19937APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
kbLA la s t=
PERMIT NO.
19937
nee. ams: Phone:
S'�ror� V -3994
CITY OP CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
p
_D�.-..® �
D
rt:
°"end.rsNanLie. No:
} 88 a'(. k
BUILDING•ELECTRICALPLUMBINGMECIIAMCAL
CATEGORY
CONTROL#
Architect/Engloeer.. Llc. No:
QTY .. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PERMITISSUANCE
El ❑ ® 1:1LICENSED
CONTRACTOR'S DECLARATION
Thereby all that tarn lkmsea .Ii.al wield Pro ollmar9(rommmc
IngwlNSedlon 7000).(Dlviclon3oftheguslnemand Profeadlon.Code,and my
It... la In fu force and effect.
License Clam C—`3 (O llc.# ggalo 1�
Date Li—\'1— \\—Conrad.,
ARCHITECT'S DECLARATION
I understand my plats shall be used as public records. �b9
APPLIANCFSRESIDENTUL
PANELS
JOB DESCRII'IION ,
•` — Qua`
4�_r
S ..J` C-2
SQ. FT. FLOOR AREA $/SQ. FT.
701-1 OOO AMT'S
OVER IOW AMPS
SIGNS ELECTRICAL
Licensed Pmfemloral
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
following reason.Section 7031.5, Buslnes.rd Profemlons Code: Any city.,
countywhlch requires a permit to construct, alter, Improve, dem°Oah,orrepair
anystmmmprlortolmismance,abomquircstheappliantforsuchpermitto
file a signed statement that he Is Licensed pursuant to the proNaloru of the
Contradoes License Lnw(Ch.pier 9(mmmencieS with Section 7000) of Div[-
.]on 3 of the Business sad Professions Code) or that he is, exempt therefrom and
the Web for the alleged exemption. Any violation of Section 70115 by any
t. a civil penalty of not ore than
applicant for a permit subjects the applicanm
five hundred dollars ($500).
I, as owner ll the property, or my employee with wages as thele dole
compensation, will the work and the structure dedun' or offeredLaw
r
SPFCIALCIRCIRT/MISC
TEMP, METER OR POLE INST.
POWER DEVICES
gWA1MING POOL ELECTRIC
OIJILETSSWITCHFSEXIURES
' l VALUATION
moo/
!! '
NEW
NEW RESIDENTIAL ELECTR _SQ.Fr,
TYPE CONSTRUCTION
044, Th Crimot
cob( Sec apply Bu sinessandf
Boxia Cade:TheCs Taw
TOTAL:
QTy, PLUMBING PERMIT FEE
, PERMITISSUANCE
property hemon
does not such pply work
rk owner ofthroag ywho bulldsoyimproves, provi ed that and
who ovementswork himself Intended through hlsor s employees, provided that such
such
improvement issold am firone earofremplatile.If, owevcpthebWldiing orhave
Improvement of o proving within .ayes of buil por Imp he ove for r -bullae nfule.).
tl�urd sowner(thethat Mdidna exclusively
for purpoaco(—ac.
u I, as owner construct
the property, am.744, contndl"g with u,Codd
and P owCode:
OCCGROUI
,
RES. UMTS
FLOOD ZONE
APN
TheconCoontor'sLiudtheproject act
License Lw aces nes apply to an owner a property who
to a. of
The Coor improves;
builds t r Improves thereon, and who contra's ficeice such p.okde with a
�➢t(ad m eemptlicensed pursuant to the Cmtra'ole Llrenm Law.
1—JI am exempt under Sec. B k P C for this reason
1
ALTER -DRAIN k VENT- WATER (G)
BACKFLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS- FLOOR ROOF, AREA, COND.
t1 TMT�q,PERTRAI' f �,1�
TJ 'V'
SANITARY Y N
RECEIPT #
Owner Date
� ORKMAN COMPENSATION DECLARATION
herebyffirm that I have • mrtlficate of consent to self -Insure, or a
certlflateofWorkere'Comperuati.n Insurance tars re
a certified copy theof(Sec.
SCHOOLTAX Y N_
RECEIPT M
GAS EA. WC.pOUH.EI'S
PARK= Y— N_.
RECEIT#
350, Lab )
Policy Is %.t�ri.� aa-
Com anv .�n.�.: ..'- . ,. 1,
GAS G.SYSTEM-OVER4(EA)
BUILDING DIVISION FEES
MrtEed copy b hereby fumlahed.
® CedRled copy b filed with the city Inspection division.
CREASE/INDUSIRL WASE INTERCEPTOR
PLANGHECIC FEE
GRFA.SETRAP
CERTIFICATE OF IN M PTION FROM WOR KERS'
COMPENSATION INSURANCE
(0r IedMion need not compl'ed i(the permit b (Drone hundred dollam
($1 W).rem)
I rent that employIn an performanceny mannerhe sa s towhibehlepert subject to theed,
I shall nes en any Laws In any manner m as to become subject t° the
Work..' plicaCompenwtlon laws of California. Date
Applicant
NOTICE TO ne subjCAM: a after making this Certificateof Exemption, you
Labor
tot he Workerth.6persalonporthis Format
Codshoa, you re hat Inaith
Code, d re rrwet forthwith comply with such provbbro.,thio permit ahall be
deemed revoked.
PAID
I Date RCMP t#
SEWER-SAMTARY-SIDRM EA. MET.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL FILMS. SQ.FF.
TOTAL:
IN
TOTAL:`�
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a construction lending agenry for the per(.rm
ance of work for which this permit b 97, Issued (Sec, 30Civ. C.)
Iander.N.me
Lender'SAddress
I mAify that l have mad thio appBaBon a nd date that the above lnformatlon
-
QTY. MECHANICAL PERMIT FE•E�
PLUMBING FEE
MECHANICAL FEE
FEESPAID:
Lammed. I agree to complywlth all cityand county ordinances and state laws
PERMIT ISSUANCE
relating to building ma tru'lon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for loopectlon purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
ages Wt Liabilities, jadgments,roc. and eapenra which may lnsnywayamve
against said City in consequence of the granting of this permit.
ALTER OR ADD TO MUCH.
AIR HANDLING UNIT (T010,000 CFM)
[# Date ReCCI
P
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,WOCFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HA] RDOUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,ODO BTU)
Wiiltheapplic, t or future buildingodvpant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9,17, and the
Health and Safety Code Section75532(a)7
❑ Yea No
Dd[C ReCCI t#
HEATING UNIT (OVER IW,DDO BTU)
TOTAL:
t2jKC50
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
(gq�si
DAIIA
Will the applicant or turebuilding cempantuse equipment ordevice.
which emit harardous ate contaminants as defined by the Bay Area Air
Quality Management Dietrid7
qYea to No
have read the hares oua materials requirements under Chapter 6.95 of I
the California Health k Safety Code, Sections 75505, 25533 and 75534. 1
BOILER-CDMP BLIP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building does not currently have a tenant, that it is my
responsibility to notify theoccupant of the requirements which must be ml
Prior to Issuance a a Certificate, of Gccvpanry
APR a.s •��yrs,
/{. 1
ISSUED BYy'�"4�i sfJTNa'reiW
Owner or authorized agent Data
TOTAL:
OFFICE COPY