19858APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
Building Proton Identification
Building Address:
PERMIT NO.
g10
19858I0-14�-10
: P ne
G� V F_qA�� �� ' �yl
r.l.^t'r'-dor 'e: � � ��_ 0,p, N..
W\ r S�iJi1_
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BNLDINGELECTRICALPLIJMBINC- MF-CI'IAMCAL
—F
CATEGORY
Architect/Engineer: Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERh9TISSUANCE
1:1 1:1 1:1LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment.
Ingwlth Se on7000)o(Divisi=3ofthe Busies and Profs OnaCode,andmy
lireme Is In ksll force and effect.
APMANCESRESIDENTIAL
JOB DESCRIPITON
- -
PANELS
Li.ese Clam Lk.#
Date Contractor
— UP TO 200ANT'S
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my latah 1 as Bc rcnpl
Licensed Profnsiovl
OVER 1000 AMPS
SQ. Ff. FLOOR AREA
$/5Q. FF.
SIGNSELECTRICAL
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Taw (or the
SPECIAL CE2C T/MISC
TEMP. MEEK OR POLE ST.
1.11.1og m.r.(Sect1on7031S,Bualnevand PmfessionsCode:Anycty.r
county which requires a perMttoconstrun, alter, improve, demolish, ormpair
anystructure prlorto its Issuance, alsorequlrealhe appllantfor such perndt to
file a signed statement that he is licensed pursuant to the provislov of the
Contractor's License Law (Chapter 9 (commencing with Section 70M) of Divi-
SI.n3 of the Business and Professions Code).,that he Is exempt therefrom and
the bash far the alIIIpppged examp"an. Any violation of Section 7MIS by any
sppilant(ora<subjectsthe epplicanttoadvll penalty of net m.re.han
five hundred doll a (5500).
I, ae ow r of he property, or my employees with wages as their sole
POWFR DOTES
SWIMMING ELE
OUTLE SWI Fl
VALUATION
NEWRES EC SQFr.
STORIES
TYPE CONSfRUCT10N
compensation, wl clothe work and the structure is not Intended or offered for
sale (Sec. 7046, usinmand Professloru Code: The Contractor's License law
does not apply to an owner of property who builds or Improves thereon, and
doessuch work himself or through hisown employees, provided that such
OCC.GROUI'
RFS. UNITS
Improvement fesold withinoneyearofcompinlon,the owner-bullderwlll have Improvements are not Intended orof(ered !.reale. If, however, the building or
TOT
the burden of pmOng that he did net build or Improve for purpose olnle.).
LJ L as owner of the pmperty, am exclusively .....acting with Ikeneed
contactom to comtnoct the project (Sec. 7054 Business and Profemlors Code:
QTY, PLLIA110URN. T FEE
PCRMI E
FLODDZONE
APN
The Contractor'. License Law don not apply to an owner of property who
Wilds or Improves thereon, and who wormers for such pt.jena with a
cqictor(s) licensed pursuant to the Contonor's License Law.
LJ 1 am exempt under Sec. B & P C for this mason
ALTER -D &VENT- WATER
BACK FLOW OTFLT. DEVICE
FEE SUMMARY
OUTSIDE FEES
DRAINS ROOF,
R AREA, GOND.
FIXTURESPERTRAP
SANITARY Y N
RECEE T #
Owner Date
WORKMAN1 have .NSATcxr D.E RATION
01 hereby affirm that I have • certlflrate u sent to opytnsum, Se e
ceni(IateofWorkers'Cam oral an certi(led.pythenvf(Sac.
00,IabC
SCHOOL TAX Y_ N
N#
GAS EA.SYSfEM-1 INC.60I1'II.EfS
PARK FEE Y_ N_
REC=#
Com�—
GAS EA. SYSTEM-OVERd(EA)
BUILDING DIVISION FEES
%Y
.stifled mpyIs erehy fu (shed,
MCe ified copy Is filed with the city Inspection division.
CREASE/INDUfEML WASTE INTERCEPTOR
PLANGHEGIC FEE
GREASE TRAP
CERTIFICATE OFEXIiMPflON FROM WORKERS'
COMPENSATION INSURANCE
(ThlssenW lon need not completed if the perMt is fm one hundred dollars
(5100)otityth)WATER
thatlothn person nce Issued,
I
I shall not employ any person in any manner w u to become subject to the
.mannerhe work su as to becomh this e subject
Worked Compensatlrn lawaof GB(ornia. Data
PAID'J— sO QQ,,
Date Recei t# Q,• -p
SEWER -SANITARY -MRM EA 200F1'
HFATERW/VENT/ELECTR
ENERGY FEE Y N—
PAID
WATER SYSTEM/TREATING
Applicant
NOTICETO APPLICANT:IL esker staking thin Cert0late of Exemption, you
'should became subject to the Workers' Compenx tI.. protalo. of the Labor
Code, you must fort hwlth comply with such provisions or this perni t shall be
Licensed revoked.
Date Recei t#
NEW RESID61TEAL PLMB. SQ.FT.
TOTAL:
BUILDING 1q
TOTAL:
15C
�s
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lend Ing agency for the perform-
ance of the work for which this perMt I. Issued (Sec 3097, Civ. C.)
Lander'. Name
Lender.Addmn
I cedifythat I have read this appBationand staiethat theaboveinformetlon
Iscorecct. I agreeto comply with all city and county ordinances and orate laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEE —PAID:
relating to building construction, and hereby authorize representatives o(this
cityto enterupon the above-mentioned property (or Impection purposes.
(We) agree to save, indemnify an If keep harmless the City of Cupertino
agabut liabilities,Odgmems,cuts .and expenses which may In any wayaccrue
against Said City In consequence of the granting of this permit.
ALTERORADDTOMECH.
AIR HANDLING UMT(TO 10,000 CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING [KNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,ODD RTU)
Will the appBantorfuture building ooupantstore or handle havrcious
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Code Section 25532(.)?
❑ Yes M NO
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL: #
VFNDLATION FAN(SINCLE R15ID)
I U_ JCE, DATE
�RI'iV
App
APR M
Will the applicant or future building occupant ussequlpment or devices
which emit haxaMous air rem aMwnts an defined by the Bay Area Air
Quality Management District?
4 Yea 9 No
have read the Fav oils materials mquirements under Chapter 6.95 of
the Califernt.11ealth&Safety CWe,Senl..25505,25533and255M. I
BOILER -COMP OM' OR 100,000 BTU)
BOILER-COMP(OVER 100,(00 BTU)
NEW RESIDENTIAL MECH. SQ.IR.
und,raundthatifthe building does not mmentl ve a tenant, that It is my
rrsor to Issuance,
ce not ify the.c pant .(risere D which muss be met
prior to bsuanre.fa Ce eo(
1J
\
ISSUED BY' R� JCJ\Y.S-'CJ��
mer or author en. Date
TOTAL:
OFFICE COPY