovWwsaf Clu.C.dornsnen,
ingwe sinfull oandleffect. the ButlrmaMPmfntloru Code, and
license duo force.Qand ef(M�2�
Lkenx CW Lk.I
Date Contract.! Ka man MAr anieal
ARCHITECT'S DECLARATION
I understand myplam shall be used as pubacnmrds
APPLIANCES -RESIDENTIAL
JOB DESCRIPTIO
I ` '
PL4J K(3 �
Y�
`-w
Yr•`L U-'
PANELS-
211-1000A.A(PS
OVER1000AM15
SQ. Ft.FLOOR AREA
S/SQ.FT.
SIGNS ELECTRICAL
Lkxneed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I un exempt frorn the Contractor. License Law for the
SPFCIALCItC1TL/MLSC
-
Ip,1P.MElTR OR POLE INST.
folbwingma .So m7O315,B sal roam Profen ns Cade:Anyetyor
muntywhkhrequl apersalttomnsbut,alter,Improve,dennlbh,orrepair
anystmctunptmtoitsbwaxgatorequbeatheappllantfmsuchpemdtto
file a signed statement that he b licensed pursuant to the prodaloro of the
POWER DEVICES
SWH,U,ONG TOOT. E],ECIRIC
Contractor. License Law (Chapter 9 (mmmrndng with Section 7000) of DIW-
aloes
n3 ofthe Buslneand Professions Code) orthat he b exempt therefremand
VALUATION
tW het for the alkged exemption. Any dolatbn of Secibn 7m15 by any
appgont fora persalt subjectethe applicant to a cdl penalty of not more than
OUTLEISSWrTCHESFLCIURES
NEW RESIDENTIAL ELECIR sQ-Ff'
five hundred dollars COM.
F1 1, as owner of the property, or rtry employees with wages u their rob
SIORiES
TYPECONSIRICTION
mmpeneation,will do the work, andthe stmGure Is not bderdeci or offered for
wProfessions erty Ixo bails CovtnctoeslA¢nse Lw
does e (Sc appy to an owner
whorl appty rkhwrerofpropghhisn em orlmppv Wt totwchr, and
wnpm,e mch m�Bmthr¢ngh Meowale.
I
OCC.GROUP-
RES. AMTS
,
arenot 11 ewes ,vdedthatsuch
bnprovemenb arenot oroffcrN forsok. IL howeves,lhe Wlldinga
Improvement bedd wflhlnoreyearo(c¢npletlon, the owner-bullderwlli have
TOTAL:
-
rdenofpmAngthsshadld notbuildorlmpmvefmpurposeofuk.).
Lj I. as owner of the property, am eachnWely contracting with licensed
mn
ntctms to construct the project(Seo. 70K Business and Professbro Code:
QTY. PLUMBINGPERMIT FEE
FLOOD ZONE
APN
'
PQ2MRL%UANCE'
The Contractor's License Law dm not apply to s, owner of property who
Wilds or Improves tiu eon, and who contracts for such ptajem with a
owil'tctm(s)Licensed pursuant to the Contractor's License Law.
LJ 1 am exempt order Sec B & P C for this temn
ALTER -DRAIN & VENT - WATER &k)
SUMMARY
BAIX FLOW PROTECT. DEVICEFEE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIVE
Owner Dab
W0R1011AN COMPENSATION DECLARATION
_Kai here affirm that I lut � a certlBate of c.t to self-trturt, m a
W
¢00, Lab f orkeriCmnperaationihmunn¢¢acertlfkd copy thereof 6ec.
3800, Lb CJ
1 olky a
S��r
SCI100L I" Y_ N_
RECEIPT If
OAS F.A. SYSTEM -1 iNC4OUTLEI5
PARK FEE Y_ N_
M
GAS EA. SYSTEM-0VFR 4 (EA)
Co nv aOSaD 115.
DI NO Df
- BUILDING DI VISION FEES
CertHfed copy b henbytumecity
CenHied ropy b fled with the Pty Inspection dldalon.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thlsaectfon need nut be complet d I thpermit e pealt b fororehundred dollar
SEWER -STORM EA 20(1FT
Date RCCOT t#
HEATER w/vF7-rT'/ELFCIIt
ENERGY FEE N
(91 W)or lese3WATER
a
I certify that In the performance of the work for which this persalt is issued,
WATQt SYSTEM/TREATING
1 'ha 11 not employ any Penmh In any manner eo u to become sVEJt t to the
Workers' Compensation laws of Ciliforna. Date
PAID
Applicant R,
NOTICE TO APPLICANT: after making this CerHfkate of Exemption, you
Date Recel t#
NEWRESIDENIIALPLMB. �.el..
TOTAL
should become sub)ect to the Worker' Compensation pmvblons of the Labor
Code, you must forthwith comply with such provbbns or this permit shall be,
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iberebysffirm
ance of the work for which this permit b issued LSec-3097, CW. C)
Mthat then b. construction lending agency for the perform
1eers Name
Urdcra Addheas
I certily that I have read this application and statethat theabove Information
bmrucct.I.greo to comply with.R ttyand countyondiaanm and state laws
TOTAL: 11 Lw
FEE
LECI'RIFE
CE
•7s"'t
QTY. MECHANICAL PERMIT FEE
LUMBIN O ZD
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby a atto.ore represcmauves of this
city to enter upon the sbole-mrntbvd property for inspection purposes.
(We) .great to save, Indemnify an d keep harmless the City of Cupertino
ALTERORADDTOMECH. -
Date RC eipt#
SUBTOTAL:
eg.lnst lLbWtka,J dgmenta,cosbsnd expenses which may In anywsyaccue
against sial City In mnecluchue of 9. gnntlnhg Antis permit. _
AIR HANDLING UNIT 0010,000 CFhD
AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Cont Date
ErHAUSTHOOD(W/DL"
CONSTRUCTION TAX PAID:
HAZARDO S MATERIALS DISCLOSURE
-
HEATING UNIT (TO 100,000 BM
WilltheappliaMorfuturebulldingo¢vpa.t store or handk havndoua
noas defined by the Cupenire Mu Mepal Code, Chapter 9.17, and the
Itrah'aesMSafty Cod hle��.Shlectiuu2S53id)7
Wllltheepplica mfutun Wllding artnpant use equipment mdevkn
m
Date Receipt
HEATING UNIT (OVER 100,000 BTU)
r�'���s
TOTAL -Tv
VENTILATION FAN(SINGLE RESID)
ISS")ATE
which eMt huardwa air contaminants as defined the Bay Arta Air
p A tt'f
BOILER -NMP OMa OR 100,0(0 RTU)
Quality Management Dbtrictt
I Ye �a
have read t1herequirements under Chapter &95 of
• Code,
the California Heaith
Health Code, Sectloro75505,75513 and I
�R'M�+
JUN 2 6 1990
BOILER-NMP(OVp2100,000 RTU)
NEW RF3IDENTIALMECFL SQFT
bSiding
s,that It fanny
understaMyto that if thenotify
does odmre-quirments
rmpommWtyto nalfy theamnpant of the requlmrrentawhich mistWmet
the nogMahout
prkrtr Lrvuaomo(a Cenifkal of Occopancy.
�k,' .
of cuBBllly,
�
o :?s�-9a
'
'5
O wner or authorired agent Date
ISSUED BY: V(j�Ll) lii4.l
TOTAL:
OFFICE COPY