21916 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
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Build ing Address: /1 1.1 16
rs ams: ..0 se: .. Ali
A -
- 3 CITY OF CUPERTINO-BUILDING DIVISION
c t.aorp rad Lm APPLICATION I PERMIT
N BUfLDINr—ELFCTMCALPLUMBINGMFCHAMCAL CATEGORY CONTROL N
Archit deco - .. Lie.No.
BUILDING PERMIT INFO
."�r,� �' QTY ELECTRIC PERMIT FEE gibe
Ad4reAf:• _ i`I V c'r l V PERNUT ISSUANCE ,+•..❑ LJ
:a:r�a I NBED CONTRACTOR'S DECLARATION
I'hereby/Xfirm t l am licensed under provisions of Chapter 9(ocareareac, APPUANCESRESIDENTIAL I -JOBDFSC ON'.
ingwith Section 7000)of Divislon3 ofthe Business and ProfevionsCode,and my
11reni.Is In d c a PANELS
E-c Cla _ Llc.a
Da Conrn -
01-7000 AMPS
ARCHITETA
p�p�uu N QZQ I understand my plans shall be used u public reconda. OVER 1000 AMPS SQ.FT. R AREA 5/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
cid a�LPM1t1 OWNERexUptfromic CommTION SPECIAL CIRCUIT/M15C
T hereby that I am DE LARATIO Lirenre Law for the
09H following....(SMion 7031.5,Buslnessand Professions Code;Any cityor TEMP MEfEROR POLE INST.
r f' cauntywhNhrequl apemattommtrua,alter, pmve,demlLLh,orrepair
a anystructure prlorto its lssuance,alsorequlmthe applicamfor such permit to
Yd V file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
OaG Conlracoor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC VALUATION
30 sbn3oftheBusoemand ProfessionsCode)orlhet heiseaempttherefromend
s+ 6 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
applicant for a permit subpecrotheapplicamto a civil penalty of nal evexthan
live hundred dolWn(A500). :. NEWRFSIDENTIALELECTRSQFC. , STORIES TYPE CONSTRUCTION
QI as adiner of the property,or my employees with wagfs as theirsok
. romps Natlon,wBldothe work and thestructure is Wendeim.ffetedfor
psale(See,70d4,Bunlr:e.and Profenlons Code:The Contractors Llbense Law
r32 does notapply to an owner of propertywho belTdeor improvesthereoR and OCC.GROUP RES.UNITS
who doessuch workhimaelf orthrough h1sownemployees,provided that such
tImprovements are one intended orolfered foreale.If,however,thebuilding or TOTAL:
Improvereahtusold w thinone yearofcomplNlari,theowner-bu'MerwRlhave
tilcIturde.cf proving that he,did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L aq emner of the property,'am evehulvely eontrauting•with licensedPERMITISSUANCE -
contractors to construct the project(Sec 7014 Business and Professions Code:
The Contradmr's Limo Law dm not apply,16 an owner of property who Aing-DRAIN k VENT•WATER(FA)
builds or Improves thereon, and who contracts for such ptmjecb with a FEE SUMMARY
/--- 'gptfactor(s)R«nsed pursuant to the Contrad.e.License Law. BACK FLOW PROTECT.DEVICE
_ \I I am exempt under Sae B k P C for this ressnn
L `; Date DRAINS-FLOOR, OUTSID FEES
ROOF,AREA,COND: SANITARYRECEIPT N
WORKMANCOMPFNSATIONDECLARATION SCHOOLTA% Y N
r� hereby&form that I have a certificate of consent to self-insure,or a FIXNRES-PER TRAP REGEIR M
6temfWorkers Compelaatlon Wm
Insurance ora certified copytheoftSec.
- .\ CAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE RECEIPT
GAS FA.SYSITM-OVER/(EA) BUILDING DIVISION FEES
��CC//nrf:ea copy v hereby furnmhed.
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
F•TI'crtlfled copyb(iled wlththe city inspection dlWalon.
4w�-• CERTIFICATE OF MEMPION FROM WORKERS' GRp'ASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-SroRM EA XpFT. Date Recef tN
(ThiasMion need not be completed If the permit is formic hundred dollars
($100)or tem.) WATER HEATER W/VENT/ELFGTR ENERGYFEE Y_ N_
I certify that In the performance of the work for which this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
OZ Appllant NEW RE4DFNIIALPLMB. SQ.FF. Date Re=ci [q
Z NOTICE TO APPLICANT:If,after raking this Certificate of Exemption,you
N should become s.b),&to the Wmrkeri Compensation provisions of the Labor TOTAL:
� ; Code,you roust forthwith comply with such provisions or this permit shall beBUILDING
deemed revoked. SEISMIC PEE
RI — CONSTRUCTION LENDING AGENCY
EL O I herebyaffirmlhit there is.construction iendingagenry,forthe pedomIx
-
Z
TOTAL: ELECTRIC FEE _me
Z ance ofthe workforwhichthigpermit is insued(Sec.3097,CIv.C.)
V O [seder's Name PLUMBING FEE
U. t— laaders Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W I«rtifythatl have read thisappliatlonand matethattheahoveinlormatlon
O
iscorrect.Iegr«to=omplywith all city and county ominancesandetaM laws PERMITISSUANCE FEES PAID:
} 1 relating to building contraction,and hereby authorlu representatives of this
N ALTEROR ADD TO MECH.
F Z city agree
to sae,Intermentioned propebarrel inspection purposes. Date Recel t�
(We)agree to use,IndemNty and.«pha which the Cityyway.Of Cu rtln. AIR HANDLING UNIT 10,000 CFM)
V agaWtllabNtks,pdgmenb,coalsand expenssa which may In any wayamue SUBTOTAL:
g cam Cl tenon. «mithegram gofthispernu' CONSTRUCTION TAX
n Al 02 AIR HANDLING TWIT(OVER IQOW CFM)
S lure.!Appllcent/ ontvd.r Date Ext HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA RDOUSM E ALS DISCLO E
Will the applIant or future bullch pant store orhandle hazardous HEATING UMT(TO10g000BTU Date Recei tit
material m defined by the Cupertino Municipal Code,Chapter 9.IZ,and the
health and SafetyCode Secti.n 25532(a)T HEATING UNIT(OVER 100,000 BTI!) TOTAL:
Rill
No 0, +'t VEN71LATION PAN RESID) ISSUAN�ATE
Ill the applicant or lure building occupant use equipmentordevim J•'/"�
1' -'•L cedl hman3ousalr conlamWntsas de0ned by the Bay Ir,
.� 'v Management Dlstddt d BOILER-COMP(3FI'DR 100,000 BT1p
ee rt-���1No tAAR 2 01991
rpQibchaz;Nouimatedai3mquimmenbunder Chaptir6.95of BOILER-COMP(OVER I DD,000 BTU)
the .rrda{3eagk� fray Code Sectione,7$505,ZW3 anC2.''+-531.1
jyr and,B 'Il the bulldog dines not ctnu tly�aveaten2M,'Iha1 VFMY a NEW RESIDENTIAL MECH. SQFT.
sibllity to notify the o«vpant fih .quiremee ME), It be met.rto tssuante of aCedifiamofOccupancy IBLMS
Owner or authorized agent . Date - ISSUE
TOTAL:
OFFICE COPY