23604APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address: - -
PEIU UT NO.
2 3 6 0 4
core: .n
DEITY OF CUPERTINO-BUILDING DIVISION
C dor'.Nan�e: /1,1c N
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mh /Ffj61^«j� L1c N¢
/ APPLICATION / PERMIT
BLnMNG-ELECl CA4ML lNGWJCHANICAL
CATDSORY CONTFOLe
QTY -ELECTRIC PERMIT FEE
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BUILDING PERMIT INFO
(rF7tAQTI�UANCE
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Address �S� v/rp ��
LCE NSEDCONTRAROR'S CLARATION
I hereby affirm that lam lkmsM oder prwlsions or Cfupler9(®nmrn
Ingwith5«tbn7000) of Dlvlston3ofthcB I.ssa dProte ..C.de,and
]I. is In full jytx and Crest.�/9
APPLIANCES -RESIDENTIAL
JOB D �
R" �{,
PANES
Licers Chas. /r_rL /Lk.Y
a I `. v e
Dau Cordrad
UP TO 2D)AN(PS
201-1000AMPS
ARCHITECPS DECLARATION -
Iurdmundmyplans.hallbeu upublicremrtL
OVER1000AMPS
SQ. Ff. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL RICAL
LI¢osed Professional
SPECIALCIRCUIT/MIS
OWNER -BUILDER DECLARATION
I heeby afflrmthat I am exempt from the Conductors Lbense law f« the
'
TEMP. MEERORPOLETNST.
following reason. (Section 70115, Business and Pmfeasbru Code: Any city or
muntywhbhrequbesaperedttomnstroa,alar,bnpmsr,de Ushormpalr
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.
anyslruQurt prf¢ ro Ila lesuarce, ala regales theappbant f«ash prnmlt to
Ne a signed statement that he is looov
med pursuant to the prisions of the
POW me DEVICES
SWIMNUNG POOL ELECTRIC
Contractor. License Law (Chapter 9(mmnencing with SeNoo 7000).( DWI-
ebn 3 of the Business and Pro(mlons Code) orrhat he le exempt therefmmand
VALUAT3f9pE
the basis for the alleged enempticn. Any oblation of Section 7015 by any
it bjectstheapplicanttos doll penalty an¢morethan
applicant fora permsu
OUTLETS-SWrICHESFIXTURES
1��/ ���C�JJ
a x./W
NEW R=EN'TIALELECTR cSQ9r
Iivundred do]" (S500),
I, as owner of the Property, or my employees wish wages as their role
STORIES
TYPE CONSTRUCTION
- f
mmperaadon, will do the work and the stmctune is not Wended or offered for
axle (Sec 7014, Business and Professions Code: The Contractors License Taw
docs not apply to an owner of property who builds or improves thereon, and
who doesnuchworkhmsalf «thrwgh hlsownemployees, Prwlded thatanch
-
UN PS'
bnpmvrmeware net lnunded oro(lcoed (or role. IL however, the Wildleg re
improvement bsoldwithinorcyearofcampletbn,the.wmuL Merwifltorr
T
t"ides or proving that he did not Wild or Improve f«purpose ofaale.).
LJ L u owner of the Property, am eschWvely, contracting whh licensed
tn
conctora to costrud the project (Sec 7Oµ Business and Professionsessions Code:
QTY, PLUMBING PERMIT
PERMIT ISSUANCE IMMIE
� NE
�i
/Irte/ b/ ,53
APN
The Contractor's License Iaw dove not apply to an owner of properly who
Wilds or Improve thereon, and who contractst« su3i p,jem with a
aNIZacterWBoemed pursuant to the Contractors License Law.
L jI am tworpt under Sec B k P C for this recon
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ALTTRDRAIN k VENT - WATER 171w)
'
FEE SUMMARY
BACK FLOW PROTFLT. DEVICE
-
ORAINSFLOOR ROOF,AREA,COND.
SANITARY Y_ N_
RECEJ T R
Owner Date
WORKMAN COMPENSATIONDECIARATION
❑I hereby atom the I have a ¢niflcau of c ntsem to self-mium, ¢ a
380), bof Workers pe tionlwun¢ora fed mpytheoof (Sec.
poic Tab CJ
Pd4cya
FIXTVRF_S PER TRAP
SCITOOL TAX Y
_ Nornifi_
RFLFEPTT s
GAS EA. SYSTEM -1 INC40UILES -
PARK FEE Y N
RECmR a
CAS-OVER4(EA)
–{
C. y
BUILDING DIVISION FEES
ICe"Iied copy is heeby furnished.
rliBed copy is filed with the city, Inspection dMaion.
GREASE/INDUSRRL WASTE INTERCEPTOR
PLANCHECKFEE '
GREASE TRAP
CERTIECATEOFFD(EMPTION FROM WORKERS
PAID
SEWER -SANITARY -STORM E.A.2)OFT
COMPENSATION INSURANCE
need n¢ becompleted bibs permit h (¢ons hundred dollarsR100)«m.)
(p or
Date Recei t#
WATER IMATER W/VENT/EIFCTR
ENERGYFEE Y N
lecfbn
1 ¢nlfy in of tmannerhe wock ermh h Issued,
WATER SYSTEM/TREATING
emplohat so as to b comhis
any person
I sluff not employ any peraot N any manner at es to become abject to the
y the
Compenurbn Uwe o/G Wonh. Dau
PAID
Applicant
pplica
Appb¢nt -
NOTICE APPLICANT: ll, after wking Wa Cettblcate of Exemption, you
Date Recei t#
NEW RESIDENTIAL PLM6. SQFr.,
TOTAL
ahold become subject to the W.rken' Competuatbn provhbns or the labor
Code, you nuat fon hwLLh comply with such provislore or this permit "it be
BUI —a
DING EEE
deemed revoked.
SEISMICFEE
CONSTRUCTION LENDING AGIENCY
Ihercbyafflrm that there Isn, construction lending agency for the perform,ELECTRIC
an¢ of the work for which this permit b issued (Sec 3097, Civ. C.)
FEE �+
PLUMBING FEE
Lender. N.nr
LerdereAdd2,e
I aentfythat I havetead thlsappBuuonaM tlatetlut theabwe In(orrnwi®
h mnect.l.go, to comply wlthill sky aM countyordinaom and stale laws
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
reutingto WlldingmM Won,hereby authW represoma,d sof this
-
cNytoemer ntk rrcnrbred property f«IrmpeCbn purpoaea.
i .mnity an d keep harmless theCity of Cupenbu
ALTERORADDTOMECR '
DatC Receipt#
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SUBTOTAL:
agalvtl BI ,j, me b,mataaM expecte whkAmrylnanyw.yamue
ages W d y uenc'e of the gra g d this permit.
S
AIR HANDLING UNIT OO 10,000 CFM)
AIRHANDUNGUNTT(OVm Ig000CFM)
CONSTRUCTION TAX
cant
nes neo u / oetranor Date
DUTAIIST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
FIAZI MATERI UISCIASURE
HEATTNG UNIT CM 100,000 ITU)
Will the.ppliant or forum Wilding cg&pant store orhardie havandoua
material as defined by the Cupertino M dpal Code, Chapter 9.17, and the
Date RCCCI t#
11EATWG UNIT (OVER 100,000 BTU)
_
TOTA k
E❑Tend Safety CodeS�Ie<toon 25532W7
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
WultheappBmener tune building«onpant use equipment or devim
which cont havrdous air conummums as deRnsd by the Bay, Area Air
.
BOI ER -COMP OTU' OR 100,000 BTU)
Quality Mavgemerd Durrkt7
Ya ❑ N'o
Ihavercadthehuard.usmaterlabrequirementsunderChapter6.9Sof'
the Obf. L. Health 6 Safely Cod, Sedlons 25505, 75533 and
uWmtaMttutlfthe Wfldingdoesnetcormntlyhaveaten.n4thatltbmy
h
p
/ ) w
awl
BO ERCOMP(OVQ 100,000 BTU
NEW RESIDENTIAL MECH.—SQ-Fr.
r porulbiltlyto.cifytheoccup.rdoftheuqubementswhkhmmtrrout
Poor m isao.ner w. Cenifieso.fOemp,my.
AY
r'l7` l 199
_
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W
ISSIlEUBY'_ pyb
Owner «authorlud agent Date
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TOTAL:
OFFICE COPY