20155APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldin Pro' Idemiflratian
ItoBdin9 "del. -
I / G,- K A -v _
PERMIT NO,
2 015 5
ams: ,,, ., -,
Cfa;g9/rC 327, Io3 F�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BU DINGELECTR CALPLUMBI GMECHAN CAL
Cwtn a me: e''—p�LloNvo
S? �a^e ' SS J r
CATEGORY
CONTROL Y
Archltm/Engineer. I. Na
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.;2,1 e✓ +e,
PFRMITISSUANCE
❑ E-1 [ALICENSED
CONTRACTORS DECLARATION
I kaby affirm that l am lbensed under pmeblona of Chapter 9 (comment,
Ingwlth Sed .7000)of Div 3ofthe Buds dProfession.Caa,andmy
Li¢ruc Clea LI,/
bIn fuB fan_and orma
Dato
rte Cntndor
ARCHITECTS DECLARATION
I uMerstand my plana shW be used As public record&
Licensed Professional -
OWNER -BUILDER DECLARATION
I herebyafflrtn that I.. exempt from the Comradcr'a Lke^m Lew f¢ the
following reason. (Section 70115, BusWn. and Pmfeaurs Code Any dty or
c ntywhlchrequWainm Wmv Mc ter,lmpr ,demnlbh,ormpalr
any Mrodurt prbrblh bwarce,abo requbrotheappBcentf«suck pemWto
Ne a ed Fed elatement that he b licensed pumunt to the provhloro of the
Cnntradori License Law (Clasper 9(mrrsMneng with Sedbo 7000)o(Dlvl-
MW
ona of Business And Pmre»ism Code) or that he b exempt thene(mIt
the bash for the alkged exemption. Any violation of Section 70715 by any
.pphrant for a perMt subjedathe appl ¢ t to. dvll peruhy a nor more than
f�ndad dabn(S.SOOf.
I, . owner of tk property, or my empkryen with wigs an theta sole
r tim,willdotkwerkandthekmduabnot Wterdedoroffe¢ for
ale 6cc. 7014. Buskuu aM Prufembra Cade The Contradoh Manse I�w
whodossuch tor^ owrcrorthrou h who Wimploymproves edthat and
imp d c we uc MmseBathrwghed f wm . If how, er theb that such
Impmvemeus anerat Wended earofce Ole k.If,hvweva,theer Min ve
Im kande ent poM S that orc id rus mmpldbn,tk a for p bunds otgakve
tk�.�urrlenwnerofg th.tkdld,am ex alwly wefaparpmeofuk.).
con." Poo with sCode:
nine as owner of the property, am evcl Bossiness."
con damn r'. L ct.k w does out apply to As o end of Ombra Code:
The Coon imp i IJ¢rue Law dm out apply b an owner d property who
Wilds or s)lheres thereoa, and who mntncts is wch p�ojem with a
o5o5actmexe raMnderS tto the Contndab Llanse Law.
al am exempt under Sec B 6 P C for this sawn
APPLIANCES-RFS1DEN L
)OB D115CREPTION
D `
UP TO
ANTS
-1 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
'
5/SQ. Ff.
-
SICNSMECTRICAL -
SI'ECIALCIRCUIT/MLSC
TEMP METER OR POLE INST.
_
POWER DEVICES
gWE.L14NG A70L ELECTRIC
OUILETSSWITCfiESFLXTURFS
VALUATIQN ,
% •I 1- /.^/� 61
ane , "T 0c) .
NEW RESIDENTIAL EI.FL'IR-
�'�'
S-]ORI6
TYPE CONSTRUCTION
_
TOTAL
QTY. PLUMBING PERMIT FEE
OCC.GROUP
R UNITS
I'FRMI"1'ISSUANCE
ALTER -DRAIN k VENT. WATER (EA)
FLOOD TDNF. -
APN
BACK FLOW PROTECT DEVICE
,
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, GOND.
FDCrURES. PER TRAP
SANITARY Y— N— -
RRCE]IT.
Owna Date
WORKMAN 1 ha,e A 4SAT10N DECLARATION
❑I hereby ffirm Nat I Faye • arturant of coruent m seB-iwa, (Sa
arHBab of Workeri Canperurtlan Iruursn¢ a a ¢klfkd copytheaof (Sec.
3800, Lab CJ
I'dky I
SCHOOLTAX Y— N_
RECEIPT a
GAS EA. SYSTEM -1 WC4OUTLETS
PARK FFR Y'— N
RECEIPT I
GAS- EA. SYSTEM -OVER 4 (FA)
Cor^ ^y
BUILDING DIVISION FEES
CertVled mpy b heabyth(1,, city
certWed ropy b mica with tk dty Iropedbm aha.lan.
CERTIFICATE OF EXEMPTION FROM WORKERS'
Cot W COMPENSATION
(for ledbn need not W complded u the permit b for one hundred dollars
6100)urlu.)'
I¢ notrtify that Wt hepudor usanymaunnrk. As lxeomthis esubjormit Weed,
I shat not empty any penin f any manner w u b heaume subject to the
WorkeafCampennaWnlrwsof CaWorrW. Date
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recti t#
�•--a
GREASETRAP
SEWER�SANITARYSTORM EA 3T(IFT
WATER HEATER W/VENT/ELECTR'
ENERGYFEE Y N —
-
PAIDAppikan_
Date Reocf til
'
WAIT3t SYS(FM/TIiFATINO
NEW RFSIDFNLAL PLMB. SQ.FT.
NOTICE
NOTICE xo APPLICAM: a after making this Certificate is Exemmµµvin, you
should become subject to the Wodun'Comp<rodbn pmvlsbro at the Labor
Cod, You muse fsthwth ®reply Mth wN provbbro orthb pemdt shall k
d¢rrad revoked.
CONSTRUCTION LENDING AGENCY
I hereby aRirm Hut tkrt b a mrotmctlan knding agency for tk pedorm-
¢ofthe work forwhich this permt W
la rM(5, 3097,Cw.C.)
Iefder. Name
Lender. Aaarx.
cerUfythat I have rear) tMeappB¢tbnard Matethat theabwa Wfcrmrum
bmrrect. Iagrtcto comply wkhaB dtyand CountyordWanmroand Mate laws
reWting to bW ?ding mnstrudlm, and hereby authodae mpresentadves atbis
City to enter upon the above-mentioned property for Inspection purposes.
(We) agree to ave, Indemnify and kap hrm
akm the City of Cupedlno
agaWM BabWtW., jadgmenta, meleand expense. which many In any way accrue
agairot said City in mn.eyuen m of the granting a this Perron.
TOTAL:
'
DUILDING FEE
SEISMICFEE
TOTAL
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERNMISSUANCE
FEES PAID: -
ALTER OR ADD TO MDMDate
AIR HANDLING UNIT 10,000 CFM)
RCCei tM
SUBTOTAL:
AIR HANDLING UNTT(OVER ig000CFM)
CONSTRUCTION TAX
Slgnutureof AppBant/Contracts Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appllont orfuture Wilding oavpant Mort or handle havrdma
material m defirud by the Cupertlw Murddpal Cod, Chapter 9.17, and the
Heath and Safely Cade SMlan 75537(a)?
R�'jj Yes No
M the app0®rets Wilding acxvpart use equipment or devkxs
which emit hanrdvus air mn1andno.0 as de0ned by the Ray Area Ab
Quality Mavgement District? '
4 Yes j1 No
haChapter
vuaad ealth&r w. Code, enequlrcmenb under Chapar.1 of
unthe erstanCAffut Heath &Safety Cade, Sections,255(15,tuT IandI that
understand that i(the Idl^gdoes nm rvrtently have ate ant, slut ltbmy
resparol Itytonotl he«xvpan dtherryulament khmustkmet
prfort .arced Cedlflate Dl panty.
EXHAUSTHOOD(W/DUC)
CONSTRUCIIONTAXPAID:
'
HEATING UNIT (M 100,000 BTU)
. Date RCCeI tN
HEATING UNIT (OVER iffl m RTI])
TOTAL:
3
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
"LL
i)/aQ
Tg"
C�of `yV
ISSUED BYE
BOMER-COMP OHP OR 100,009 BTU)
BOR.FRCOMP(OVFR 100,000 RTU)
NEW RESIDENTIAL MEt7-1. SQFf
orlaed agent to
TOTAL-
OFFICE COPY