19532APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Fm'ect Identification
Building Address:
PiRMITNO.
-4a z M9e : yl
19532
ners ame: Phone:
/rt,
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A
contra Mame: Lie, No:
BU)LDING-ELECIRICALMUMBING-MECHANICAL
CATEGORY
CO
AmMtect/Engtnrer. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: 9 6; N J'jF
PERAUTISSUANCE
❑ 1:1 1:1LICENSED
CONTRACTOR'S DECLARATION
I hereby affiren'hat l am licensed under provisions of Chapter 9(commene
ingwlthgection7000)of Divt, , oftheBminessand Pro(esslonaCodGand my
li=ICfn d dfod.
Licenso CVs _ LICN L -c
APPLIANGFSRESIDENTIAL
OB RIPDON
MVV ��r—
PANELS
Date Contactor
201-1000 AMPS
ARCHITECT RATION
OVER 1000 AMPS
SQ. IT. FLOOR AREA
$/SQ. FT.
I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professlonal
OWNER -BUILDER DECLARATION
I hereby affirm that am exempt from the Cordradoes License Law for the
SPECIALCIRCUIT/M15C
, J
TEMP. MEIEROR POLEINST.
following mason. (Section 7MI5, Business and Profession Code: Any city or
countywhich requirna pered'tommimM alter, improve, demolish, orrepair
JV�
anystmRure pdortolts Issuance, also requlresthe applicant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOLECTPJ
OUILE SWIM ES
Contractor's License Law (Chapter 9 (comer arcing with Section 7000) of Divi-
shoo 3of'he Busincssand Profetalora Code) ortha' he is exemp"lu,mfromand
the W sis for the alleged exemption. Any violation of Section 7MI,5 by any
applicant fees permit subjects the applicant to a civil peruity ofnot more'Wn
VALUATION ®�
•"i /, b/'1/�
NEW R IDEMT ;CTR SQ'
fivehundoIWa($SOI.
n1, as=er of the property, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
compensation, wllldothe work andthestmRure is no' Intended or offered for
.In &c. 7040 Businessand Professloro Code: The Contractors Lt.. Law
thered
docs na apply to an owner of pmpertywho builds or Improve on, an
who does such work himself or through his own employees, provided that such
:::he
OCC. GROUP
RIS. UNITS
improvements an not intended oroffered for sale. If, howevegthe building or
TOTAL:
Improverrent is sold withln oneyearofcomplalom the owner -builder will ave
th,e..pnrden of proving that he did na build orimpeave for purpose ofsale.).
LJ L as owner of the property, am exclusively contracting with Icamed
contactors to mrutruct the project (Sec 7074 Business and Pr axaxiom Code:
UMBING PERMIT FEE
QTY,JPERMIT
FLOOD ZONE
APN
UANCE
The Contemor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts far such p(oje x with a
rato the Contractors License Law.
rypllactor(.) Brensed pusunt
[:]1 am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT- WATER ffNN
FEE SUMMARY
BACK HAW PROTECT. DEVICE
OUTS I DE H ES
SID. ROOF, AREA, COD.
DRAINS COI
SANITARY Y N_
RECEIPT N
OwnerDate
WORKMAN COMPENSATION DECLARATION
F11 hereby affirm that I have a cedlRate of consent to sell -loam, ora
mriffrate&Workers'Compemationlryre
urance ma cedlfed copytheof(Sec.
3500, Lab C.)
Policy p
FIXTURES— PER TRAP
SCI'100L TAX Y_ N_
RECEIPT N
S
GAEA. SYSTEM -1 INCAOUTLETS
PARK FEE Y N
RECEIPT N
GAS EA. SYSTEM -OVER 6 (EA)
Com any
BUILDING DIVISION FEES
Certified copy is hereby famished.
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKE
GREASE/INDUSTRLWASIEINTERCEPIDR
PLANCHECK FEE
1a [fq/��
PAID ` l- o 5p_
GREASETRAP
SEWER -SANITARY -STORM EA "FT
COMPENSATION INSURAN E
Rhissmion needs mm Fiend if the pemJ faro undred dollars
_�
Date Reml t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N
I 1'�x'
PAID �l V
l
(eyx1.
(f100)or less)
Icadifyt In the o_a- the whlc apennitt,issurd,
I shall not em a perwn 1 ny n ras t b' to the
_
Wmkeri Co pea on Laws G cam stn /
WATER SYSTEM/TREATING
NEW RESIDENTIAL ['LMB. _SIFT.
Armhctm
fRstaef Exemption,
Date Remi t#
NOTICE MPLICANT: If, erma ng this a you
shouldbecomesul, to'he m]xam'Campenation provlsiom .(the Labor
TOTAL:
BUILDING FEE
Cade, you most forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
In.$O
I hereby affirm that there is a conBuctlon lending agency for the perform
Lnm of the work for which this permit is issued (Sec. 3097, Clv. CJ
ender's Name
lenderspddre.a
I cadify that I have mad this application and sta'ethat the above Information
1; ended. l agree to comply with all city and county ordinances and pate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building conatmetlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agalna liabilities, pdgments, coda and expenses which may he any wayarene
against said City In consequence of the granting of this permit.
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,ODO CrM)
SUBTOTAL:
Z.O
AIR HANDLING UNIT (OVER lit, Wit CFM)
CONSTRUCTION TAX
Slgwm re of Applicant/Contractor Date
IXHAUBT HOOD (W/DulcD
CONSTRUCTION TAX PAID:
HA] R DOLS MATER IALS DISCLOSURE
HEATING UNIT (TO 1(0,000 BTU)
Date ReceI t#
Will the applicant orfutu re building cocopant store or ha ad le hazardous
material as defined by the Cupertino Mu Ncipal Code, Chapter 9.1 2, and the
Hal'h and Safety Cod c Section 25532(a)i
nYes M No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENILATION FAN (SINGLE RESID)
IIJLI(1�DATE
Will the appilant o,future building occv pant use equipment or devices
which ens Wzzrdous air contaminants as defined by the Bay Are Alr
Quality Ma wgcrra nt Dist dci7
Yes No
have read the nus materia quire ntsun haps .95 of
�1�Y/
q p1990
M R 00
BOILER -COMP OHP OR 100,000 BTU)
BORER-COMP(OVPR tO0,00067U)
the Glifo sahib fcty Cod los 505, and .1
KEW RESIDENTIAL MECH. FQ.FT.
unders luitif' uildingd anam ntlyh tena tl'ismy
repo ibility to Ity the ant it , require ntsw must be met
Isla,. rllA'�
prior to u co a Certif tc of0 panty.
city
,•'/
ISSUEDBY: V tk 7M1 VCS
rau'hort gent Date
TOTAL:
OFFICE COPY