20955APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification+ �+
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUrLDINGELECTRIGVIPLUNBINGMECHAMCAL
,
3I"'g0-
can daraN me: Le. Na:
CATEGORY
CONTROL.
ArehRact/En rear.
6 Lk Nu
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PFRA9TISSUANOi
❑ ❑
LICENSED CONTR 9 C ION
I Mrtby affirm that lam llcenud carder ane of CMapter9 (oornmen
unTjrr
ingwlth Sedbn7000)of Dl Wl 3oftMB"..dProfn .Codgand
APPLIANCES -RESIDENTIAL
JOB ON
'
license le In fou to. and a fe
1arygC6�a�� Llc I
ate Cmttrador
PANELS
� B
n -IM AMPS
ARCHITECTS DECLARATION
I understand my plaroahau beuN upubucreood•
—
OVEt10D0AMN
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNSELEC TICAL
Licensed Professional
9'ECJAL CIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am d
exempt from the CoMraor's Lkense Taw for the
'
TEMP METER OR POLE INST.
foBowing nason.(Sedlan 70315, Buainm and lkufessbn Code:Mydty«
cvuntywh4 requbnapemdttommimu alter,Improve,demolish,ornpair
anystrudunpr tatte aMe•aborequbutheappBOntfm°uchpermltt0
file a atoned statement that he b Bmnme l pursuant to the proWlors of the
POWER DEVICES
,
gWLMA7ING POOL ELECTRICabn
Contrax,t.e. ,Ase Law (Chapter 9(mmmendng with Section 7000) of DiA-
3 of thm
e Buslnand Professions Code) orthat heb exempt therefromaM
VALUATION
the basis for the alleged exemption. ,Any violation of Section 7m15 by any
epph=t fora pemdt sub" the applicant to a cWil penalty d na monthan
OUTLEISSN77LFIESFO(T11RE5
NEW RESIDENTIAL ELEC R SQFT.
fivedollarsladollars (SW.1, asown
I, as s of the property, or my employees wages asthele sob
STORIES
TYPE CONSTRICTION
,
compensation, ovaldothe w«kand thesCde: isnot UdeMed oroffered for
vie 70K an essow and ebv Code: The C rs Wcenee Law
Am apply to f pro Impro and
don not apply to an owner or property who bu1Ws or Improveded that
who dmsuchwork himself«thrmgh his own employea,pmvldMthatach
OCC. GROUP
RES. UNITS
Impmverrcnts an nmt Intended oroffercd for sale. If, however, thebuliding «
lmpraverrcnt bsaW wW b orcyurdaornptellorLthe ownerbullderwW Hve
TOTAL
t ben of proving that he did Act bund or Impnwe for purpose of sale.).
Lj L u owner of the Property, am exchNely mntnding with tla�d
mmtracton to mvt,mi the pm)ed(Sem 7014, Buinma and Pmfmbro Code:
The Contractor's Llceue Law dome not apply to an owrcr of property who
Wilds or Imprwn thereon, and who contracts for much pV" wnh a
Tctor(.)IlmAmxdp..ntt.theC.mdoe.Ll-A Law.
TI am exempt under Sem B 4 P C for this reconOUTSIDE
QTY, PLUMBING PERMIT FEE
PERMITISSUANCE
— 121W
ALTER -DRAIN & VENT -WATER
FLOOD LONE
AM
FEE SUMMARY
BACK FIDWPROTFGC. DEVICE
FEES
DRAINS FLOOR, ROOF, AREA, COND.
F0(7VRFS PER TRAP
SANITARY Y N_
RECETT Y
Owner Date
WORK MAN COMPENSATION DECLARATION
❑[ herfMNve cenl
by an at I haw of convent to aeurta
. orni-Inau, a
mrtlucaof Wortrn CompenuHanlrsuranmwaartif{ed ropythesaf44e
3000, Tabb CJ
SCHOOL TAX Y_ N_
RELER'1
GAS, F.A. SYSTEM-11NC4 OUTLETS
PARK FFP Y_ N
1 dict' Y
RECQ['I' Y
GAS EA. SYS EM -DYER 4 (EA)
Com ny
BUILDING DIVISION FEES
[CCenlned ropy b hereby hnrnbhea
❑Cenmed mpy is filed with the a ty Wpectlon division.
eREAse/wouslRL WASTE INTERCEPTOR
FEE
GREASE Thr
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(I'hbsedbn need red be campletad I(the permit bf« arc hundred dollars
PAID
Date Recti tp
SEWTFgANUARYSTOR.MEA. 70*T.
(5100)«fyth
mdm b the pe tha work forwMch this p
WATER HEATER W/VENT'/FI.ECTR
ENERGY FEE Y N
IshaI amp person In aA subject to the
Wort nm employ any penin N any manner so u to hemme wnbject to tis
Workeri Compensnlon Lvn of UWomb. Date
WATER SYSTEM/TREATING
PAID
nppuont
NOTICEeAAI'PLIC tothe,afterm'Crthis Cn IcA press Exemption,bo
ahold bnmme abkd to the Wohen'Camparonbn provbbuo the Labor
Code, yen conn forthwith comply with ouch proNabv orthb pnmdt Nall be
deemed rewlerd.
Date Recei tit
NEW RESIDENTIAL PLMB. SQ.ET..
A
TOTAL:
B
SEISMIC FEE
CONSTRUCTION LwowG AGENCY
I hereby.film" that there ba eonamr lion lenMing.geKty for the perform-
anmofthaworkforwhlchthbpermttbbmned(Sem3(N7,CIv.C.)
Tenders Name
Lender. Address
I mnifythat I love madthbappuotbn.Mnate thattheabove inlorrtatlm
is mrtnt.Iagree to comply wtth all ety and musty oNlnanm and late laws
rdatl AS to building mnstructloe, and hereby aWhorlx rcpnQntaiives of this
[�.,
TOTA 1']V
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE S•
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
city to enter u Pon the abova-mentioned property !« impaction purposes.
(We) agree to save, Inde an d Yeep hamdm the Chy of Cupertw
ALTER OR ADD TO MECFL
Doh., Rxei tM
� SUBTOTAL:
.Set. WbW g�nta andexP m. which may In any ways.,
agalw sai o(the gnNEig dtNs pertnu.
/�j
AIR HANDLING UNIT CIO 10,000 CFM)
AIR HANDLING UN (OVER 10,=CFM)
.
CONSTRUCTION TAX
gwtumof plit mnct« Date
EXHAUST HOOD(W/DICD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUMT(TO1fA,000BTU)
Will the .pptlont« future building omnpant non orhandle h—rdma
oatedal as defined by the Cupertino Munidpal Coda Chapter 9.1Z and the
Date Recd tp
HEATING UNIT (OVER 100,000 BM
TOTAL: t
IIealthand Safety Cad(e-Saei'm' 25532(a)7
VENTILATION FAN 6INGLE RFSID)
ISSUANCE DATE
IlrmIt unm«/Iuturebuilding oavp[nad by or
the Bay. .Aivim
rets as darned by the Bay Arca Air
whicheMthap,dnt
BORPR-0OMP DIi!'GR 100,(Kq BTU)
Quality Nonagemena Dbtrld7
intrict?
Yn0
PAM
BOILIiR-CbMP(OVER 1fU,0(p BTU)
hove read thehuarilou° eb nequlremenb under Chapter 695 of
California l lealth4�t fetyC g5cct m25505,25533and255M. T
I Ing rot wmantly have a tenant, that It h my
a (]n
SEP 51g,9Q
NEW RESIDENTIAL MECH. SQFTomlbil
na ify a rdoftherequiremantswhkhw
to an rel of Ocaparuy.
;==�2that
ISSUEDBY:
er o authorized N to
OTAL I—
OFFICE COPY