22830APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldl Project Identification
Building Address:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /'PERMIT
BUILDING—ELECTRICALPLUMBING-MFGHAMCAL
l
Co°r��,t/rano/e Name: ti
p e. N.
LCA.V PG L /' Y78? 7 a
CATEGORY
CONTROL V
Amhltect/Englreer. Lk. No,
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
-
Addrma
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
th<r<by aAlrm thatiam lkm,M uMn provlaim•a(Chapler9 (moron n
Ingwith5«Ibn7DOO)ofDiv Won3oftheBualrenandPmfml Codpandmy
1b,e.1sto ilrq)aandtile v a%�s
Lkcn.ch® OO-%%
Date_rtraGorUP
APPLIANCFSRESIDEMUL
PANELS
TO 200 AMM
JOB DISC N
1
�� 1
IDI- AMPS
AKCHFIECIpS DECLARATION
OVERIODDAMP5
SQ. FT. FLOOR AREA
$/SQ. FT. ,
I urdcrNami my phru ehaE be used as public records.
SIGNS ELECTRICAL
Licensed Pmfeelorul
OWNER -BUILDER DECLARATION
I hereby afRrmthat I am exempt from the Contraxwe. LI¢me Taw f« the
SPECIAL CIRCUIT/MLSC
TEM[P.METERORPOLEINST.
follm gm.6e m7Q3l S.B lnmard Pmfmbm Code:Mydtyor
countywhichrequtr apemdttommtmMalter,tmprovgdermlbh,orrepair
anystronvrc prbrto lu bsuarce,.borequlm theappBantf«ouch pemdt to
Me • Wgnod statement NN he b Bc«nsed pursuant to the provblom of the
Contractor's Lkeme Lav, (Chapter 9(mmmcncing whh Senbn 7000) of DM-
tlon3 of tha Businm and Pm(mb.Code) canal he b <ampt therefmmam
the basis for the alleged exemption. Any vlelatbn of Seetbn 7011.5 by any
applicant fora permit subjecothe app"M to • dvR penalty of not more than
POWER DEVICES
5WIMMING POOL ELECTRIC
LUATFOty'
a I
OUTLET SWITCHES-Fl=ItES
N RESIDENTIAL Fr M,[R F7
five hundred dollars %W_
❑I,.s owmr of the Property, ar my employe. whh wag. as their sola
STORIES
TYPECONSIRUC71ON
compematlm, will dothe work and thestruaum Is cot Intended or offend for
sale apply alnm.b Pm(mbm Cade The C s LI¢non I�w
not to impar,
,.om.ehapply to rk owrcr ofproperty
whodoementsmrkhimself ughIdawho bulmpoyees,pv.thertoRand
hhor h
OCC -CROUP
RFSUNITS
ded ormgh
ak. If,h epr,theb ildinghat
Improvemew art rent Intended earofred (rials. If, over-bmebulld have
Improvement is sold with In omyearofcompletbRthe owner-bullderwlD have
TOTAL
tgC*rdan of proving that be dm not baud or improve for purpose of sale.).
U I, as «over of the property, am exchufvdy contracting with Imenaed
cuntranas to construn the project (Sec 70K Business or
and Prmbm Code:
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD
AI'N
The Co metori Limn x Law does not apply to an owner of property who
builmo m
ds or Improves therny and who, for such PPjeae w
c�t�+ctor(N llansed pursuant to the ContnctaYS Lioenae Lw,
LJ 1 am exempt under Sec B k P C for Nb mason
ALTER -DRAIN 4 VENT -WATER (EA)
BACK F(nw PROTECT. DEVICE
FEE SUMMARY
DRAINSFLOORROOP,ARG,ODND.
FIXIl1RES-PER TRAP -
SANITARY Y N
RST 0
Owner Dns
WORKMAN COMPENSATION DE,.ttoION
hereby ,rnrm wt I nave , «nmt< ar aammt to sail-t�,rc, a •
SCiiOOLTA% Y_ N—
mninate arwark<r; Compe.atlm Imuranm «a «naiad copy mertor Sec.
3800, Iib C.)
RCfFmr r
GAS-
GAS FA. SYSTEM-]ING4OUTLETS .
PARKFEE Y_ N
r
RINFIlTr
Cam
GAS EA. SYSTEM-OVERI(EA)
BUILDING DI V ISION FE FS
CeY
rtified copy b filedwfumWed.
❑ Certified copy b filed with the mY Impectbn dhitlm.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF E)(EMPTION FROM WORKERS
COMPENSATION INSURANCE
(ThbeMbn need sad tr completed tithe permitb («ore hundred dollars
(Yt m)alm.)
he any
I llnot hat in employ in any hew«k so as to beco permit 1. booed,
I dull not employ any perm b any manner so n to ben orb to the
W«kera'cm�pe}sa�bn L- f h. Date iC1— —
PAID
Date Recd tic
SEWER- SANITARY STORM EA. 700(7
WAMIfrATFRW/VENT/ELECTR
ENERGYFEE Y N
PAID
WATER SYSTEM/TREATING
Appllant' 1//L._, / fGe -
Date Recei tN
NEW RESIDENTIAL PLMB. SOFT'.
NU 11LE'IV APPLICANT: If, aftnn fin, this Cenifl e,," Exemption, you
ahmld become subjeet to the Worken' Compensation provhbm of the Labor deemed ��
Code, you at fmhwkh comply with such provisions; permit shall be
TOTAL:
BUILDING
TOTAL
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LFTDING AGENCY
IheabyafPrtn that there b a onkneuction lerdingagemy for me perform
onceofm<workforwitchthispermitbiw bee3(197,Ch.C3
Penmi:s Name
Lende.anddreaa
1 anlfythetl have read tMa applhtbn and •atethat meabove In(ortvtim
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
bmrmn. Icgree to comply Naim all dtyaM esuntyordlnanmand state laws
PERMIT ISSUANCE
relatingtobuildingmabove- on,and h<rtby orbs o(thb
styWto estaventer to sae,Inemnify a. d property!«Wile Cit purposes.
propertypeau purposes.
(We) Ill'to arty hdemNty an d F+'eP harmless the City of Cupenirm
ago 4atW ftyn h, mets•sad.arding which permit. ywayamue
agave Id TryN tic gndhyd Wopemdt
ALIFRORADD TO M'^•-
AIRI-IANDWNG UNIT RO 10,000 CFM)
Date Recel NI
SUBTOTAL'
AIRHANDLlNGUNTT(0vERl0,l100CFM)
CONSTRUCFIONTAX
4
Date
ignlintm of Appllant/C-.V1
EXHAUST HOOD M/DUCT)
CONSTRUCTION TAX PAID:
HA or DO MATEReupart SCIASURE
' Will the appnoM tie futurebuildingMunielpantstartoapter ha�andoua
material Ithim Sof by the Cupertino Mu NdpalCode,Cnaper 9.t; and me
I�f�I YA fey :fg Toon 7553zG)7
Date RCYCI t#
IiFATWG UNIT UO tm,00p BTDI
I-IGTTNc uNTr (ovERt%coo BTU)
TOTAL:
VENTILATION FAN C3WGLE RFSID)
PftNGE DATE
wthe appBarLL wre bulldingomrpant use cqulprrcd «devkxs
which emit hanretous air conamW Na as defined by the Bay Area Alr
BORFR-0DMP PHP OR 100,000 BTU)
Qua avgemerd DintrkYi
BORER-COMP(OVER100,000 It
4tYa
haveradtheh rNsonutedabr<qulmmenhunderChapler6.95of
OCT
the GlBomb Heahhk SafetyCode,Se l..25.505,25533.d75SM. I
v 1
NEW RESIDENTIAL MECH. SQFr
understand that if the building dm cot mrrently have. tenant that itis my
mpormmBby, to notify the occvpart o(the requirement, which must be met
prior to Wuanm or a Certlfkate of Onuparmy.
GRY1 YN rtlyrr�'[%J
y��
ISSUED BY: S iG�i
Owner a aulhod � agent pate
TOTAL
OFFICE COPY
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