22452APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Peen Mmt]flration
Flooding Address:
PERMIT NO.
f^t /'a r (�
/O LSO S. f oo 155-,
G G \5 G
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUD,DING-ELDCTRIGV-PLUMBINGMECHAMCAL
C.taaor'.- -Name: [Ae No.
-f
I /r Z
CATEGORY CONTROL♦
ArchitM/Englraer. IJr. Na
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
q/pN/ �j
me:y-/
Add6%j i- f% ,�/ /Q, fes%
PFRMITISSUANCE
❑ �I PLUM 11 ❑
LICENSED CONTRACTORS DECLARATION
Iherebyaffr thatlamlkmredunderpm Wwaof CM1apter9(mmn�m
Ingwit SMbn]OW)&MD m3ofNe Budnemand Pmfea Codpand
Iles. la In full tote and effe
APPLIANCISRES[DF.MIAL
JOB DE9C N
_rs
(�
PANELSLic
Dur Com
Date Coot Cordrador
— UP TO 2DOAMpS
-1000 AMPS
ARCHITECTS DECLARATION
Iundenm rnypbm.h2Uheuwdupubhcaceds
OVER 1000 AMPS
Fy AI
$/SQ. FT.
SIGNS ELECTRICAL
Llansed Professional
�5Qaii.•
11{{...-.... U
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Coa Lkerue LawAny for the
PUT E R
SPECIALCIRCUIT/MIST
TEMP. METERORPOLE INST.
DATE--
POWER DEVICES A
r lesion
county waasm. 6edl.]mtor Bostro a"Pefembns Code:Anyd�r
apmve d,motfors ch.orm r
county requtrna permit or comWuires; the
any
any 0roetum prlarto Its andtheuncpabooe,Ii poesuattothet(a.uions of to
file
Die a dgnrd statement that he br9 (com cumin ret to the jon 7 00) of the
sdur,3C-ritrof the Usines and Pro osicusC Code) or the with SM"ere)of DM-
slon3ofthe Butl AI, and PrduiamCode)orthatzi fexempt7MISIbmand
the 6asb for the alleged e.emptbn. Any v1olNbn of SMbn 70115 by any
it untforapermitsubjatsthe •pplkant toa dull pensbydnet moa than
tiv hmdred dollant +M1.
�I,uvwrier of the property, or my empbyem wdh wagesut flee sole
SWA1MTNG POOL ELECTRIC
OUTLE7SSWITCHISFUlTURES
VALUATION
NEWRFSIDDMALEI TR }T.
STORIES
TYPE CON'SIRIICI'ION'
andn.CY uabrotorae"ed orofferedfor
sole&a0KwWBothewwk
Bale 6ec. ]ON, Buelav std Iha(embns Code: Tk Cantradot. Lienee Law
don not apply to an owner of property who builds or impruw tkaon,and
whodoeautchworkhlnweDathrough Msmvnemployen, provided that such
OCC. CROUP
RFS.UNITS
improvements art twt Intended oroffead!weals. If, however, the buiHing w
Reprover ntba wh omyearofcmrpIMt Ntheowner-builderw illove
TOTAL.
tlAjZrrdenofpmdngthrthedWtw Udorbnpr fwpurpo.eofaale.).
UI, as .mer of the property, am exclusively ntract
ively culng wtlh Ilarued
contractee to mmtrua the project 6ec70K Business." Profemlons Code:
QTy. PLUMBING PERMIT FEE
FLOOD LONE
AI'N
PFRMIT ISSUANCE
The Cwundori Lfoene Lw dm red apply to an owner d property who
bundsALTER-DRAIN&
or Improves thaton, area who mo ram for ptpem jwith ,
u,Rtraete�
(s)11cerd m
pursuant to the Ctrador. License Law.
ED I am e.empt under Sec B k P C for this reason
VENT- WATER (EA)
BAIX PIDWP120TFt]'. DEVICE '
FEE SUMMARYn
OUTSIDE FEES
DRAINS FLOOR, ROOF, AREA, CONTI.
1'1)(NRES' PER TRAP
SANITARY Y N—
RECFL T
Owner Date
WORKMAN COMPENSATION ,onsenATION
❑1 hereby affirm that I have • arDfiute of content to Ulf-Iwa,
5Cii00T•TAX Y_ N
or a
erDlimo o(Worketi CenpenuHmlwnna as ertlfled copy thereof (Sec.
M00,Lsb C.)
RFLEPT a
GAS EA. SYSTEM -I ING40[IH.EIS
PARK FEE Y N_
Pola
If
Com
GASFA.SYSEM-0VFR4(EA)
BUILD NG�IVISIONFEES
Ned ropy V hereby ho d, the city
Certified ropy 1a filed with the dry Inspection division.
GRFACF/INDUSTRL WASTE INTERCEPTOR
PLANCHECK PGE
CRFA.SETRAP
CERTIHCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Rhlaaedbn need not be completed B lh<pemdt b fwone hundred dellen
PAID
Date Recti t#
SEWER SANITARY STORM EA 20IFT
(5100)wlem")
lartifyth.tlothe perfomune o(the wmkforwMch Wepemdt lal®reQ
1.1nailnm employ any penin lo any manner m u to become subjeotto the
Wwkcn'Cer�pem.tbn lwwe o(Gllfomla. Date
.TO
WATER HEATERW/VENT/EL,ECIR
ENERGYFEE Y N —
PAID
Date Rett'♦ t#
WATER SYSTEM/TREATING
NEW RESIDENtIAL PLMB. SQFf.
�. --`` ll
UT�g tW
AppllNOTICnt
AITI.ICANT:IL.fler maFJng the CertBiwte o(Elemptlan, yin
should become subyad to the WorFen'Coepetuatbn provisionsof the labor
Cedeke/atthwhhcomplywithsuchproWbnsorthlspemdtWllbe
deemoedi d ked.
TOTAL:
BVILDINQ FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that thea in a mdtrodlm lendlog.geruy forthe perbrm
ane .(the work for whkh thin permit Is lmued (Sec 30 V], Civ. C)
lenders Name
Lenderi Adam,
vedd
I'l--1hnIhave readtM.thaUdt
TOTAL: add
SEISMIC ECE
ELGCTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PEES PAID
aandroteNatih.,b t.1ion
end Ratelawa
locomen. Wilding
000aatm lth andtyud muhtyrepresentatives
Mating to Ng m std hereby rc ntaDw of this
PERMIT ISSUANCE
y to enter p bove- en property fee ctio
dt(W)ngmpon save, Indemnify
propertyfa lupe Cit ofpurpieca.Cupertino
an of Cupertino
(We) agree to rove, l"s, e -j and keep wheb the In any
agalrnt Wk1C Irdgmerus, and expemn whkh may litany way accrue
age Wt old Cy�y mnseque fj rantingd pemdt.
ALTFRORADD 70MFfH.
AIR HANDLING UMT(TO 10,000 CFlsD
Date Revel t#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CF\n
CONSTRUCIONTAX
Sig—nature off AppD^unt/Cmtatta`/(/✓"" Date
EUHnusr HooD(w/DUCT
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100," 0`1"
Will the.ppheam or future building omrpant.wne.r handle haratd.s
material as dell and by the Cupertino Munldpal Cade, Chapter 9.1 Z and the
He. hh and Safety Cine SMI.=2Wt
n Y. No
111 the a pplluMa tun bu0ding p..t ole equipment a devfm
which emit harardmaair ormundrantaa. defined by the Bay Area Air
Matugemerd ]Tod k 7
Dale RMeI t#
HEATING UNIT(OVER 100,000 BTU)
TOTAL:
....ss'..�1
W
VENTILATION FAN 6INCLE RE9D)
ISSUANCE DATE
��
�'
ft
BODER -CAMP OHP OR 100p(0 BTU)
YIlty
Yn I� No
— �Ii,
BOILER-CO.MP(OVER 1fA,000 BTU)
luveaa the H.It ms materials W. ZSentsunder Ch. ptM.I of
HealthbSafety Code, SMbmntlyhvea
1114 a 'on,
�lV V
NEW RESIDPNML MF.CH. SQFT.
understandt
undentandriot lithe Wiwi paea tort a requir,merns tenant, that It trey
than, that
responsibilityore to naoy the orxvpa a the rcqulmmeta. whkh moat be cont
prior to hmarce of a Certlf{ate of Onsrparcy.
�.�,.,,cT�-. �I
ISSTIEDBY �t
OwnerwtrN
author.gent Date
TOTAL
OFFICE COPY