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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN.ONLY
Building Pro'ed IdemHiotlen^^�
POMIT NO.
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22899
net 11hon
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
N�
c�yC� c- .�5.� .�� Lk
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BUIIOINGME.TRICALPLUMBING-MCCHAMCALGTEGORY
CONTROLIf
A'K',Engf
Sig
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add
PFRM1ffCISSUANCEID
0
LICENSED CONTRACTORS OECLAR ION
I
Ingwith
lire^heb IncfuRrrota and df7m. 3edunderr provision. Chapter
Sethn70DMof Divinon Jofthe Bust rc.AvCoee,and my
NCFSRESIDEM7AL
.)OB D
--
PANELS
enCks Llca
Date
Date Coritrador
UP TO 2DO ANTS
701-1000 AMPS
ARCHITECPS DECLARATION
I understand my pkroehall be used as poblle recmis.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
g/9]. FT.
SIGNSELECTRICAL
LIcevM Pmf.L nal
OWNER -BUILDER DECLARATION
I herebyafRrmthat lamexempt fromthe Codractori Llan Lawfa the
SI'ECIALCIRCI117
ip,(p MBT772OR MOL IN
ED
following rtawn.(Section 7MIS, Busiest and Profobro Code: My city or
assn re permit re, mrotmci, Irnp demoWh,or rtpar
1
I�
mdtum Peru to its
anygmarretatemeltsbsuan I, 11rensdpursueatothe fasuchpemdte
h lea
es the
a signed statement that he b Ik pumunt it the provblov of the
pLyWpRD��
C
Con3ofthe Lk— LwtQuptWMC( )ort gwhh 9emp"hem(mrt Divi-
(co
and
the hofthe theallegod Rdmbro Code) clatioheb Seamon MIS
My ttolabn d Seaton normo by any
the beans for the akged eaempte applicant
apeButdred apermi subjects theapp0canttoatldl pevhydnor more than
SWOPQUNG FOOL ELECTRIC
OIfILE1SSWifQ-�"'FI
VALUATION
Gi t
NEW RF9DFNTIAI, F1.FS7R SQFT,
❑wan hunand doBas p
E] 1, u I, ownof thehe property, or my employee with wage as their sok
sTuBLEV
"IYI+E CONSTRUCTION
cornperuation, wBl do the .k. and the trumare b not Wended or offend for
sale (Sec 7014, Business and Pro csalcm Code: The Contnaor'a (Jame Law
ti
does not apply In an owner of property who Wilda or Improve thereon, and
nhrgh his own employ, pmdd
whodoeeuch work himself or aee providedl
OCC.GROUIa
RFS.UNTT$
IrnWrovemenasaaoot Ntendedorofke fasale. ILhavever,the WlMinger
Improvement la sold wNhln me yearof canpletbR the owner -W IlderwIthave
TOTAL
'
try,,* rden of proving than beau rat Wud orimpmw, fapurpo.eofnk.).
hely cting with Ilanse
Lj L as owner of the property, am ehn�wd
mntr =to combo^the project (Sm 70K Businmard Prefesbro Code:
QTY. PLUMBING. PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
AM
The Coomi Lloen Taw does not apply to an owner of property who
Wilde or imp. thereon, and who mdnce for ouch peojecis.whh a
aggRaear(a uamea pe.annt m the cadraaa: Llan Law.
01 am exempt order Sec B 6 P C for this reason
ALTER -DRAIN &VENT-WATEt(FA)
FEE SUMMARY
BAac Flnwl'IeoTF r. DEVICE
OUTS I DE FEES
DRAINS FLOOR ROOF, AREA, COND. ��
SANITARY Y N
RECEIPT 0
Owner Dae
WORKMAN COMPENSATION DECLARATION
❑I hereby afilnm that I have • certificate of consent to self -Imre, or a
¢Mate of Worken'Comperoatlon Iruurana or a artBkd ropy thereof Sec.
3300,7.6 CJ
I'oI Try I
-
FIXTURES PER TRAP
SCHOOL TAX, Y N
REGFD7 R
GAS PA. SYSTEM-11NC4OUTLETS
PARKFER Y_ N_
TO
GAS EA. SYSTQ.f-0VFR 1(EA)
Ca
DING DIVISION
BUILDING DI VISION FEES
Hied mpybhercby fumished.
Can=y ropy b tiled with the city iropeaTbn dW Won.
GREASE/NDUSTRI, WASTE INTERCEPTOR
PLANCHECK FEE
GRFASEIRAP
CERTDTGTEOF EXEMPTION FROM WORKERS
PAID
SEN,E2SANRARY SIORM E.A.700F1.
COMPENSATION INSURANCE
(This.W. need no be completed tithe permit infer one hundred dollar
Date '• Receipts[
WATER HEATER W/VENT/m FCTR
ENERGYFEE Y N
-
PAIDApplican-'
MW)or ions.)
I rertlfy that In the pcaomwca of the work for which this permh is blued,
I shag no employ any person In any manner so as to become subject to the
Woclomi Compmenbn laws of California. Date
WATER SYSTEM]/TREATING
NOTICEt
Nould beOAPPLICANT:e aftermatingthinCetor, preisonempte you
the Wor, provisions
should becomesubth
Date Reeei tN
NEW RESIDENTIAL PLN(B. SOFT.
it with such proabn
permit Y. forthwith shell be
deemed rewkcd.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffi rm re b than thea mnstru¢Ion lending age �y for the perfomv
once of the work for which this permit is issued (Sc, 3097, CW. C.)
Tl7Te
ELECTRIC FEE
IenderName
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
Lender'sAdd.
1onii hat I have read nhhapplictbn and ranethattheabove Infomudon
b mmret. I agree to comply with all city and county ordeanm and gate laws
MECHANICAL FEE
PERMIT ISSUANCE
_
FEES PAID:
relating to building mrmtmallon, and hereby a W horlm representatives of this
city to enter upon the abmo-menlbvd property for Wpectbn purposes.
(We) agree m ave, IndcmNfy an d keep harmless the City of CW
upert
ALTERORADDTOMI3CH.
Date Retei [p
SUBTOTAL:
aga4ut wbiblylndgmen cogsand expenses, which may In arnywayaavue
a Ivtgala pRR�t to the nathin mdc
�g �`
Aare HANDLING UNIT CFO 10,000 CFM)
AIR HANDiJNG UNIT (OVER l4aoo CFM)
CONSTRUCTION TAX
romamofAA—�- oMACogf nor QTD��
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HALxDOUS MATERIALS DISCLOSURE
Will the applicant orfuture beadingprt gore or handle harardasHATING
material as defired by the Cupertino Municipal Code, Chapter 9.17, and the
Date Revel fk
UNTT(TO 100,000 BTU) sf
HFATING UMT (OVER IOO,000 Bftn
TOTAL
Health ard Sa ny Cade Scadon 75537taH
F-11Ye No
Mico
VENTILATION FAN SINGLE RFSID)
IS9W*(jE8ATE
/{
OCT. 24 199 1
Will the appOaM Wilding occupant use equipment or devices
whish cmlt ha,ranlas air contaminates as defined by the Bay Arca A1,
QualoMavgemeen Wtrict7
4o' I ] Kb
haveread the h=mougmaterials mcfuinementsunderChapterb95of
the C.Ifornla health 4 Safety Cade, Sectinm 75505, 755]3 and 75536. I
R-
BOIIECOMP ODOR 100,00i) BM
IK)ILER-ODMP(OVER l0%000BTU)
NEWRESIDFMIALMEOHL SQFT
urala ndthat lfthe Wlleingdoes ataanentlyhaveatenant that it bury
responsibility to notify theamrpant d the requUcmerds which mut b, met
priortnlsuarccofa CenifcateofQavpancy.
C'7Da
OF CUPERT INO
'–
ISSUED BI:et
Owners authortrad agent Date
OTAL /
OFFICE COPY