21850 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Address:Building Project Identification PIiRMITh'O.
`�� H 21850
one. p
nsra UA- CITY OF CUPERTINO-BUILDING DIVISION
Contracto aNarrc: Lk.No: APPLICATION /PERMIT .Cr
BUILDINGFLFCTRICAL-PLUMBINGMFCIIAMCAL CATEGORY CON'PtOir2Y
Architect/Engineer. Lk.No: tp
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrns: PERMUTISSUANCE El 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I thereby 70tM1atLamBcenaounder omofGncAPPLIANCES-RESIDENTIAL JOB DESCRR'1lON
ingwith&ection 7000)of Divblon3oftheBusinemand ProfessionsCode,and
my /�.� map
license b In full foe°an —
+ tO4
d effect. PANELS COOL f- 3S-P,
LicenseClam Lle.p
Date Contractor —UP TO 2DO ANUS
ARCHITECTS DECLARATION 2II-10DOAMPS
es I understand my plamshalibe used as public records. JOVERIODOAMPS - SQ.FT.FLOOR AREA $M.FT.
ww O
U
C 0 Licensed Professional SIGNS ELECTRICAL
�6m OWNER-BUILDER DECLARATION
�n a SPECIAL CBiCU1T/MISC
owngraformlMtlam01.5,B fmmthe d Probesorbs icorea,Code:LawAny fort he
po (o0owing reason.(Section 7m1.5,Business and Pro(eolona Code:Any city or
FZF'u9 =ntywhichrequlmsapermittommtmd,alter,lmpmve,dernlbh,orrepair TEMP.METER OR POLE INST.
q`"YY3gar,��a anystroRure prior to its Wasece,alsomquirestheappBant for such permit to POWER DEVICES
k5 re E V file a stymd statement that he is licensed pursuant to the provisiom of the
�Qj 30rContralto/s Llcereelaw(CM 9(mmmencin withSection7000)ofDivl-
^ sion3 ofthe Business and ProfessionsCode)orthatt he b exempt therefromand SWAIMINO rN VALUATION
the basis for the alleged exemption. Any violation of Section 70715 by any OU7LE.IS
6 Q
applicant for a permit subjects the applicant to a civil penalty a not room than
RC five hundred dollars e50B. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION'
..�, ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure b not intended or offered for
5 ❑ vie(Sec.7044,Rosiness and Pmfeoloss Code:The Contrad s'.License law
�5 8 does not apply to a t owner of property who Wilds or Improves thereon,and OCC.CROUP RES.UNITS
whodoocuch work himself orthrough Msoweemployees,provided that such
Improvements ore not intended oroffered for sale.I(hmveveq the W ilding or TOTAL:
Improvementbsoldwithinomycarofcampleti the-wner-Wilderwtll have
t refers of prowngthat he did not Wild orimprove for purpose ofmle.). QTY. PLUMBING P IT FEE FLOOD TONE APN
1,ae owner of the property,am exclusively contracting with Ilcensed PERMTTLSSUANCE
contractors to construct the project(Sec.7044,Business and Professore Code:
The Contmdor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-W
Wilds or Improve. thereon, and who contracts for such pRojem with a FEE SUMMARY
co,➢2rec.aclor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L_I I am exempt under SB &P C for this masonOUTSIDE FEES
DRAINS FIOOK ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RECEIPT
WORKMAN COMP a mrifi ON DECLARATION �.�S PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certiflale of consent to self-Inure,ora RFCI]I'I'N
certificate ofWorken'Compensation Insurance or a certified copy therrofpec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.) —
RFCEPT I
Policy X GAS EA.SYSTEM-0VER d(FA) BUILDING OI VISION FEES
ca�m+any
.ICeAffied copy is hereby fumished. GREASE/INDUSIRL WASE INTERCEPTOR LANCHE•CK FEE
Certified copy is filed with the city inspection division. r
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID .�(] �}
!7
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MFT. Date Recei t#1-2,n3
(Fhissedionneednot Wcomplded Btheper tbforonehundreddollars
($100)orless.) WATER t-IFnTER w/vFxr/EI.ECTR ENERGY FEE Y_ N_
I c rtifythat In the performance of the work forwhlch this permit la loved,
1 shall not employ any person in any manner so as to become subject to the WATFRSYSTEM/TREATING
Workers Compensation Laws of California. Date
PAID
O Z Applic rat NEWREADENTALPLMB. SQ TDate RCttI IM
Z U NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you . -a-
Hshould becomeaubjedto the Worliem'Compensation proo,knuofthe Labor TOTAL: I
N Cade,you must forthwith comply with such provisions orthb permit shall be -BUILDING E I
W j deemed revoked.
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE r
tl Ihereby affirothat there is a construction lending agency for the perforrm
Z ECTRIC FEE
7 ance of the work for which this permit b TOTAL: EL
issued(Sec.3097,CIv.C.) ELECTRIC FEE
(. 0 Lander'.Name
F Lender's Addreas QTY. MECHANICAL PERMIT FEE
LL U Icertlfythail Mveread this application and statethat Wus Information MECHANICALFEE
0 W is cored.7 agree to comply with all an county Ina moandstatelaws PERMIT ISSUANCE FEES PAID:
>. a relatingtobulldlegcorelmRion,an dM auth ne sentativesofthb
Z city to enter upon the above-mentions pertyf rIna ion purpasn. ALTER OR ADD TO MECH.
(We)agree m nave,Indemnl d p ha a he City of Cupertino Date ReeeiptN
U ag n tllabilltietij d rata,co sand chmayinanywayacnus AIR HANDLING UNIT(TO 10,=CFM) SUBTOTAL:.d
ago a In f grant'rl ofthl.pey(V� CONSTRUCPIONTAX
'7 ' AIR HANDLING UNIT(OVER I0,000CFM)
Sig urs of Appllant/ ntract to E%HAI15'r HOOD M/DUCT) CONSTRUCTION TAX PAID:
HA DOU MATERIALS DISCLOSURE
illtheappBant rfutu ulldmgodvpant store or handle hacardous HEATING UNIT(TO 1fD,000 BTU) Date Recd tic
terbl as defined by pertion Municipal Code,Chapter 9.12,and the
iealth and SafetyCade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Yea No
Will theappllcantorutvm Wilding occupant aaeequlperent ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air PAM
Quality Management District? BOILER-COMP QH POR 100,000 BTU),
4Ye 1❑' Na
Mve rda Health
Safer materials tions 2mentaundcr Ch a pier 6.95 of BORER-COMP(OVFR IW,OW BTU) APR 4 199*,
the Ca tang to Health&Safety Code,Sections 2tly h ve.tenant,and 25534. I U
understand thatn tifyhe building
occedoor not emqu lyreentshicmost
it bey NEW RFSIDEKIIAL MECH. SQ.FT.
responsibility to notify the oavpant of the requirements which must be rtKY
prior to issuance of a Certificate of Occupancy.
Owner or authorlaed agent Date
TOTAL: ISSUED BY.. VCL
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
• PERMIT NO. AL)DRhSS
P UWNER
(�f2��tt.rtJ�<v10CL[�� �l�l2U
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
pin 77775-6
ic _i75
Plumbing Power Pole
Mechanical 1a-*'5 gm
e as ec Ito�u ererH 1rih Solar Walls
Fire rin c erei in , p-
Sign ixtures int/Ext
Motors _
Misc. Groundin
e ower
r
FINAL INSPECTIONS DATE INSP. orove -
Gas
Electric - _Fs"
um ing -Z- PLUMBING DATE INSP.
c�ianIc-a
Solar Backflow
�00 Underdun
ra in r oor
annin arti u
ire a t. u ete _
Health a t. boiar Rough
Building o K r 3.7 PS ater '& Insulation
erin . ain
o aln
Gas
Other
BUILDING DATE INSP. Not rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
re- unite
Slab-Membrane UnderfloorS.M.
Bond Beam cts nsu ation
Undertloor Girders ..irF ewers _
Floor teel _ irer lace
ie owns urpase ct 0 flood
i.a rams - �ne-Mc�TT t
psmec racing -CmDrain
Nal
_FAM / �_u pm t Anc ora e
7rame /-G! . 6- � 4- Flues on r
_ - —
at Ttt ler
1 a�Tm xt. _ �� of rov6d ---
lrewa3 s — — i
6t6er
of rove
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
TUSCELLANEOUS