20315APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm ed Identification
Building Address:
PLRMITNO. •
JD/00 49 vE iss i .1
20 315
sere Nan
ak
APPLICAIT593011PITTAX=
'
CITY OF CUPERTIN06BUILDINGDIVISION
APPLICATION / PERMIT
6 o
Contractor's Name: LIc. No;
BUILDINGELECTRICALPLUMBINGMECHANICAL
CA RY
CONTROL N
Architect/Engineer. LIc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO—,
-
Address:
RX � al, I/y
LJ �aON I-
PERhETISSUANCE
LmEDCONTRAROr DECLARATION
that
Iherebya.t70thatlun BcensedheBusi vlalonsoffeam r9(commenc-
pr
lice..i.follf.Weand.felon3o(the BuelneeeandPro(eWonsCpde, and my
limens lelnfuB farce and
APPLIANCES -RESIDENTIAL
DCRIITTON
�..1 •L/
PANELS
LicenseClass LION
t,N
Date Cmmr.om
UP TO 200 AMPS
271-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall W used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. Ft.
SIGNSELECTRICAL
Llrenaed Professional
OWNER -BUILDER DECLARATIONfhereb
following moson.(Seelan 7031.5, mthatl Businesst and Professions Cade Any city or
muntywhkhmquiresaper twmruta c"ter,impmve,demoWh,orrepalr
Spp-CIAL CIRCUIT/MISC
¢D �•+e
a 1
TEMP. METEROR POLE INST.
anystruRurc prior Colts Issuance, also requlrestheappBrant(orsuch permit to
file a signed statement that he Is licensed pursuant to the pmvhior s of the
Contractors License Law (Chapter 9(commencing with Seekers 70[0) of Divi-
eon 3 ofthe Business and PMenlom Code)arthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7071.5 by any
applicant fare permit subjerts theapplicant to a civil penalty, of not more than.311-.L
five hundreddollars($.500),
0 as owner of the property, or employees in wages their soh
LOWER DEVICES
SWIMMING IDOL ELECTRIC
' OUTLETSSWITCHFSFIXTUItES
VALUATION
o
NEW RESIDENTIAL ELECTR SQ.Fr.
STORIES
TYPECONSIRUCTION
e he
compensation, wfieires,l do work, and tn. Code:ThrwtIntended oroffered for
of r
dale (Sec. Business and Code: The License Law
f property orContractorsIblues
apply orlmprwvided dory and
dao notepply torn owner offpmperh We
f or own employees, p such
whodae'suchments
OCC.GROUP
RES UNITS
am notlmee
dedoroffe d If,ho ,the builat
ing or
Improvements ithinmayearotcomproale.lf, comer -y deer Ml have
Improvement hwldwlthat he did notbuild
tfU I, as weer ft he thaerty,abxclorvely efwpurpoeao(WeJ.
or improve for purposerwBle.).
=trading esd IkenrM
tr L u owner of the property, am exclusively Business
roeContrcomnstrocithe appy Business and Profession Code:
TOTAL:
QTY. •, .: PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE /
,Law does
The Contractor's imp's ss, the law dose eat apply to so owner of property who
Wilds t r Improves thereon, and who rsomea for such p(okm with a
c L -j4 or exemptdnder Snt to the Conenctore Lkerue Law.
LJ I am exempt under sec. ' B s P C for this rc,.an
ALTER -DRAIN A VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_ -
RECEIPT N '
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a mrtifirate of consent to self-imme, or
aertifiate of Workeri Comperwtlon losommoe me artifled copy thereof (Sec.
3800,UbC.)
Policy N
FIXTURES -PER TRAP
SCHOOL TAX Y_ N _
RECEIPT N
GAS EA. SYSTEM -1 INCAOU'TLEIB
PARK FEE Y_ N_
REC= N
Com any
CASEA.SYSrW,0VER4(EA)
BUILDING DIVISION FEES
ed copy h herebyte
srtNed copy h filed withh the cifty Impaction division.
ty
GREASE/INDUSML WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E(EMPFIONFROM WORKERS'
PAID
COMPENSATION INSURANCE
(fhlssectlon need not be completed lithe permit h forone hundred dollars
SEWER -SANITARY -STORM FA pOFi.
Date Reeef [q
WATER BEATER W/VEN.I./ELDCTR
ENERGY FEE Y N—
PAID
(S10D)mlees3
performancertl(ythat lathe performanceof the wmk forwNmbl
rh this psdt la blued,
I stall not employ any person In any manner ex as to became subject to the
Workers' Compensation Lowe of Callfomh. Date
WATER SYSTGt/TREATING
Applicant
Nouldb OAPPLICAtotheaftermakingprCeril(lpro ofExemption,oftlen, you
becomeabth to the Work en' Compevatbnpmvhlovofthe Labor
NEW RESIDENTIAL PLMB. SQFr.
Date Recei tB
TOTAL:
Code,
dermadoumusttmtFwlth comply with each provIslans or this permit shall be
domed revoked.
1 N ov
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihercbya(Ormthat there Isammwcilon lending agency (orthe perform-
dna of the work fmwhkh this permit is Issued (Sec. 3097, Clv. CJ
Lender. Name
Lender. Address
I cart Ry that I have read t hh a ppliallon a nd state th at the above In forrnet ion
hcomact. l agree to comply with all city and county ordinance and state lawn
TOTAL:
ELECTRIC FEE
PLUMBING FEE
-
QTY: ''MECHANICAL PERMIT - FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEE$PAID:•
relating to Wilding construction, and hereby authorize repremnlatives of this
'
city to enter upon the abovcmenttooed property for inspection purpoms.
(We) agree to sats, mdomolly an d keep harmless the City of Cupertino
against liabilities, judgment., coetsand expenseswhich may lnanywayaccrus
ago Wt/saig.CBy Inerace rr th n if of this permit /
S�G/�JO
ALTER OR ADD TO MECH.
Date Reeel tilt
AIRHANDLING UNIT CFO 10,000CFM) -
SUBTOTAL: S`6
-
AIRruNouNC I1�(ovFx lo,000cFTa)
CONSTRUCTION TAX .
Slgoelureof Applicant/C.mcwtm a�tee
IXIdAU5THO0D(W/DUC)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
_
HEATING UNIT DO 100,000 BTU)
Willthe applicant orfumm building occupant store or handle hazardous
l asde0d bythe Cupertino MuNcipal Code, Chapter 9.IZ and the
materhne
I Pealt Y rd SafetyCodeSScNion 25531 WI
❑
'Date RCEei lif
HEATING UNIT (OVER 100,000 BTI!)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or device
which emit hazardous air contaminants as defined by the Bay Area Air
Ouality Management Mind?
4Yea FF��II No
hateread/hehazaTousmaterials requirements underChapter6,95of
'
2b.AP
BOILER -COMP OHP OR 10[,0(0 BTU)
BOILER-COMP(OVER 100,DODRTf1)
the Califomh Health h Safety Code, Sect lma 75505, 25533 and 25534.1
understand that if the building does not currently have a tenant, that it is my
NEW RESIDENTIAL MECH. SQFT.
r¢pomibility to notify the occupant of the requirements which must be root
prior to Issuance of a Certificate of Occupancy.
/�
City OI cllrliorttn n
BY: d U�
Owner or authorized agent Date
TOTAL:ISSUED
OFFICE COPY