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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'en Identification
Building dRs
PERMIT NO.
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21633
nen ane: aAFFUt-A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BLRAING-E.BCTRICALPLUMBINC-MECHAMCAL
HUN bUBMITTAL DATE
Contacto's Name: 'Lic. Nce
C5—z-- G A179r
CATEGORY
Architect/Em Deer. I.Ic. No:
C01^Z�
ELHCrRI_CPERMr.r. ,, FEE'S -
�� BUILDING PERMIT INFO,.;
Address I*f ///E�
i;�' ❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby Oflno that l am Licensed under provisions of Cha pier 9(mmmen
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
ingwlth Sectlan7DODot DiWslm3ofthe Buslneaand ProfessionsCode,and my
I icense b In (u effect.
Llance Ch ICY y%.S�%]
�e
�L 1
DaleGantnctor TG! �CiaTUP
TO 200 AICS
Ni.1 OOO AMP$
ARCHITECT'S DECLAR ION
I understand my p es . �
OVER 7000 AMTS
S. Fr. FLOOR AREA
$ISO. FS.
SIGNS ELECTRICAL
Licensed Professio
OWNE UILDER DECLARATION
I hereby.rnrenthat I am exempt from the Committees Lice.. Law for the
A'ECLLLCItCUTi/h45C
TEMP. MErM ORIOLE INST.
fallowing reason. (Seaton 70315, Bua au
slnend ProfebM
ru Code: y city or
oatntywhi.h requbesa permit tommtruct, alter, improve, demolish, orrepair
anyatm=mprlortoib Nuance,alwnqulreatheappfia tfmsuehpemdtto
file a signed statement that he is Limned pursuant to the provisions of the
Contactors Licerese lAw(Chapter9(commencing with Section 7000) of Divi.
don3 ofthe Bualncaand Pmf.I.m Ccde)ortha he is exempt thenfmm.
the basis for the alleged exemption. My violation of Section 7031S by any
applicant fora permit subjects the applica• ot more nt to civil penalty of nIlan
POWER DEVICES
SWI,f)PINGIWL ELECTRIC
se
DOTUM5WIICHES,PDfTURES
VALUATION
R Q/
Ovundad dollars (5500).
L u er ownof the Property, or my employees with wages a their sole
NEW RESmFM7AL E-ECIRSQ'FI'
RIES
TYPECONSTRUCTION
mmperuation, will do the work, and the structure is ret Intended or offered for
sale (Sec 7096, Business and Professions, Code: The Committees Un me [Aso
does not apply to an owner of property who build or improves thereon,and
who does such work himself orthrough his own employees, provided that such
improvements arc not Intended oroffered for axle. IL however, the build Ing or
TOTAL:
�OCC.GROUP
/
RES. UNITS
improvement is sold within one yarofcompletiors the owneoWBderwN have
01LIlurden of proving that he did notbu0dorimpmvefwpurposec(akJ.
LJ L as owner of the Property, am exclusively contacting with licensed
mntnnon to mmwtlthe project (See 706`BwInesa and Prerfessbm Code:
.. -
QTY;'•;v..PLUMBINGPERMTT,{';.. �v 'i"�FEE-;
FLOOD ZONE
MN
EMIT ISSUANCE
The Contractors License lAw does net apply to ant owner of Property who
builds or Improves thereon, and who mmacts (m such ppgects with a
ryllfacur(s)Ixesed pursuant to the Co.Ratlors License Law.
UI am exempt uMa Sec B & P C for this reason
ALTER -DRAIN & VENT- WATER MA)
,FBB�SUMMARY
"
EC
BACK FLAWPROTT. DEVICE
DRAINS FLOOR EA, ROOF, ARCOND.
SANITARY Y_ N_
BBC=Y
Owner Date
WORKMAN COMPENSATION DECLARATION
E31 hereby .farm that I have a certificate of consent to self -inure, or a
certificate of Worken'Compensadon Insurance ma certified copythereof (Sec.
3600, Lb C,,jj
Pollq {'G �Y7y0 i
TT STRAP
S17100L TAR Y_ NRECEIPT _
Y
GAS EA. SYSTEM -1 INC60U7LEf5
PARK FEE Y_ N_
RECEIPT Y
Y_
Cam an�E�UG�L.e�/r A/Oce�
GAS FA. SYSTEM.OVER6 (EAI
BUILDING DIVISION FEES
Certfied copy is here role cid.
Certified
�ropy is Ned with the city inspection division.
GREASE/IN DDSM WA SM Bd7'FRCFTTOR
PLANCHECKFEE
GRFASETRAP
CERTIFICATE OF EXEM PITON FROM WORKERS
PAID
SEWER -SANITARY -STORM EA. 200FT.
COMPENSATION INSURANCE
(Thlsseetlon need not be completed B the permit is intone hundred dollars
Date - Rtowipt#20t 5-0
WA.��A.�W/VENT/FT.ECIR
ENERGY FEE Y N
PAID o/� �ay�
Date RCCei t# / cLc
6100)or len.)
] anlfythat In the Performance of the work forwhlch this permit is Issued,
I shall no employ any person In any manner an n m been ub'etl o the
Worken'Com yt lAwaof CaBfoyr�DaIs
Appllunt I /if'+1S
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFC.
NO7TCE 'PLICAM:R' dngt ertRI�Y fFxemptlon, you
should me ub#ctnW orkers'Cga .."flan provisione ofthe Labor
TOTAL:
BUILDING FEE tbc
Code, you nest forthwlth comply with such provisionsorthis permit shell be
deemed revoked.
SEISMIC FEE Lac
CONSTRUCTION LENDING AGENCY
I hereby aNnnthet there is a conanutllon lending agency for the perforrm
ance o(thework forwhlchthis permit d&c,3097,CIv.C.)
Lenders Name i. /
Lender'.Addren/ T
I.Aifythstl have reads apPbalienardaatethotheabovelnfornatlon
ismrnct. I agmeto comply with ail city and county ordinances and pate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
- .„
Q7Y. �' - `MECHANICAL PERMjt�7'- • ,FEE'.:
PERMIT ISSUANCE
MECHANICAL FEE
7
FEES PAID:
relating to building mmtrutlion, and hereby authorize representatives.(this
city to enter upon the abovcmentlomd Property for inspection purposes.
(We) agree to save, Indemnify an d keep hareu the City of Cupertino
mi
against liabilities, Odgerems,costsand e.peme. which may in any wayaocrue
Dale ReCei t#
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 1(,ODO CFM)
SUBTOTAL
against said City In O
conseque fthegart
n oflhl.penit.
�e
AIR HANDLING UNIT (OVER IO,OODCFM)
CONSTRUCTION TAX
Sigruum.f /c nor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZA DOUSMATERIALS DI SCLOSURE
HEATING UNIT (TO 100,030 BTU)
Will the Applicant orfuum building occupant store or handle hauunlaus
material as defined by the Cupertino Municipal Coda Chapter 9.17, and the
Health and Safety Code Section 25S32(a)?
0 Yes MN.
Will the applicant or tutuce building onopant use equipment or devices
Date Recei t#
HEATING UNIT (OVER 100,00B BTU)
TOTAL' 1' 0
VENTILATION FAN (SINGLE RESMD)
't��.
ISSU40AMTF
which emit hannlous ab contamimna as defined by the Bay Area At,
Quality Management District?
4Yn ❑❑No
have readthehazartlausrvteria)faqulremcn%under Chapter6.93of
"a'�/ I
j,, ) CC��
JAN 3 Q �J�� i
BOR.ER-CAMP 0HPOR 100,0013 BTU)
BOTLELCOMP(OVEt 1W,000 BN)
the Calitomla Health & Safety Code, Sections, 25505,25M3 and 25536. 1
KEW RESIDENTIAL MECH. SQFT
understand that if the building dna not urmntly have a tenant that it is my
nopomem
ibllity to notify the occupant of the requirements which must be mint
/s�1
City 11
prbtin suane of.cdi teof
' ,
�/9� �
\
ISSUEDBYC:i
lOwneror rad agge Date
TOTAL:
OFFICE COPY