20866APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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Bulling Address:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BULDINGELFCTRICALPLUMBINGMF HAMCAL
A
Contndor'.Name: Llc. N.
GITCARY
CONTROL#
Archlted/Engleeer. Lk No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Adder. •
❑ ❑❑
PERhO'C ISSUANCE
LICENSED CONTRACTORS DECLARATION
harelay on7OOO)offfirm that Di kmaedheBuunder p wanrlorof pter9(mmmm
Ingweix idfan formaudeffl n3obneBuslrcasand ProfeWomCode, and
Ikeneabin /uB (ora ane erred.
ame Clara Lon
D #
Date Cle.ontarador
ARCHITECTS DECLARATION
I understand my plans shall be used as public moords.
Limmed Pro,®bvl
OWNER -BUILDER DECLARATION
I herebyaf irmthat I am exempt from the Comndora Lkrrue Law far the
following mawn.5ecti.70715, Bu.Inesa,d Profs da.Code:Mydtyar
countywhkhrequhesaper tommemd,alta,improve,demolbh,ormpatr
any stm=m prientolta Lmamr, abo requbnthe appll forwch permit to
file a signed statement that he is licensed purwant to the provbbm of the
Contractors Lceme Law (Chapter 9(or.cing with 5nflan 7(100) of pW-
slon3 of the Buainess and Profedom Code) mthat he b exempt therefromand
the bash, for the alkged exemption. Any viclatbn of Se ion 70115 by anyWDEISSWITCFI6FIXNRFS
net more than
appheantfor. permit sub)ecb the appheant too d"I penalty d o
frvr ndmdddlare(L500).
ae owrer of the property, or rtry empbyees with wages ae tkIn wk
pematlon, wBldothe work and themmdum b not Intended or offered for
aak &, 7011, RoWne, and Profesbm Code: The Comedos Limme Law
don natapply to an owner of property who build. or improves tnereo, and
whodonauchwork himatUmthwgh hbownemployees, provided thatsuch
Improvemema are not Intended oroffered four sale. IL haweNer, the bulli Ing or
Improvement braid within one yesrofcompidloa, the owner-0underwW have
ben of pmWng that he did not bund or Improve far purpoc of oak.).
Lj L a. owner of the property, am t.hudin ly mntru ting with unreel
mntr.ctars to mratrud the projed(Sec. 7061, Bushes and Prdesbm Code:
The Comrwor'a Lice. Law don ata apply to m owner of property who
WIWI or Improsv thereon, and who mmnrta for audi p(o)ach with a
elf+dm(s) liamed pu noon to the Cantndar. Llama law.
U I am exempt ural" Sec B k P C for thb renin
APPLIANCESRE9DCNTIAL
RIWlO^L �`
' \
,/7 e'f �11CaPl (�fN�
�CiI%•���Y
PANELS
UP TO 2DO AMMYO
211-1000 AAiIS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
'
f/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUTT/M192
TEMJp METERORPOLEINST.
POWER DEVICES
SHrpr�gNC POOL ELECTRIC
VALUATION
/n Q�
/ lJ
NEWR]SDENTIALELECTR SQ}T.
STORIES
TYPECONSIRLCTION
TOTAL
QTY. PLUMBING PERMIT FEE
OCC GROUP
,
RFS UNITS
FLOOD ZONE
APN
PFRMITI".SUANCE
-
,-DRAW kVENT WATER
FEE SUMMARY
BACK FLOW PROTECT DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N -
RELFLIT 0
Owner Date
WORKMAN COMPENSATION DECLARATION
711 hereby eflrm the I hast a certificate of consent to elf-iwre, or f
a,tifirate of Worknn Compematlmc Imunna or a mrtffW copy therm! (Sec.
3500,Iab CJ
Palley # -
FIXTURES- PER TRAP
SCHOOL TAX Y_ N_
RFLFIPf #
GAS FA. SYSTEM -1 WCI OIIIT.ETS
PARK FFE Y_ N_
RECEIPT #
GAS EA. SYS 0,FIOVER 4(EA)
Comp ny
BUILDING DIVISION FEES
I-- IcenWea copy b hedwiffi wnef.
Cartined ropy b he withthe dty inspection dlvlYon.
CERTIFICATE OF IX2MMON FROM WORKERS
COMPENSATION INSURANCE
(Thlaaectbnot b
n need ne completed lithe Perot b fmrc red ahunddollar
R1lmnlfesJ
mewak to as tohthbpemdlblwN,
Illnot tedoyan Penton
Worlo not employ any perwn rf any manner n u to become erb)v to the
Workcn Compenatbn Iaay.dGllfmnb. Date
Applica1,IOUCnt
NOTICE TO APPLICANT: E, o „eking fhb Certificate d mofpthon,you
Coda you ,rust forthwith comply wine ouch proal bar ormb pemdt "the
Cud,�wlxxaama abthwit oa Workers' Comperurtim,pmvbb p ormdt the
lamed rebuked.
CONSTRUCTION LENDING AGENCY
Ihamby.fnrm that then is. comtrudlon lending agency for the pedom,
ana of the work for which this permit b lased (See 3097nne,, CW. C.)
IandaeLandt".Adama.
(certify that I heremad m withall cit1and orate thatineabovedtorrtutim
bmingt Iagrseto complywith alldtyamd maflh , repreeandsatabws
cebtlne to r Ild upon a exwe ion, and hereby wthortre cepmentatNes dthb
mytoen4rupontkabova�membrcdpmpertyfalmpenbnpurpoan.
(We) agme to ave Indemnify an d kmp henniea the City of Cu pertlno
ago ret llablBlka, jrdgmenaa, mvaaM eape. whLh may In any wayamwe
a lstatsekicfty�w a tingdmb pe,mN.
GREASE/WDUSrRL WAS'T'E INTERCEPTOR
PLANCHECK FEE
PAID
Date RLYC1 111
GREASE TRAP
gEWFR-SANI'T'ARY STORM EA 200Tf
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Recei tp
WATER SYSTEM/TREATIIx
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING FEE2
�
SEISMIC FEE
TOTAL
ELECTRIC FEE
QTY.. MECHANICAL PERMIT 'FEE
FEE
PLUMANICAL
MECHANICAL FEE
PF]U1R 6A)ANCE
FEES PAID.
ALTER OR ADD TOMFLFL
Date Recei til
AIR HANDLINGUNIT CFO 10,000 CFM)
SUBTOTAL_
'
AIRHANDLPJGUNIT(OVERIk"CEM)
CONSTRUCTION TAX
slgna a ppbant Co rasa
EIATA USMATERIALSDISCLOSUR6
WWtl applfant or tore bundingomrpant atone orhardle havedous
ort lasdefinedbythe Cupeniro Mu NdpalCoda Chapter9.17,andthe
ick❑alt Yund Safdy Codc No 25532W7
Wnl the applia6int or o¢upant u.etyuipment or devices
which emelt hara,dous ab mhumsa. defined by the Bay Area Al,
Qua111yMamgement MO
4 Yn o
have read theh matenab requiremenb u nder Cha Ater 6.95 of
ted Caldomla Holth k Safety Code, S.CW. 25505, 25$33 and 25531. I
understand that ifthe building don mat aurently have a tenant, that It b my
rapomlbilftytondify theoccu dtherequiamenbwhkh ,ru beard
to da Cent d(oaupaetcy. T
(J
FJO3AuhI FLOOD Iw/DUCT)
CONSTRUCTION TAX PAID:
_
FIFATINGUMT90100,000BTU)
Date RCCei tN
HEATINGIINIT(OVERIffl,"B'M
TOTAL:
VENTILATION FAN (SINGLE RESID) -
ISSUANCE DATE
-
.n'�
1990
.AUG y
r-T�.�+ �jFy�rs� Sr
ISSUED B lyN�V1-`^mss
BOILER -COMP DHF OR 100,000 BM
IonXR-COMP(OVER 100,00) BM
NEW RESIDENTIAL MECH. SQ.FT.
Own thori� Date
TOTAL:
OFFICE COPY