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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pruett Identification - ..
Building Address: .' a
PERMIT NO,
20836
ners amu: 1_ one:
CITY OF CUPERTINO-BUILDING DIVISIONytic)
APPLICATION / PERMIT
BUILDINGELECTRICAI PLUMBING-MECHAMCAL
APPLICATION SUBMiTrAE=
V 1. -
cnnt ctor'a Name: ams i ie. No:
C S
CATEGORY
COL�
Architect/Engineer: Lic. No:
grf .,.,,, 'ELECTRIC PERMTT ,+:, FEE
'• HUICDINGPERMIT"INFO
Address:
PERMITISSUANCE
LICENSED CONTRACTOR'SunderDECnsofChON
[hereby affirmthatlam licensed under provisions ofChapter9 (comment-
ingwith Sedion7B0Oof Divsion3ofthe BusinessandProfesslonsCode,andmy
nee is in foll fr and cited.
(cense Cl ss Lie. p /�
Date Contractor �pNir•UP
ARCHITECPS DECLARATION
-
APPLIANCESRFSIDENTTAL
JOB DESCaRaII'IfO
�'pQh��...r�
(Js----�•V•L `�sy��.
PANES
IQ 200AMPS
201-1000 AMPS
OVERI000AMPS
SQ. FT. FLOOR AREA
q L+
4/}SQ.FT.
I understand my plans shall be used as public record&
Licensed Professional
SIGNS ELECTRICAL
SPECIAL CIl2CUIT/MIST
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
Limns
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhichrequlresaper ttocomtmct,alter,lmpmve,demil h,ormpair
anystructure prim to its Issuance, also requlreathe applcamfor such permitto
file a signed statement that he is licensed pursuant to the pro4mes of the
ppWgg DEVICES
'
'SWIMMING POOL ELECTRIC
rzoOIITLETSSWITCHFSFUCTURES CD
I�
Contradoes License Law (Chapter 9(commencing with Section TIDO) of Divi.
sion 3 of the Businessand Prousalona Code) orthat he iseumpt t1klu�refromand
the basis for the alleged exemption. Any violation ol,SeUlon 7MLS by any
applicant for a permit subjects the applicant to aldsRpeoaltycotnotnnrethan
five hundred dollars ($500). IJ' "
❑ E as owner o(the property, my employee. with wages ai Ihgii@ole
compensation, wBldathe work. an the5tmdure is not Intended dr'ufdre2 for
sale (Sec 7044, Bueineaa and Professions Code: The Contrz'doe. Llceose Law
VALUATION
�I SI�`
Is(EW RESIDENTIAL ELECTR SQxT.
STORIES Y
TYPE CONSTRUCTION
'
does not apply to an owner of pneperty,who�bulks or Improves thereon, and
who doem nts are not intended
oIp formic if, my pr th.4Ihataucrr
Improvements are not intended or.lferelorele. If, howeveCihe bulldln m
Improverrentlssoldwithmoneyeat fcompldlon, thepwwner bdiWe{will v
th,E*rden of proving that he did not buildoi�lmprov�feLlp '.aiofsa .).
u L as owner of the property, am exclus yely coy`6its Ing wljh licensed
contradorstomnstmettheproject(Sec.7044, uame { and Prescealons Code:
'
q
- '' TOTAL:
.
'qTy; ,: PLUMBING PERMIT. YFEE'C
.� OCC. GROUP
RES, UNITS
STOOD ZONE
APN
1 PERMIT ISSUANCE 1�a
The Contractor's License Law don not apply to an owner of property who
Wilds or Improve ch thereon, and who contracts fm oup�uje ia with a
c tractors) licensed pursuant to the Contractor's License Law.
I am exempt under Sec. B & P C for this reason
-'
ALTER -DRAIN & VENT - WATER con)
'FEE SUMA'IARY'-
BACK FLOW PROTECT. DEVICE%
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP l
SANITARY Y N_
RECEIPT If
Owner Date
WOR KMAN COMPENSATION DECWRATION
❑I hereby affirm that I have a certificate of consent to self -insure, or amfti
of Workers'Comperuatlonleuranceoracertifled mpythereof(See.
3800, CJ
3800, Lab
Policy p
SCHOOL TAX Y- N_
RECEIVE p
S F.A.a
GAY SYSTEM -1 INCA OUTLETS e�e(�
PARK FEE N
RECEIPT p
-
GA&EA. SYSTEM-OVER4(FA)
Com any
_.
BUILDING DIVISION FEES
copy is herebydwithfurnished,city
Certified copy V filed with the city Ir�epeclion division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCFIECIC FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200FT.
COMPENSATION INSURANCE
(Chissection need not be completedpletedpermit hundred dollars
r�
Date Remi t#
µJ
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($100)or Ines)
(certify that in the performance of the work for which this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner an as to become subject to the
Workern'Compensatlonlawa of California. Date
-
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
NEW RESIDENTIAL PLMB. SQ'r'
Date Recei t#
TOTAL:
should become subject to the Workers Compensation provisions ofthe Labor
Code, you =at forthwith comply with such provisions orthls permtshall be
deemed revoked. '
BUILDING E
-
SEISMIC FEE
- CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a mmtmction lending agency for the perform:
Ince of the work for which this permit is Issued (See. 3097, C1v. C.)
Lender's Name
Lender's Address
ImAifythatIhavemadthlsappllcationandmawthatth.above information
Is cored. l ogres to comply with al city and county ordinanrcas cistatelawa
.. TOTAL: lx�
ELECTRIC FEE 'in
. •
QTY. ;'MECHANICAGPBRM�T, -; '^ FEE"
PLUMBING FEE ',), Q7
MECHANICAL FEE L �
FEES PAID:
r�
PERMIT ISSUANCE 1' Lt�
relating to building construction, and hereby authorize representatives o(thls
city W)areeI the above-mentioned property for inape Cit purpose.'
(We) ogre. to ve, IndemNfy.an d keep harmless the City of Cupertino
age on liaklliti ,' d.rsvis,ms[sand expense ofthwpay Nanywayaccme
a sleet sal ty nconsequence of the granting of this pe "It. -
g
Date ReCeiPt#
r ALTER OR ADD TO METH.
AIR HANDLING UNIT (TO IO,fgO CPM)
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
sign re uta o dor Dam
D(HAUS'T HOOD (W/DUCT)
CONSTRUCTION. TAX PAID:
H RDOUS MAT SDISCLOSURE
Ill thsopplice or future building occupant storeor handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety ode Ion 25532'a)7
❑ Yea
Will the applicanto future buadingoccvpart use equipment or devices
Date RCCeI t#
HEATING UNIT (TO 100,0008'fU)
HEATING UNIT 100,000 BTU)
TOTAL: -Ell l 36
VENTILATION FAN (SING IRFSID) 2�Q(j
'
I$$(Jphjlt',DATE
which emit hors, sous tr contaminants as defined by the gay Area Air
BORER -COMP (311P OR 5(X1,000 BTU)
Quality Managemen e"r -
4Yea
BOILER -COMP (OVER 100,000 BTU)
-
have read the hat, ous matenalsreium, rsunder Chapter6.95of
, t
the Calilornu Health Ssfety Code, Sedlor,a 25505, 25533 and 25534. 1
NEWRFSIDENTIALMECH. SQ.I•T.
understandthatifth ulldingdoes not currently have a tenant, that it is my
responsibility tl the occupant of the requirements which must be met
priortohes: C a Certificate of 0c nry:
(;IIi)PI11ni)
t�Ity, of -
� d
ISSUEDBY: 7��1L�UU.,7U-M
c au oared t Dat
TOTAL:
OFFICE COPY
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ADDITIONAL PERMIT FEES O -p, �26g,3)
BUILDING PROJECT IDENTIFICATION
VALUATION
II. ILO NG
.00xess 7 L -I
J(/`,
y�
Y
M
A EQ l \ �"'� HONE
FEE SUMMARY
coMENacraxs (�
A ei lP` uc_xo. J (7�Z�
BUILDING
PLAN CHECK
FEE
coxrxAcrans
nooBEss
PHONE
SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
—OUTLETS -SWITCHES -RECEP
ELECTRIC
LIGHTING FIXTURES
PLUMBING
PPLIANCES- RESIDENTIAL
PANELS
MECHANICAL
SIGNS
TOTAL
SIGNS TRANS.
SPECIAL CIRCUIT
EMP. METER OR POLE INS.
—VALIDATION
ISSUANCE DATE.
MOTORS SEE FEE SCH.
SERVICE CHANGE
TOTA 8•
DNPLUMBING PERMIT FEES
eLOc.
ELEcr.
Pw.
❑
IUECN.
❑
ALTER -DRAIN & VENT -WATER IEA.I�
BACKFLOW PROTECT. DEVICE
MSV
PAW
®�; 10 1990
/1��V �P ,, W{
M61!,,...ympPP+.�
DRAINS -FLOOR, ROOF, AREA, COND.
FIXTURES- PER TRAP
GAS - EA. SYSTEM -IINC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 IEA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS -I INC5 V.B.
LAWN SPRINKLERS - OVER 5(EA.)
SEWER -SANITARY -STORM EA. 200ft/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
I TOT -At
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT ITO 10400CF.M.1
AIR HANDLING UNIT (OVER IO)MCEM.1
EXHAUST HOOD (WITH DUCT)
HEATING UNIT ITO 100,000 B.T.U.)
HEATING UNIT IOV OVER 100,000 B.T.U.)
VENTILATION FAN (SINGLE)
BOILER COMP (0 H.P. or 100,000 B.T.U.)
BOILER -COMP (Dw. 100.000 BTU) SEE GEE SCN.
TOTAL