22047APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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CITY OF CUPERTINO, BUILDING DIVISION
APPLICATION / PERMIT
Contraaor'^Nanr: Lk. No:
INGMFLHANICAL
CATFGORY
CONTROL Z
Archltea/EnBUILDING-ELEILTRICALPLUJ
glrcer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING
BUILDING PERMIT INFO
Add.
PERMITISSUANCE C,y/
❑
LICENSED COATRAOR'S DECLARATION
I hereby a(lirtn())ofDmkcm3 ftheunder BuptoveuiPm islons Chains odea na,
Jo(Ihe BUNrcasand Pmlesloru Code, and my
APPf.IANCESRES1DENffAl
JOB D N
Lou.ingwlt
infol]7000)ofdeffean
Lbenec Clay
Lmom b In fail (ora and k,11
PANELS
Date CoMranor
onto
UP TO 2DOAWIS
271-1070 AMPS
ARCHITECTS DECLARATION
Iurdermand my phn.shall be used as pubec r ... da
JOVFRIMAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
Llmnsed Proferobvl
I rr1A/
6{7C[[(`/
(�
SIGNSELECTRICAL
OWNER -BUILDER DECLARATION
Ikrtbyafflrmtktlam exrmpt Tran Ne Comndofm Lkense lawfalk
foBo1ingneasm.6NIon 70315, &minmard Pmfmlorm Code:Mydtyor
muntywhWrequ apermnnmt maJter,Improve,de=o h,ornpair
( v
rS
Cwt )....RR i
SpFLIAL CIRCUIT/MISE
TEMP, METER OR POLE INST.
any.tmcture prlorto It leewnce, abo requlreatheappuant fornch ptomtto
Ilk a signed statement that he t licensed pursuant to the prcvtbna of the
Comneor'm Lkenee Taw (Chapter 9 (romrrcnCng with Seclon 700D) of Divi-
of the Buelnessand Profembru Code) or that he a emmpt thert(mm and
POWER DEVICES
aKV(.a.lpR,( s 1/ (i
gWLV{AgNG POOL ELECTRICabn3
VALUATION
the baats for the alleged e.emptbn. Any vlalatbn of Stolon 70)5 by any
ppIlant fora permit aubjeets the app"nt to a dWl penalty d nae mon than
flryl�,'ndred dollars (6500).
I__I'• u owner of the property, on my employees with wages as theb sole
OVDSISSWI7CI ES-FD(TURFS
NEW RESIDENTIAL ELFL7R 9�FT.
RIES
7YPECONSIRUCTION
compensation, will do the wmit and th. structure b not W anted or offered for
sale (Sec 70K Bluntness and Prdeaelorm Cade: The Contrume. Llanea Taw
dm rot apply to an owner of property who Wild. or Improve thereon, and
himself orthratgh hinownemployees provided thatsuch
OCC GROUT'
RIS. UNITS
Impmotmenu are rot Intended orokered forsale. If, havever, the W IW Ing or
Impmvement bald wkhln orcyeare(completlogtk .,e-WIlderwEl have
TOTAL:
n of pruning that he did not build or tmos
prove for purpose of said.).
1 .. owner of the pmperty, en erchuively contracting with licensed
iracton to mnrod the project (See. 7051, Bushs. and Ptofndo. Cade:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE ei
Lr
FLOOD ZONE
APN
Coranctori Lie nse Law dm nor apply to an owner of property who
Wild
Wilda or Improves thereon, and who connm fee much ptoJects with a
.WLEa erp)Bansed panu.nt to the Contraaa: Llan. Law.
LJ I am eaempt under sec B 4 P C for this rcnon
ALTER-DRAIN k VFM-WATER
FEE SUMMARY
BACK Plow PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, CONED.
FIXTURES— PER .I1ZVa
SANITARY Y N_
RECEIPT' N
Owner Date
WOR"AN COMPENSATION DELLA RATION
❑1 herebi afErm that I have a artiflalc of cwcxnt to self -Inure, m
artiflate of orken'Canperuatlm lnaunnaea•rexlftedrapythereof�ec.
3800, Tab C.)
sC]{OOL TAX Y_ N_
RECEIVEN
GAS -FA.SYSTEM-11NC40U7LM
PARK FEE Y_ N
N
RN
Com Y
GAS EI. SYSUM-0VER4(EA)
BUILDING DTDI V ISION FEES
ITropy b hereby with the red.
Certed mpyb(Iled withthe tlty Inspection division.
�N
CERTIFICATE OF EXEh1PTION FROM WORKERS
GREASE/WIXJSDtI, WASTE INTERCEPTOR
PLANCHGCK FEE
PAID �f�
baa a�
GREASE TRAP
COMPENSATIONINSURANCE
sent na be completed tithe permit b faorc hundtud dollen
(D
Date Receipt
SEWERSANITARYSTURM EA 10FT
or I.on
($t OD) Hffyth b house,
I snot
ortk wakan
wATIRHATERw/vEIVT/EI.EcrR
ENERGYFEE Y N
mpe anon ua
employ am to b,eoneveemdt
Wu,k not emPlo—tk person b any manner n u to become eub}m to the
Waken Compenuatbn law. o(G Want. Date
PAID
WATER SYSITM/TREATING
Applicant
NOT[CE
NO7TCE TO APPLICANT: if, Aft" reekingldreeking, akg this CrrtBkate of EaemptbY.
y
shmld become subjeet to the Workers' Compernatlon prevlsbne of the Labor
Cade,yourntatforthwdhcomplywithwc pmvb morthbpemdt.hallhe
deemed revoked.BUILDING
Date Reccl tk
NEW RESIDENTIAL PLMB. SQFT.n,
TOTAL:
FEE
/
SEISMIC FEE
1
CONSTRUCTION LENDING AGENCY
l herebyaflirm that there h a mnetruction lerWingagency for the perform-
area of the work for which this permit Is teats (See. 3097, CN. C.)
TOTAL
ELECTRIC FEE
Leru rr.Name
kndds Address
1 e,rtlfy that I have read Ihbappllatbnard state thatthe above tnfcrmatm
t
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
QO
MECHANICAL FEE
FEES PAI D:
bmrrtct.)agnetoromPlywitheJc3tyard county anlinanon and slate laws
PERMITISSUANCE
relating to building oo—dine, and hereby eahorlae represenntives of this
city toenteruponthe above-mentbned propertyfor kapnjem purpose.
(We) agree to cavo, Ind emudfy an d keep harmlm the City of Cu pMo
]^
ALTER OR ADD TO MEM.
Date R2CC1 IM
.8 1Wblllties, jrdgrrc msa.od en whkh nay yway...
.'abut fin= nos ofthe gra n ofthls �r/
/6
AIR HANDLING UNITED 10," CFM)
SUBTOTAL.
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
SlgnaWre of Aret/conttanor Dan
EXHAUST HOOD(w/DUCT)
CONSTRUCTION TAX PA ID:
ZARDOUS MATERIALS DISCLOSURE
HEATING UNIT D0100,000 BHI)
Willthe app rdortunn buildingoccupantstomor handle havrdoun
material a. defiraci by the Cuperttm Mutddpal Code, Chapter 9.lZ and the
Ile❑alth andSafety Code Section25532(a)?
Ya No
WBlthr applkarda lure Wlldtgo pantuseequipmenadevkes
which emit horani.s air mntaminme, s defined by the Bay Area Nr
Quality Management DW rkt7
Y. EE��No
1,` have mad the h.Qus materials requirement underckpter G95 of
the California Health 6 Safety Code, Sectbm 25.90.5, 25533 and 25534.1
Date Revel tit
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
. 5
VENTILATION FAN (SINGLE RESEED)
ISSULINCE DATE
MAY j/
s1
BOILE&WMP pts' OR 100,000 BTU]
BORER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
understand that if the Wilding dos rat oamnlly have a tenant, that It is my
1
mpotolto Cori ,en uirdo(therequlrtment which must met
prior to imtna.
ISSl1ED BY�a
OwnararaulhorUad agent Date
TOTAL:
OFFICE
OFFICE COPY