23775APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm co Identification
PEltMITNO..
Building Address:i.J
E
23775
n one.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMITY�-
Corton«.Name: _ Uc.N.
1U1 DINGEI.ECIIUCALPLUMBINGMECHANICAL
CATEGORY
CONTROL Y
A Rea/ gime,. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ndareasCONT_
PERMIT ISSUANCE �"'•
❑ ❑
ENS
LICF.DBACTOR'S DECIA TION
IhmbydfU tlutlamikenaeduMe pmvblauofC pter9(mmmenc
ltn7DOO)�Dim3aftheRdmandPmfbsCdcmdrrty
Iiterse 1b 1. full to. and dffict.
APPLIANCESRESDEMfAL
-)()aDESCRIPTION
N
'
PANELS?PI*4jG
Lkrvc Cbep LILY �'S�/3%
Date
'
t AMPS
• �ARCHITECTg DECLARATION
RCIIInCT DECL RATIIO
OVER 1000 AMPS
SQ. Ff. FLOOR AREA
5/SQ. FT.
I uMerd.rd my pans .hail be used u public rmmda
SIGNSELECIRICAL IN I
Licensed Professional
OWNT:R-BUILDER DECLARATION-Ti
I hereby affirmthat I am exempt from the Contnctorb License law fo the
L
LED I
SPDCIALCIRCNT/ML9C
TEMP METTR OR POLE INST.
follodng reason. ion7015, Businm and Pmfcalov Code: My dtyor
muntywhkh requ ma permit tommtmM alter, lmprvaq demolath, arrepa r
1
P TER
anysiructumprlortolUl me,aL requimtheappBantfowchpe tto
Ne a signed statement the he Is Bayed pursuant to the pravbbv of the
POWER DEVICES
S14�hgNG LELECIRIC
Contnctoh LkeveLw(Cluper9 (mmmenMg wtlh Section 7000)of qv{-
ebn 3 f the Buanem ane Prdeabv Code) ortha he b exempt there[mmsrd
the basois for the alleged exemption. Any Walnbn of Seabn 7m15 by any,
appho tforapemdtwbjedstheappB ito•d 1penaltydrwmoathin
OUT MSIVITCHESFIXTURES
NEW RESIDENTIAL ELDCIR SQFI.
flue hundred dollar (frW.
F-1 1, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
compensation, wlll doth work and thestruchim is not intended or offered for
nab (SM- 7054, Bualuesue and Iho(eabv Code: The Contraaoes License Law
dm not apply to an owmer of property, who builds or imprwes thereon, and
who dooewchworkMmseEothmugh hbm
owneplrymov
, prided that such
OCC CROUP
RFS. UNITS-
Rmpmvemerm are ret Intended oroHertd fmsale If, hawear, the buildbg or
Improvement bwld wrhlnomyeardcanpletbrtlhowmr-bu0derwW have
7
t enofpngth.t wt
Mddbuddor Rnpmvefcepurpossofsale.).'
Urovias nvner of the pmperty, am exchNvely contraeting with lensed
mntnctws to construct the projea(Sm 7054, Buslues, and Proleabv Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
AI'N
Tlse Contractor'. License Law does not apply to an owner d property who
build, or imp. thereon, and who contracts for such profess wish a
licenued pure nt to the Conbaaora Lianas Law.RACK
LJ I am exempt under Sec B k P C for that reninOUTSIDF
�.(� DRABJ 6 VENT WATER
FEE SUMMARY
FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONTI.
FIXES PER TRAP
SANITARY Y_ N
RECEIPT' Y
Own<r Dae
WORKMAN COMPENSATION DECLARATION
❑1 hereby orM that 1 Mve W i rt rfi e d rommnt b opythwre, mRECEIPT
38W, L to of WorYers'Compeva[ion Ivurana or a anlfkd copy Hiereof (Sec.
3800, Tab G)
SCHOOL TAX Y N_
Y
GAS EA. SYSTEM -1 BJG40UD.E15
PARK FEE Y_ N_
Y
RECEIPT
GAS FA.SYSTEM-0VFR4(FA)
PoIm y
BUILDING DIVISION FEES
Cenlfled copy at filedherwfumWed.
Certllled mpy b filed with the city ivpectlon division.
GREASE/lINDUSTRL WASTE INTERCEPTOR
PLANCHECKFr
'
GREA''�TRM
CERTIFICATE OF ININIPTION FROM WORKERS
COMPENSATION INSURANCE
IThfn.ectlon need net be completed tithe permit at froom hundred dollar
PAID
Date Remi t#
D'
SEWEILSANARYS70A. RM F2DOFT
WATER HEATER W/YF.I./pTR
,�
ENERGY FEE Y N
($1Ic ceIha
Iceorfy that lothe performanceof the work for which this permit is bored,
I.hau not employ any penin in y noon., so as to ct to the
n Borst' .vet ha i
rPlfcant ffC La � �l..p -_� �
NOTICETO CANT:e Work rs'Co tea lateof Esc=Lyou
shoald come the Worker' Compematlonpmvatb
WATFRSYSTEM/TREATING
PAID
Date Reaei t#
NEW RESIDENTIAL PIMB. SQFI,.
- TOTAL:
ode,yo Orth it permit Ibebor
Code, you ,mut forthwith comply with such pmW by or this permit dull be
doomed resoled.
BUILDING FEE
'ISMIC FEE
ELECTRIC FEE a
CONSTRUCTION LENDINGAGENCY
1 hereby aRlrm that there is a construction lending agency for the perform,I
anma the work for which this permit is Issued C&m 3097, Cf,C)
TOTAL
render'. Name
LeMer.Add
I artifythat I have read thbappllatbn.M waethaUhesbovelnfomrution
ecorrect. IagrectoconplywohaBcltyandmunty ordrunmand ateriaws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICALFEE
PERMIT ISSUANCE 1'5—
FEES PAID:
' muting to bufldbgmvtruMon, and hereby wthoic reprceertut ofthis
cNy to enter upon the abwtmentbmd property for Inspect Ion purposes.
(We) agree to sour, Rd.mntfy an d keep harmless the Cry of Cu pertma
ALTERORADDTOMECH.
Date Recei t#
SUBTOTAL:
.g. Lon lbbWtles, pdgments, cjsmd eapmse. winiclenty N any way..
agaivt City Nth. guarding ipertnr.
AIR HA NDLING UNIT CIO 10,= CFM)
AIR HANDLING UNTf(OVER 1(I,000CFM)
CONSTRUCTION TAX
signatu fApp art/ ontractorIhI IEXfiAu5m000(W/DUC)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS UISCLOSU
HEATING UNIT 170100,000 BTU)
Will theappllant ce future building occupant son ur Fundic havrdou.
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Date Recei t
HEATING UNIT (OVER 100,000 BTU)
IOTA
%
Ekahh aM Safely Code Section 25532(x)7
Yes No
01the or
sppliqant tureWidbgomupalrtuacquipmentord.vim
which emit havrdau air contambants am defined by the Bay Area Ab
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
BOILER -COMP OHP OR 1(10,0(10 BTU)
Qualitynanagement Dattridi
4YY �j No
ha..madthehuam..mateiabmrylnmenbunderChapte,6Mof
ps p '
PSI
r 1 D
BOILERCO.MP(OVER 100,0CDBTU
the C.IBomb Health 6 Safety Code, Smbv 25505, 25533 and 25535. I
NEWRESIDFNfIALMECH. SQFT
undo nd that if the building does not currently have. tenant, that It at my
ru
pomlBty to net ify the occupant d the requirements which must be met
��� 199an®
prior to atsua not, of a Ceaifkate of Occupa my.
V
ISSUED BY: '
Owners authorised agent Date
TOW,
OFFICE COPY
CITY OF CUPERTINO
' INSPECTION DIVISION
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