20659APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address: l9 moo S,6118. 5`, T e y O
1(. JT
PERMIT NO.
20659
ners am¢: one:
wy,srygb4�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
3—QO
l
Conmeter'.N.me: L1c.No:
BUILDINC-ELECTRICALPEIMBING-MECHAMCAL
CATEGORY
CONTROLp�j
F7 ��ll
ArcMtect/En neer, Lk. No:
A114^P C•-9Z/GQn
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO,
10/ ME7S_U OR. Su/76 -7$-U
Address: � jVS� _-^ a 9SN�0
❑ ❑ ❑
PERMITISSUANCE
-
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflrnthatlamlicensedunderprovisions of Chapter9(commene-
ingwlth SeM1on70(U)of Dlvislon3ofthe Businessaru ProfesdonsCode, and my
license is in full farce and effect.
APPLIANCES RESIDENTIAL
100 DESCRIPTION
`I
PANELS
License Clam LIc.N
Date Contractor
UP 10 2DO AMPS
201-1000 AMPS
ARCHITECTS DECLARATION
I n to dm las sbW used as public records.
OVER 1000 AMP'S
SQ. FT. FLOOR AR,,,EAA,,,
$/SQ. FT.
SIGNSELECTRICAL
Licensed Profess %
(a^I L�O 111
IJIJ
2Q
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I son exempt from the Contractor's License Lew for the
U l
TEMP MEM OR POLE INST.
following reason. (Seat.70315, Business and Professions Code: Any city or
countywhichrequtr saper ttocoatmd,alter,Improve,demolish,orrepalr
anystmdure priortolts lssuance,alsorqulrestheappBrant for such permltto
file a signed statement that he V licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Ulvl-
slon3otthe Busi.esand Professbmg Code) orthe he is, exempt therefromand
]OWER DEVICES
SVIMMING POOL ELECTRIC
VALUATION
the baso for the alleg¢d excmplbn. Any vl.ladon of Section 70)15 by any
appllrant f.ra permit eubjecdtheappgcaMtoacivll pealty o(nd marcthan
OUTILETSSWITCHESFIXTUR
(�- f)oo,
NEW RESIDENTIAL ELPLTR
five hundred dollars (5500).
❑ I, as owner of the property, or my employee with wages u their ale
STORIES
TYPE CONSTRUCT ION
compe.satlon,wllld.the work andthe structure is net Intended or offered for
sale (Sec, 70K Business and Professions Code: The Contradoes License Law
doe net apply to an owner of property who builds or Improve therm.,and
who does such work himself or through hisown employees, provided that such
OCC,CROUI'
RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building or
Improvement issold within one yearofeomplMbn, the owner -be llderwlil have
the to nice of proving that he did nut build or Improve for purpose of sale.).
u I, as owner of the property, am exclusively mntr.Mlng with Ilmnaed
contractors to mnstmlee. d the project (S 7014 Business and Professions Code;
QTY PLUMBING PERMIT
PERMIT ISSUANCE
FTAOD70NE
APN
TheContractor's License Law does nM apply to an owner of property who
bu1Ms or improve thereon, and who contra. for such pinkds with a
contractor(s) licensed pursuant to the Contractors Li«nee Law.
Lf I am exempt under Sec. B A P C for this reason
ALTER -DRAIN VENT-WATER (EN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consu
to self -Inure, or
certificate mfWorkem Compemad.n Insurance or a certified copy thereof (Sit.
380D, lab C.)
SCI TAX Y_ N_ent
RECEIPT
CAS EA. SYSI'FM-]INC.I OUTLETS
PARK FTE Y N
Policy N
RECEIPT a
Com any
CAS EA. SYSTE.1.OVER 4 (EA)
BU ILIIING DI VI SION FE ES
[Certified copy E hereby td.
�Certitled copy V filed withh the the city inspection division.
CREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
�^/
PAID ? 7b
COMPENSATION INSURANCE
Rhlseedlon need notbe completed lithe permit V (Drone hundmd dollars
�¢�/'+
Date Reed tp l itos QQ
r
SEWFR-SANITARY-STORM EA 200FT
($100)orlyth
I not that employ anyhe performanceIn any hework
I shall not employ any.Law. i. any manner at as m become subject to the
an as tobeco permit ie Ito the
W.rkere'Compenaatl.n lawn o(Cellfornla. Dete
Applicant
NOTICE TO APPLICANT: If, after making this C¢dltkam of Exemption, you
should become subject to the Workers' Compensation provlsloiu of the labor
Code, you must fort hwith comply with such previsions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N—
Q I
PAID 5 Y'T7
Date Recei tN
WATERSYSTEM/TREATING
NEWREEDENIIALPIMB. SQFr.
TOTAL: sBand
D 0`1.00
�,
SEISMIC FEE
I hereby affirm that there ka construction lending agency forthe perform-
anw of the work for which this permit h issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
PLUMBING FEE
Lender's Name
Lenders Address
I certitythat I have read thlnappliotionand statethat theabove Information
Is correct. Iagreeto complywlthall dtyand cm.ty.,clean., and state law.
MECHANICAL FEE
FEES PAID:
relating tobullding construction, and hereby authorize representatives of thla
city to enter upon the ,bon -mentioned property for Wpeatlon purposes.
(WL) agree to save, indemnily an d keep harmless the City of Cupertino
ALTERORADDTOMECH.
Date Receiptq
- SUBTOTAL:
against liabilities, pdgemets,cost .and expense which may in anywayaceme
a ales said City In consequence n
of the granting of this preit.
17
AIR HANDLING UNIT OD 10,MO CFM)
AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTIONTAX
igatureo ppliant/Contractor Date
EErHAUS'f EIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or handle hazardous
ma
material a, defined by the Cupertino Municipal Code, Chapter 9,12, and the
Date Recei to
HEATING UNIT (OVER 100,000 BTU)
TOTAL: .2
Health and Safety Code Section 25532(a)2
MYes No
VENTILATION FAN (SINGLE RESID)
IP
I$SU�gN�CE DATE'
11
Will the applicant (u m building occupant use equipment or devices
m
which endt hazardous air ntamiants as defined by the Bay Area Air
BOILER -COMP DHP OR 100,000 BTU)
Quality Mawgemcnt DWrict7
Yea No
have read the h ous materials requirements under Chapter 6.95 of
the California Health k Safety Code, Sections 25505, 25533 and 25531. I
•t a1- I�90
J-
BOILER -COMP (OVER 100,000 B11)
NEW RESIDENTIAL MEG I. S'Q.FT
understandthalifthe building does not currently have a tenant, that it b my
responsibility to notify the occupant of the requirements which most be not
prio tO'mo ceofaCertificateofOocupancy.
(s
�Ity 0f GIIRPrtinO
"f
�ISSUEDBY. j A VC
L
ne uthonzed agent pat¢
TOTAL:
OFFICE COPY