21814 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification y—a' PERMITNOO..
Building Add.: (,( 8i-4
--r—Phone: IIUN SUHMII I AL UA Ih
L
^ � CITY OF CUPERTINO-BUILDING DIVISION ^c '
C rectors a :�. Lic.N. APPLICATION / PERMIT •J
L 3 BUILDING-ELECTWCALPLUMBINGMECHANICAL CATEGORY CONTROLN
' Architect/Engineer. LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:'�� BLDG ,
PERMIT ISSUANCE'„ - -1-00 Y 9 CJI ❑
LICENSEDCONTRACTOR'SDECLARATION IjJ L/J ,
Ihereby affirm that l am licensed under provlalons of Chapter 9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section70M)o(Dlvlsloo3ofthe Busimseand ProfesnonsCode,and m
lirenx le in full(y}e and affect. �'y Z Z'7-5 PANELS
Date Cla® LJ LIC# zUP TO 2DOAMPS RET ^
Date - Contractor 201-IODOAMPS
ARsCHITECTSDECLARATION OVERIOWAMPS SQ.I7.FLOOR AREA StSQ.FT.
cell'x lundentand my pia shall be used upublic rccards
goLicensed Professional j SIGNS ELECTRICAL
ddd 6 OWNER-BUILDER DECLARATION I
IJn] 2 SIPECIAL CIRCUIT/MISC
Zti IherebyafOrmthetlamexemptfromthe Cantracta/e Lkevelaw for the
following reason.(Section 70315,Business and Professions Code:Any city or
O F.,� TCMP.METER ORI'OLE INSf.' 000,
�ntyF� anystm mpriult.apermmea6omquimter,impmvgderrolbhper Ito
a any at95ned statemenortDit
that
he s,also sed pursuant t the rtwidhpermit a POWER DEVICES
O V file a actors License
that he la r 9(com pursuant it the ti o 7") o!D the '
Contractor's Liceue Iaw(Chapter 9(commencing with Section 70W)of Divi-
SWIMMING IDOL ELECTRIC
<3 elon3ofthe Business end Professlo.Code)orthat helaexmpttherc(romand VALUA71ON •
the bash for the alleged exemption. Any violation of Section 70315 by any !,O OUTLETS-SWITCHMFIX TURES (.�
O
applicant fora permit subjectsthe applicant to a civil penalty of out room tthan l 10/ow ♦ Qct
$ five hundred dollars($500). NEW RESIDENTIAL ELECTR
n1,as owner of the property,or my employers with wag.as their sola �'�' STOW[5 TYPECONSIRUCTION
R7C ocon Iation,Mild.the work and thestructure la cm intended or offered for - -
O sale(Sec 7064,Buslneas and Pe feaskma Code:TheContnctot'a Limosa Law
docs notapply to an owner of property who builds or Improves themes,and OCC.CROUP RFS.UNITS
whadoessuchworkhtn lforlht ghhbowhemployees,pr idedthatmch _
Improvements are not Intended oroffered forsals.If,however,thebullding or ; TOTAL:
Improvement lasoldwlthln oneyeaiofco npletion,the owner-bullderwlll have
thLIZurden of proving that he did nor Wild or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
LJ I,as owner of the property,am exclusively contncting with It sed
FLOOD ZONE APN
mntncton to eurutruct the project(Sm 7046,Business and L8 kna Code: PERMIT ISSUANCE •1 �
The
Contractor's Limose Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER 4
Wilds or Improves thereon,and who contracts for such p(ojeco,with a FEE SUMMARY.,
cj5actor(s)licensed pursuant to the Contractor's License Law. '• BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B&P C for,thsi reasonrvrq
DRAINS FUDOIR ROOF,AREA,COND. SANITARY Y N�
Owner Date MRFLEIrf- .
WORKAN COMPENSATION DECLARATION
hereby
affirm certificate I have• rcertificconsente o!consent to uarc ��S�.�P SCHOOL TAX V N
self-In ,or a J �� RFGEPT N
J certifinteaf Worken'Caomppp�//e ytlonl unnre oracertBkd mpythersof(Sec.moo, GAS EA.SY5717.1-i INC.40[TfLE15 PARK FEE Y N
Polis Lab Cd/(�b 9/O p`� RECEIPT#
Policy p GAS EA.SYSTEM-OVER 4(EA)
CoETC- �-f{F _ - BUILDING DTVI SION FE ES
Certl—nc�c-o>�j:U Fe by faro shed. GREASE/INDUSTRL WASTE INTERCEPTORPLANCHECK FEE,
Certified copy la filed with the city Imposition division.
CERTIFICATE OF EXEMPTION FROM WOR K ERS' CREASE IRM r PAID
COMPENSATION INSURANCE 5E'WER.SANTfARY-STORM EA 210FF Date RCtt•I III
(Thissectton need not he completed lithe permit la(Drone hundred dollars
(51(0)orfthat
WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
certify that In the performance ollhe work for which W
s permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WAS SYSTEM/TREATING
W&I cos Compensation Laws m Callforma.Date PAID
-
Z Z Applicant NEW RESIDENTIAL LMB. SQF. Date' IiCcel [4
Z O NOTICE TO APPLICANT:[!,after mating this Certificate of Exemption,you
should beer.subject to the Wmkeri Compewtlon provlalo,o of tha Labor TOTAL:
�'4) Code,you must forthwith cemplywith such provisloruorthis permit shall be BU •E ♦�
LM > deemed revoked. - O
LI c CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhercbyafOrmthet there isa romtructlon leadingagenry forthe perform
M Z ane, ofthe work forwhichthla permit la iuuELECTRIC FEE
O ed(Sm.3W7,CIv.C.) TOTAL: S♦C� �
O larder's Name - ` - PLUMBING FEE
IL F enders Address QTY, MECHANICAL PERMIT FEE ' MECHANICAL FEE ' *�
U Icertifythatl have read this applleatlonand statethattheabove lnfornution
O w - Isconect,Idgmatocomply with all city and county ordinances and Asia taw, PERMITISSUANCE FEES PAID:
). CL relating to building construction,and hereby authorize representatives of this -
F N' city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z gree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# -.
V ago it i11ti.,pd menta A and z nm which may In anyway.mmw AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
ag natear City Jr as nce t antingoft9lapermt.•1 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SI a oApplimn ontrrtom- EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID: _.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cmpant store or hand In hazardous HEATING UNIT(TO 100,0DO BTU) Date RCCCi IN
material as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the
❑Yes I]No
health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL-
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) SSI IAN!CE DATE
which emit hazardousalr contaminants as deflned by the Bay Area Air -
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) t
T Y. ❑No re9u _ rep + 1991
Ihavenia the haurdoet Code,Sections
(mmDS,25 der Cha er6.95 of BOILER-COMP(OV[R 100,000 BTU) Y y
the California ed t Health&Safety Cod.irg rat. 75505,have.
tenant,sad 75534.'1
understand that if tifyhe the occupant not erequirantly haves whichthat b mat NEW RESIDENTIAL MECH. SQ.FT.
responsibility hanane of a Ctheoate o(O ftherequlrementa which moat be mat �1y5y j
prior to Issuance ofa Certlticate ofOmpanry.
Owner or authorized agent. Date
TOTAL: ISSUED BY:
OFFICE COPY
ADDITIONAL PERMIT FEES,
'.'BUILDING PROJECT IDENTIFICATION VniUATION'(y
A.EAlSl
f. 'FEE SUMMARY
' - Co sRAcr Rs - BUILDING -
RAW j`
i. . . rv["I••. Ll,,, • ,4lle 'm`"rvn!1 2_ l PLAN CHECK '
1 r.^^oN.R/AAcW - ",FEE '•I
12 <,q V{�.C.,�rNo �'l � ����` SEISMICFEE ..,
:• DTV. - ELECTRICPERMIT "FEES '
UTLETS-SWITCHES-.RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL -
SIGNS ; - '
" T
SIGNS TRANS:
SPECIAL CIRCUIT
EMP.METER OR POLE INS: FEHMET VILIDATION
1 9.399•
EE
MOTORS SEE FSOH. 1 '
O SERVICE CHANGE
1— o TOTAL
(C N •l '.-• '•• .'ISSUANCE DATE .
^t. w,> . " QTY.' PLUMBING PERMIT' FEE'S eEoc. EEECT. vw. .meCH.
: ALTER-DRAIN&VENT-WATER IEA.1
BACK FLOW PROTECT:DEVICE u
I.L. U „ DRAINS-FLOOR,ROOF;AREA,COND. -
O i r
FIXTURES-PER TRAP
"F ? GAS'-EA.SYSTEM:I INC.4 OUTLETS 0w�' v l\'1"\ �•
U
GAS-EA:SYSTEMI'OVER 41EA.) I
- '• INDUSTRIAL WASTEINTER y^!�
-v y LAWN SPRINKLERS,I INCBVB 2'L
LAWN SPRINKLERS:OVER,S(EA.)
SEWER�SANITARY-STORM,EA.200/s( --
-� WATER HEATER W/VENT " ' ,
WATER:SYSTEM _
WATER TREATING EQUIP.
CITY. '.- ' MECHANICAL PERMIT FEE• -"
ALTER OR ADD:TO MECH.' _
APPLIANCE
AIR HANDLING UNIT(TO1OQ00 C F.M.) '
AIR HANDLING UNIT(OVER 10=C.F.M.) '3 -
EXHAUST HOOD(WITH DUCT) .
HEATING UNIT(TO 100,000 B.T.U:)
HEATING UNIT.(OVER 100,000B.T.U.)
VENTILATION FAN ISINGLE)
BOILER-OOMP(3 H.P.o",100,000 B.T.U.) ..
.. ^ BOILER-COMP I0 100.000 BTU)SEE FEE SETT.
r
` .TOTAL.