21010APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
NuildinA Project Identification
Building Addm°:
k Co c 4,4 f!W
PERhUTNO.
, 21010
rcr. are: me.
CITY OF CUPERTINO- ILDING DIVISION
APPLICATION / PERMIT
BUMMNr-E•ECIRICA PLUMBING-MECHANICAI.
Conn°°"'^° f k "re
'E ` aS 'I O - C
CATEGORY
CONTROL Y
Architect/Fsglnesn Lk, No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PERMITISSUAN(lZ
❑ ❑ ❑
LICENSEDCONTRACTORS DECLARATION
I hereby affirm that lam lkeved under provWm.of Chapter 9 (comernme,
ing Mth Section7p0D)of DivL 3oftheBwtn mdI fev Code,and
DE
APPLIANCES-RE4NTiAL
JOB DFSC
Ika,. b In fufl fgR end
Da.Clara `'/li Lloa S� �
Da `
le �/�7%TfU CorCraRor {./ _,^� ` JVNS
IS
PANS
PANE
-IDDO AMPS
ARCHITECTS DECLARATION
Iundenbnd my plm.hall be used as publicnada
OVERI(IWAMPS
SQ. Fr. FLOOR AREA
}/SQ. Ff.
SIGNSELECTRICAL
Licensed Professional
��
OWNERBUILDER DECLARATION
m e
I hereby aluslut I am exempt from the Contractor's License Law for the
SPECIALCHICUIT/MISE
_
TEMP. ME111RORPOLE INST. �
following reawn.(Sed ino 70315, Business a nd Professbv Code: Any city or
county which requWap,n i, torr cl aher,Impmve,demo h,orrepalr-
1990
pesnunt to the for suchpermkm
ale. signed statements Issuance, licensed
flit • signed statement the k b Ikxnsed pursuant to the pmvbloro of the
Contnctoh License Law (Chapter 9 (commencing wnh Section 7DW) of DM-
°ion 3 ofthe Bu einem and Pmdubv Code) orthst he b eumpt therefrom and
POWER DEVICES
'
- '
SWIMMING POOL ELECTRIC !�„
_. VALUATION
the ba.b for the alleged a emptbn. My violation of Section 7015 by any
applicant fora permit subject,&th,.pp&.t to a dull penalty done more than
OUTLETSSWCICFffSFUCTURFS �-
NEW RESIDENTIAL FT ECTR SQFr.
five hundred dollars (f50D).
nI, as owner of the property, or my employees with wages as their sole
ST WFS
TYPECONSIRUCIION
'
ompevatbn,wllldothewmikandthestwcture bot Intended or offs ifor
sale (sec 7034, Bustin° and Professions Code: The Contractor. I.inroe Taw
s�
��.s
— I 06X2 TOTAL:
don fid apply to an owerd property who bildsor impro,n thereon, and
whodoessuehworkhmueimthrwgh hbownemployees providedthatwA
fmprovementsanot WtndedoroHeredforu4. ILhoweverthe Wildingor
Improvement beold whhlnorcyearofc«nplelbgtheawnerbullderwW love
OCC.GROUIa
RES. UNITS '
tl)t,¢mdenofpmvingthathedLdotbuudorlmprovefrpurpoaeofole.).
LI L a. avner d the pro", am ercbsfiwiy contracting with Tinned
coduselon to ..red the project (Sec 7044, Ruslnesaand Pmf.iov Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD PONE
APN
The Contractoes License Law don nor apply to so owner of property who
Wilds or Improves thereon, and who cont am for such p,o)eas with
e�lVsetor(s)1k:exd pursuant to the Contractor's Llave Law.
,LJ I am esempt under Sec B Is P C for this reason
ALTER -DRAIN k VENT - WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
FLXTURES PER TRAP
SANITARY Y N
RECEI T of
Owner Dee
WORKMAN COMPENSATION DECLARATION
FIE hereby affirm that I ha,e a mplRute of crones.[ to self-tosure, o a
certtfcidedworkenCompemationlwmmeeor. certified! copy theneofl$ec.
380Lab C
, d
SOi00L TAX Y_ N_
RELFIIT. Y -
GAS FA.SYSI.EM-1 INCA OUTLETS
PARK FTE Y N
PolkyIt
Ce ny A f
CFF
RMET'Y
GAr FA
cRPA.sE N Lw
I BUILDING DIVISION FEES
PI:ANCHECK FEE
IID
copy is hereby furNehed.
F-1Certifiedcopy b filed with the city Inspection dNlpon.
GREA—gE
CERTIFICATEOFIXFIvI TION FROM WORKERS'
COMPENSATION INSURANCE
(Thbsectbn need not W completed B the permit Is fm oro hundred dollen
P
Date Recei tH
sE,VER-SAIJI'I.ARY SIT]RM
(slomorleu.)
lcoAlfythe theperfomunoeof Du kforwhlchtN pemJtbb ,
I shag not employ any person in any manner so as to become subject to the
Wohm
eW Copereatbn laws of California. Dec
W FffA
ERCYFEE Y N
PAID
WATER SYSTEM/TRFA'DNG
Applicant
WIICE co APPLICANT: ll, cork making this Cerfifcation pro of E�s ofthe , you
°holdbemussurth to the Workers' Cush pmrislnprovbbvofthe Ibe
Cade, you noel fmthwkh comply with such pmvWbro orthb permit shall be
deemed revoked.
Date Remi tic
NEWRmDDETIALPLh1B. SQFr.
TOTAL:
TH ITT ONG FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is. corotmctlon lending agency for the perform
ance ofthe work for which thio permit b Issued 5c 3D97, CN. C.)
TOTAL
ELECTRIC FEE
Tender. Name -
Lender's Add
I oedifythatl have read [es.ppllatbn and patethet theabove Nformetlon
bcol.8t buildiitcomplywhhaBdtyandauntyo repr,eandveeofthin
oarutruelon,and hereby orb<nprcxnPurposof this
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE '
PERMIT ISSUANCE
F� 57859
090
city to etorupon I
city to sed , Inde mentbrcd prop harem he City of Cupertino es.
property
(We)agreeto uve,ir es,"sandknpharness the .a ywaya
agaWtiabllltlee, jndgmew,cow.and expenses which mayln any wayamue
a ivteald Cf t . (�7ni Yf he gsntmgdthis pemdt.
ALTER OR AI DTO MTiH.
AIR HANDLING UNIT (3010,000 CFM).
bate ReCeiPtk
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,00CFM)
CONSTRUCTION TAX
t� pate
EXHAUST Hoop (w/pLY,'17
CONSTRUCTION TAX PAID:
AZARDOUS ALScepa DISCLOSURE
HEATING UMT(TO 100,000 BiTJ)
ddirgo
e ilcurtnedb oche C WidlM n,IPanod,Chhandbhaanndous
Wilasdefined
materlaoels.ftycodeeCu rtioM)nitlpal Coda Chapter 9.17, and the
rfeaunes s,fery cm zss37p>I
f��v Yn No
Date ReceI t#
HEATING uMT(OVER lro,000 eTTn
- TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Illthe.ppics or tun WOdingonvpsntuserquipmentordevi®
which enut henndouser inn ds as deflned by the Bay Arca Air
BOILER ODMP (31U' OR 100pID BM
Qualuy Management Wt
4 Yn o
BORER-COMP(OVER 10,00 BTU)
havereadtheh ous materisb requirements under Chapter 495 of
the Calimnb Health h Safety Cod, Sections 75505, 75531 and 25534. 1
NEW MEIN. SQ FT
understand tha t if the Wllding don not currently have. tenant that it bRESIDENTIAL my
I)
I�
n°povlbfllty to notify the occupand of the nqulmerords which mese he met
II
Fbeusnce Occupancy,
pp
— I ATO
1
ISSUED BY
ut pate
TOTAL
OFFICE COPY