S 4403APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY (IF CUPERTINO BUILDING - ELECTRICAL. PERMIT NO.
LBUII,DING DIVISION APPLICATIONIPERMIT PLUMBING- MECHANICAL ,l d d n
NAME:
❑ Consultant Fen Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DF,CIARAI'[ON QTY
1 It y ren that I em lin nxd tiler Provisions of Cheaper 9 E, in,
X07. wimS, ]IgM dDlvisiun9nfmc Business and Prof"iuu Co-k,omnlylM.is
� to full fusee anal lBal.
QFU�j I.icenw Class Lic.N
N Q L Dair o
Coacur
ARCl1ITELA
CFS DECRATION
z0(7n LundeoaNmy planx nmII be m-itto publlcaao,E
oz -o
Gomel"InNoi.-I
OWNER BUILDER DECLARATION
-y 6 I hcmb, wErs. mat 1 um sxcna,t from the Contractor'. License Law for the
3
'c-
U following reason. (Section 7031.5. Business and Prmioioru Code Any city or awmy
qa which nxx,ui f a permil to construct, eller, improve, dem011Jl. or relator N)' muctYrt
FLLOJ
prior o its iswmec. nlsnreamre, Je uppliam lar inch emil to Ili, a signed sumtrent
fN that he is licensed paraoral to the pro,mis, of the Contractors License Law (ChaPterY
OO Ic"mncncing wim S,," m 7(w) (if Divi,i,,n J of the entire. oM Promsoons Coax) or
a a e C thin , is exempt t,refrom utd Be basis fm the allege l iter mon. Any violation of
Sawn 70313 by any.pplicont for v Permit subjects the applicant to v civil penalty
,� n more that rove hundred &Ilan (S5W).
❑I. as r..arofl, pmPenY•or mYrmPlvizs atom wagetulhchrnk cmnpenwian.
will Ju thewtA, mt IM1c-vlruclurt ro rnl imerulN-nRcred lin sal, Sc,. 9194, Barineu
a3 $ and profs xionx Code: T, Comracaor'. liccn.se Us. ret lam a,,Iy an an owner of
progeny atm builds or mmmvet thrmn, vagi who docs wch won himeelfor mmtgn
hi, nwm empinyeet. provided that sten impor»emcn0 aro is. tmcmn) nr mremu for
sdc. It, howcvrr, the hooting or improvement it told within oma year W.,AeOon, the
waer,ilJer will moe an, rut of proving met m did m9 miid eta improve lin par-
posc of side).
M I, m ofmc pro trty. and exdusivcly cnnoaling wilh limnmat ommicnn In
caustrmt the laoi (Sec. 70W. Bwarrat" Pmfrniwt Corte) The CmBmmrs U-
ulawJocxnmupplymannwmrofptoPenyu1tnMriMl.mimpmvcx ltreiCml. atd QTY,
who contracts for such pojects with a ururacam, it licensed pursuant to me Conlrvclor't
U. U.
❑ I am rxempt under Scc. ,B&PC for miarcusm
aJ
Dam
WORKERS COMPENSATION DECLARATION
I herthy affirm nadirnder penalty of perjury me of the following declaration,
I have and will mearmi n it CcniOcam of Consent n self-inwm for Words Con,er-
suion, as mvtdd for by Section 37M of the labor Code for the permninua a of IN,
—A for which this lemin is itsovd,
❑ 1 bare art will maiwin Wa rl er, Compcnwim intmalac, is regaird by Section
3700 oft, lahm Cite, for the Pcrfomtmcc or the work for which thin lentil k noted.
My W nsalian a and Policy number
r. Pulley No.:
CE FICA )F 51"' ION FROM D KERS'r
COMPENSATION INSURANCE J G
Ctit,cmtmn ,d,,ena hr:,nmp,n:.D irme hambcd AAms(SIM)
ale )
Iccnify li perfumtutcan fayy''fftticht islxnnil is iawed.ishdl
rad rnynloy an in any owneroa�wbj to I, Wuhan' Cr.nprn-
Ol'ICEW APPI-ICANT: ILSBcr maskiM To%CeniOcue of Exemption you unset
Lrxme.wbjal to the Workers Compunsamon pmvisinns of the WmrCote, you must
Qfonhwim comply with such rovirin, or tldx Pernik shall, leaned rxvolvd.
z CONSTRUCTION LINDING AGENCY
L) Q I,reby affirm that there is amr,mrctiontesting ageley for Be perfomwrttt of
D. ma work for which this pcnnit ix issued (.Sec PYA. Civ. C.)
C) U Lrlmern Nano
U Lcndcrs Adore.
Fy I cenify mat I nave rat wit ti'lcatim sal Sue tlw the above bcmrtm w. i.
Uh "'re" l agars m amply with dl city aM ttumy moi— and w¢ own rclmme m QTY.
Z mtlmng conWlYl'mn. unimovby aaJtm; a,par.wmvi.ec nnhn,'nr w,meraPtn m,
.mate -mentis property rmtmpaamn urr,o�,
(We) agrm m tro, mdonmify and kap hamnlev Ihn Cit int a, an
Itabilities.jWgmenit,c dnpcmeswhich may at any attoue agin 'J Cay
in comrqucoceot the I gofmisletmil.
APPLIC NDS AND WILL CO 7611 ALL NON DINT
HAI RDDUS MATERIALS DISCLOSURE
Will me applicant or tumm,ihling «euparal sore or mmlk hmearrious material
as de0red by me Cupcnino Munwipel CW, Chapter 9.12, nod t, Hit aced Safety
Cote, Salient 25532(a)^
Dyes F-1 No
W,11 Im v,f.m or fanatic mi ling mnupanl t¢ eyi ipmnnt m dcveo whkh
JI hinsix t dr cmmmitunts as eicfned by the Bay Area Air Qunlily Mantgclrem
li,trk,'
0 Ye NO
v rC,1 ser ❑it nvu,aln nyul cot r(Tu p,,r95 the Cvlh
foto Liu C . Saloon 25505, " 38 H. I u thio if me
milli harcamnnnt,t Ibilitymmn-I,tieupmtl
of ase h nun , mit tet Cern tl l centra v.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDI!N IAL
PANELS
UP'IU M) AMPS
201-IIN)(DAMPS
OVER BOB AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITMISC.
TEMP. MEIF,R OR POLE, ST.
POWER DEVICES
SWIMMING P9&ELIi
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOL AREA, GOND,
Fl%TURP_Y - PER TRAP
GAS - EA. SYSTEM -I INC. a OUTLETS
GAS - EA. SYSTEM -OV ER J (FA)
GRIASFANDUSTRL WASTE IN`HRCEPTOR
GRIT SIi'I'RAP
SEWER -SANITARY -STORM EA. 2f10 FT.
WATER BEATER W'NENT/FEECfR
WATER SYSIEAVIREATING
WATER SERVICE
NEW RESIUEM'IAL PLMB. SO ET
MECHANICAL PERMIT
PERNUT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT OVER 10,0110 CPM)
EXHAUST HOOD(WB)UCT)
HEATING UNIT (TO 100,000 BTU
HEATING UNIT (OVER 100 BIU)
YEN'MAUON PANIKGLE RCSID)
BOILER - COM 3HPOR IBLBX) BTU)
BOILER -XMP (OVER 1011,000 BTU)
SQ. FT.
FEE
❑ ❑
JOB Q
RUIDENTIAI:
OSHWL
❑ ADDITION
❑ MULTI-UNR
E3 INTERIOR
7w
❑ KITCHIiN '
Van
S CIURAL
MODIFICATION
❑ CHIMNEY REPAIR
Ej S W NIMING POOLS
PAIR ❑DEMOLITION
LJ NEW BLDG/ADDITION-,=-701- N
❑TENANT ❑Itll
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR
FEE
VALUATION
STORIES TYPE CONSTRUCTION
11,115CC. GROUP APN
BUILDING DIVISION FEES
PLANCH _
7 ENERGY
GRADIN
SOBS Pill
Lj
PAID
Rae N
TOTAL
BUILDING FEF.
FEE SEISMICIEE
IfILLEcTRICFEE
PLUMBING HE As
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MMOATION FEE
PAID
al uetP
OTAL
ISSUANCE DATE
autgrnt Umc TOTAL: ISSUED BY:
372, 94go OFFICE
s
t
CUPERTINO SANITARY DISTRICT
20065 Stevens Creek Blvd., Bldg. C
Cupertino, California 95014
(408) 253-7071
"OVER THE COUNTER REVIEW'
Community Development Department
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014-3202
Gentlemen:
Building
Re: Subject:
DER: _
CHB: _
AEF: _
File:
Date: %—�-9 9
File: CuSD -MOP
Building Dept -Cupertino
Name: lj L �jP V ✓ g
Address:
APN: dl�3
Control/Plan Ck No:
Permit No:
0.1.1 L V _
Ann L-7
The Cupertino Sanitary District has reviewed the plans for the subject project:
No additional conditions/requirements by the Distr//I Gr+�'/c�to C_o
ict. ( t'J/ayre�t'f1'Lil
❑ Sanitary sewer is available and the existing building is connected to sanitary sewer, see! /
conditions/requirements listed below.
❑ Sanitary sewer is (not) available, see conditions/requirements listed below.
The following Conditions/Requirements are made:
❑ Cupertino Sanitary District Fees or Permits are required for the subject
improvements please do not issue any building/grading permits
❑ Plans shall be reviewed by the Industrial Waste Division of the San Jose /Santa Clara
Water Pollution Control Plant, Phone 945-3000 for questions and to schedule an plan
appointment. Please Do Not Issue permits until pretreatment recommendations have
been forwarded to you by the District.
❑ Locate and raise to grade a property line cleanout (verify serviceability if existing.)
❑ Install a backflow protective device (verify serviceability if existing.)
❑ Break areas authorized minor electrical appliances only.
❑ No commercial disposal or commercial dishwasher, installations.
❑ No added lab/office equipment which results in additional wastewater discharge.
❑ Other: ........................................................................................................................................
Storm water from surface or roof drains, other general surface runoff water or condensate from any
residential HVAC equipment shall not be discharged to the sanitary sewer.
File CBLDLTR
Reviud 7/99