28099APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO - '-•-• RICA],
APPLICATION/PERMIT PING PRNG-MNIDENTICAL
BUILDING DIVISION BUILDING I'HO.IEC'1' IDIiN'1'IFICA'1'1f3N
FICA
PENMITNO.
28099
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DAIS.
6If P',� NNs 3
1 �JL. v"L' UNIT LOTH
�-CCrqn 'S
OWNaNAME: PHONE:
CONTRACT'OR'S NAME: LICNO:
N/C
❑
CONTROL
Q _ 33 4
ARCM rECDENGINEIz. LIC NO:
ADDRESS:
CONTACT: PHONE:
L"0a
QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG LE PLUMB MECH
PERMIT ISSUANCE
1 n 996 ase
❑ ❑ ❑
LICfiSEDatiml CONTRACTORSrpmvi iansof RATION
I hcmby affirmthalemliisDECL DECLARATION
with
pppLIANCCS- RESIDENTIAL
y _ /pg CRIPfION
CTi
aC»Le 1
Smsion70fir of DivisinnJnf@e Nusinev end Prafeviona Code. and mylieenu isin
full and effect,
PANELS
sy
Licamrce
Clax.
Lleense Class Lic.N
UP TO 203 AMPS
201 - high AMPS
Data Contract.,
ARCHITECTS DECLARATION
I understand my plans shell he used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. lel•.
SIGNS ELECTRICAL
Licensed Professional
ER
OWNER -BUILDER
SPECIAL CIRCUIT/MISC.
I I'm exempt d the Contractors License Low for the
I hereby aft inn that 1 nm exempt from the Cosions
TEMP. METER OR POLE INS 1'.
o
Code: Any tiny nfcnumy
roll.ewhichingrcasoa.ermit H,alte,
whichrequires uperil to construct, alter,improve,demolish, orrepair any rtmmare
inqure, demolish.
patlie its imuancqalso re quires the Ne ase statement
thevisiosof the
POWER DEVICES
nttotir Co mature La
that he in Iiccng w pursuant m the) of O Inns of the Contreenors license a Law m, Coder
ingwhhhaaion9(NIII of Dlvisinn Sof the Buslnese anU l4ofessI.I. Code)
9(mmhe
SWIMMING POOL ELIiCT2l0
VALUATION
a
onhnthcl31.5 ixt byar, tipromnnd the basisfnnjectshe the to civilprialry of
Semon703n se anyapplicantforapermit subjects the epplicnm,oacivil penally of
nm more Than foflhepro rty,ocol rniyemp.
❑ Lasnwnerofthepmpcny,onny employceswirh wages aslheirsolecompensation,
OUTLET'S-SWITCI IES - FIXTURES
NEW RESIULN'TIAL ELECTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
will do the work, and the suunure is not musudedoreffmcd forsale(Sec. 7041 Business
and Professions Cale: The Contractors License Low does not apply to an owner of
progeny who builds or impmvea thereon, and who does such work himselfor through his
ownempinyees,provided rhatsuch improvements we not intended interfered berserk, If,
OCC GROUP
RES. UNI'1:S
howeveq the built ingor improvcmenl is sold within one yearofcampletion, themema.
builder will have the burden of proving that he did not build chimprove for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑ I, as owner ofthe property. um exclusively contracting with licensed commuters to
FLOODZONE
APN
construct the project (Sec. 7044, Business and Professions Cade:) The Contractors
License Lewd«snot apply loan uwnanfpropcny whobuildxorimproves Narcan.end
PERMIT ISSUANCE.
who commits forsuch projectswith a conommr(s) licensed pursuant trust Contractors
1-facnsa Law.
ALTER
FEE SUMMARY
❑ 1 an exempt under Sec. , B & P C for this mason
BACK ROW PROTECT. DEVICE
TY D
SANITARY N
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ Thereby aRmnhanlhavicecenificam o(cenunuo selGinsurt, ora eenificam of
Workeri Compensation Inammtceora certifcalmpy thcrcef(Sce. 3800, Lab C.) which
DRAINS - FLOOR, ROOp, AREA, CO ND.
SCHOOL TAX YN
RECEIPT#
FIXTURES -PER TRAP
PARK FEE Y N
coven all employee's on&, this perm.
Policy #
GAS - P.A.SYSTEM-1 INC. OUTLETS
RECEIPT N
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CF.RTIFICA'1'E Op CXEMPfION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER -SANITARY -STORM EA. 20017.
ENERGY FEE
(This section need nor be completed ifthe permit is boom hundred dollars I$ IM)
in lass.)
WATER HEATER WN ENTAN.ECTR
I terifythrt in amfonnune.of the work far which this perit is issued, Ishar
not employ any Person in any m as to become subject no the Workers
so
PAID
Compcnsatinnl.vwsnf Cullfomia. Dore
WATER SYSTEMITREA'I'ING
Data Receipt#
Applicant
NOTICE TO APPLICANT. ILufter making this Certificate of Exemption, you should
NE VNIDF TIAL PLMB. SQIn',
TOTAL:
became subject to the Workers Cmnpenaation provisions mine taper Code,you st
forthwith comply with such provisions or Ibis peril shall be deemed revo ed.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affix thanhercis aconstruction lending agency for the performanc, of
the work for which this pari, is issued (So,, 31197. Co. C.)
Lenders Name
TOTAL:
ELECTRIC FEE h
Lenders Address
QTY. M CHANICAL PERMIT FEE
PLUMBING FEE
1 cenify that I have read this application it slate that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction. and hereby authorize representatives ofthis city loenterupon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmenrs, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10." CIM)
in masequenceo granting of nhi
AIR HANDLING UNIT (OVER 10," CFM)
Signor of APPli<anl/Cnmranor Dahe
EXHAUST HOOD(W/DUC<)
PAID
HEATING UNIT GO 100,00(1 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date "p, I,
Will the applicant or future building emoting snort or handle harmeous material
as defined by the Copeman Municipal Code, Chapter 9.12, and the health and Safety
HEATING UNIT (OVER 100,000 BTU)
T
Cade, Section 25532(e)'!
EI Ya 11 Na
�N
VENTILATION FAN (SINGLE. RISID)
Willtheapplicanuafuturebuildingaacupanluseequipmentadeviceewhiche I
Bo1KK1 nlv)
aeR-coMP(3HPOR IW .
ISSUANCE DATE
BOILER - COMP (OVER 100,000 BTU)
azormus air Imiciamorts as defined by the Bay Area Air Quality Management
Dl,triin7
No
1:1 yes 13T
{#�p
1 V
NEW RESIDENTIAL MECH L SQ. PT.
1 have and the hazardous materials requirements under Chapter 6.95 of the
California l leuhh&Safety Cale. Sections 25505,25533 and 25534. 1understundlhal
if Ota building docs not currently have a tenant. that it is my responsibility mortify the
MAY a.
4lVICiH g
occupant of thmbe
e requlrecnts which must met prior 10 Issuance of a CeNfivma or
sOYn
Oreapuncy.
TING
ISSUED BY:
Owner or authorized agent Date
TOTAL:
OFFICE