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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pminet Identification
PERMITNO.
Building Address: '
102(so s.����ec �u�� c4
23655
r. ame: me:
!"xxxxxxxxxxxx
t C6✓7 637
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT
BU D NGQ R CALF UMBINGMLC UMCAL
L�
Cmmene' ante Lk. N-
Si /Y Q Z4
CATEGORY
CONTROL
dltect/
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
Irk7thBT1.SUANCE
❑ O ❑
LICENSED CONTRACTORS DEM ON
T hereby Nfbmtivtlam llcrosed undttprwlslot ptcr9 (o>mmm
In with Section 7000)ofa,ision3ofthe Bunw rad f atCode, and
]to. Ia In full for¢ and effect.
APPIIANCESRESmEMIAL
JOB DE9CRIPf7 N
PA 1E S
License, Class Llnc I
Date (brtacta
UP 3V 2M AMI -S
MI -1000 AM15
ARCHITECTS DECLARATION
I understand my plan ehaB be used as pubBc remrda
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. Fr.
SGNS ELECTRICAL
Lkenxea Professional
_
OWNER-BUILDFR DECLARATION
I hereby affirm that l am exempt from the CoMnctor's License Law for the
SPECIAL CIRCUIT/MLSC
-
TEMPMETFRORPOLEINST.
following reaam. (Section 70115, Beer. and Pmfmbn Any y city or
cvuntywhc requ apermfttomntruct,alter,Impm ,demolbh,orrep4r
anyat =mpJ wibh me,alsorequU theappBantfasuchpe to
file a signed statement that he b Becnsed pursuant to the prwvbbt ed the
Contractors Liceree law (Chapter 9 (commencing with Section 7000) of Divi-
sbn3oftheBuYnwandPrdesrbtCod<)mthd he besmpt therefmmud
the Wes for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the apphoet to a civil penalty of not more than
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTL SN7,ICE)6FU(7"URES
-
RESDENTIAL ELFGTR SQ'Fr'
hundmd dollen %SMI.
TiNETY
I, as owner of the property, or my employees with wages u their sole
STORIES
TYPE Q0NSIRU=N
mmpemUon, will do the work, and thea rumrn is not Intended or offered for
uk alec. 70K Rtentax and Profession Code: The Cortracturs Wane Taw
don not apply to an owner of pmperty who builds or Improves theren,and
who dwesnuch work himself a tough but, own employees, provided that such
OCG GROUP
RES, UNITS
lmptovemems are not Intended or.ffend forsee. If, however, the building or
Impmvemnt baold within oneyearafcanpletbn,tk owner-builderwN have
TOTAL
t rden of pving that he new m Improve build or re fa purpose of aak.).
Lm
[ as owner of the property, am eschu}vely contracting with Bated
mntnctas to mntruct tlr projM (Sec. ]011, Business and Pmfessiot Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE ��
FLOOD ZONE
AM
The Contractor• Lkenae Law don not apply to an owner m property who
builds or Imp. thneory and who mmncts for inch p(ojeci, whh a
cent(+ctor(a)Barued Pursuant to the Cmtnctwrs Lice. Law.
Cl 1 am exempt under Sec B k P C for W ve
man
ALTER-DIWN4 VENT -WATER (EN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, ODND.
PER TRAP
SANITARY Y_ N
RECD.
Owner Dale
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have • artiBate m consem self -blurt,
SCiiOpl,TAX Y N
(Sa
mAifl d
38M, ab of Worken'CompetaHm Iwrana as anlfled copy thereof pec.
3800, Lb GI
RECEIPT a
GAS FA. SYSTEM -1 MG40[IDPB
PARK FEE Y N
Policy a
_
RECEIPT
nY
CAS E.A.SYS[TM-0VFR 4 (EA7
BUILDING DIVISION FEES
Certified copy at hercbytm cit.
Ce b filed withhthe TRY inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFECertifiedropy
CRIAUM ]RAP
CERTIFICATE OF EXIIMPTION FROM WORKERS
COMPENSAT70NINSURANCE
OEbaenbn need not be compimed Bthe permt h (sone hundred daBan
PAID
Date Recei IN
SEWER-RSANTIARYSIDRM EA 700FT.
(S140)a1Ch
lartifythat in the perfomanaofthe work forwMch this permit hs Issued,
1 •hail nm empane.Lawn In any manner so es to bemme subject to the
Wmkenn Compemtbnlaws of California. Date
WATER I-ffA77R W/VFM/ELE(:lR
ENERGYFEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICExc nIsubjCAM:e after makingteaaxrx Op teof Exemption, you
Compemt a provhbnwfthe Labor
Code,Amibecome abjecttothe ply with
dndrewkefmtl,wlth comply Mth such provlabt wrthb permit Jul] be
Date Recei tat
NEW RESIDENTIAL. PLMB. SQJ7
TOTAL:
BUILDING
T /�
SEISMIC FEE
ELECTRIC PEE
CONSTRUCTION LENDING AGENCY
I hereby afitrmthat there h a mttmction lending agency for the perform-
anmoftheworkforwhkhthhpermhbbau C( c3M,CIv.C.)
La'r'der• Name
lenders AddressaH
Iwertlfy1lhavere.d thbappBotbnand Wtet otheabove Infomution
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
-
MECHANICAL FEE
FEES PAI D:
boomer lagrtetwcomplyw aUdy.M untyurdbunasandrntelaws
PERMIT ISSUANCE
relating to bul6iing mttmctmnd orbe
l, ahereby authmpreeenbtio
ves f thio
city to enter upon the abovsmenUoned property for lexpectlon purposes.
(We) agree ave, ve, Indemnify an d keep Cupertino]arm the City of Cupertino
ALTERORADDTOMTiCH.
Date Recti t#
aga4ut liabilities, l' owesande.Pu. which may lnanyway.ce a
agerst gala Cfty, snit enoe '7 ming of thl. /
GAIR
AIR BANDUNG UNIT(TO l0,W0 CFM)
SUBTOTAL:
BANDUNG UNIT(OVER 10,Me CEM)
CONSTRUCTION TAX
Sgt�rAppllont/Coetractor a Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAMRDDUS MATERIALS DISCLOSURE
HEATING UNIT(TO IN,000 BM
Will the applicant or future building part more or handle havedous
material u defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I kahh and Sefety Code SeMm 75337 W7
I—I Yes j`� No
Date RCLCI Iq
HEATING UNIT (OVER 700,0X0 BM
TOTAL:
VENTILATION TAN (SINGLE RFSIU)
ISSUANCE DATE
-
A D
PY
dime 1,e.,d u.eu conoccutaminant... dpanlux aqui. ma Air
which eMaruge rdma ab cmbMtms as de0ned by led Bay Area Alr
r lNyhbtgcnnnt Dhtrftt? No
lave read the
4 Yes �mw mqui 6.95 of
s material,od,Sections
BOLTER-cUMPDD DR 100,0(0BM
BOILfiR cUMP (OVER l00,D00 BTU)
Health& e 25505, 5533underaChapter
the California Health kSafety Code, Section5505,ve a t and 25534. 1
lithe building does nape mrrently that It
IMAY13 �QOr�
NEW RESIDENTIAL MECH. c-QtT
mxpntandtiat
entatethL
rapotlb ttyu. ce a. the cate.f c the requBcmew which nwJ be met
met
prior to l:tom or a cenukate wrom,paay.
1JJ�
11,
lauf Cn U7rV
ISSUED BY:ax
'
Owner or authorbed agent Date
TOTAL:
OFFICE COPY