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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proed Identification
Building Address:
93*337 l4 1 L CO � ,� «-,95
PERMITNO.
214 ,
acre: wy�/ p a...
� � ,� Le A
Leff
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECnUCAI.PLUMBINGMECHAMCAL
.
— C
c°"° cp Name: �oGl=�q
CATEGORY
CONTROL It
A tegimyr^ `CU 2n'�_' Lk. No:
Q ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addnss:�� `�� / � �' - y
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafirmthst l amllcensed under pmvinlonsof Chapter9(commenc
IngwlthSnt1on7000)of Divldon3afthe Busty and Pmfession$Code,andmy
Dce�It. l�n7 B a andLellect'
Con Tactor 0 ILU) `-
ARCHITECTS DECLARATIO
I ung B be used as public record.
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyafBrmthatl—exempt fromtheC m.corb License Lswfmthe
to wiwhre exon
ichrquim lon7QiltecesNm and Profenbna Code Anycttyor
coon which requlrcaa permlttommtruct, alter,lmpmve, dennlbh,orrepalr
anystru re prior lb Issuance, also mqulrcslhe+ppBant for permit to
RM a 4gne statement that M V licensed pursuant m the provL+lov of the
Conlrarorb evelaw(Chapter9 (commendng with Section 7000)o(Divi-
s1on3 o(lhe Bu Band Profemlana Code)orthet he fit exempt there(romand
the bash for the al ed exemption. Any Wolatlon of Section 78115 by any
appllant fora permit bjede the+ppacant toadWl penaky of not moretlun
Bve hundred dollar
❑Las ownar ofthe ro
p sty, or my employee with wages as their sok
compeneatlan,wBldolhewar end thertrudure bnoHntended or o!(ered (or
sale (Ser. 706y Business end Iona Code The Conlrac License law
does not appty to an owner of pro who hulWs or lmprovss lhereoR+nd
whodmseuch weIsown employess,provided that such
Improvements am not Intended oro((. or Bale. If, howeveg the building or
Impowementissohlw(thm...yea m(com imolheowner-bullderwN have
ty4 urden of proving that he did not build u provefmpurpose°fseled.
I_I 4 as owner of the Pmperty, am e¢Weiv contracting with Ilr<nxd
rontnd. toomen.. the prefect(Ser-7064, Busln and Pro(enlona Cade:
The Contractor's License Law does not apply to an a et of property who
builds or Improve. thereon, and who contours fm so pt,oJem with a
r
co�(aor(s) licensed pursuant to the Centnrol's License Law.
L� I am exempt under Sec B Ar P C for this reason
APPLIANCESRESIDENTIAL
JOB DESCRIPTION -
^
`
PANES /
7014MOAMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA a
s/sa.FT.
SIGNS ELEC
SPECIAL CIl2C /
TFMpM O INSf
POWER DE'aV
SWENMI LELECT
TCHESFl
VALUATION .
NE RESIDENTIAL LECTR .FT.
STORIES
OCC.GRONP
FLOOD TONE
TYPE CONSTRUCTION
RFS UNITS
APN
_ TOTAL:
QTY, PLUMB GPERMIT FEE
PERMIT ISSUANCE oil
ALTER -DRAIN & VEM-WATER (EeU
FEE SUMMARY
BACK FLOW PROTECT.
DRAINS FLDOR ROOF, AREA, COND. 00
SANITARY Y_ N�
RECEIPT N
Owner Date
5�// WORKMAN COMPENSATION DECLARATION
11'1[ hereby affirm that 1 have • certificate of consent to self -Insure, or a
certificate of Worken'Co7mpevatlonlvunnm or a mrtified copy thereof (Sec.
3800, Lab CJ 0/7 /)U
Po ^Y
FIXTURES PER TMP
SCHOOL TAX Y N_
RECEPT N
GAS M. SYSTEM -1 INCAOUTLEIS
PARK FEE
RECEBTN
AS
GFA. SYSTEM -OVER V
to a
to
Com - - -
BUILDING DIVISION FEES
copy is hereby te ty
CertlBed copy V Iliad withh the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCESEWEILSANCTARY-SiDRMEA
hls.ction need not becompleted if the permit isfor onehundred dollar
($100 )
I.Aifyt lhepedomnnceofthewmkforwhich this permit lsissued,
I shall not employ ft4person In any manner so as to become wbfed to the
Workers'Compensatlon iwsof llfomia. Date
Applicant
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date RCcei tk
GREASETRAP
700F7
wATERHEAreRw/VeNT/F1ECTR
ENERGY FEE Y N
PAID
Date RC i tM
WATEt SYSIFM/TREATING
NEW RFSIDENTUL PLMB. SQ.FI'.
NOTICE TO APPLICANT: R, after RwRing1llis certificate of Exemption, you
should become subject to the WorkerCompensation provisions of the Labor
Code, you mustforthwith complywlth such provislovorthis permit shallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ih sflmothattherebaconahucton knuingegenry for the perorne
sere of the for which this permit Is Loved (Sec 3097, Civ. C3
Name
Lender's Address
lanifythatlluverea appliemionand statethattheltomonmmunlon
ocormd.lagreetocomplyw all city and counlyordlnanm and state laws
relating to building construction, hereby authmrt a represntativesofthla
city to enter upon the above,mention pedy for Inspection purposes.
(We) a to sans=, Indemn11y a e rmlew the City of Cupertino
agaly lea, jadgmenb, cost. d per.. mlylnanywayacnue
agai t d ityN o granting of this It
// oig
TOTAL:
1 DIN FEE
SEISMIC FEE
TOTAL: OD
(f§,
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
, t7
MECHANICAL FEE
O -
PERMIT ISSUANCE U
FEES PAII}
'
ALTERORADDTLIMECH. V
Dale Recei tTf
AIR HANDLING UNIT CFO 10,000 CFM)
SUBTOTAL'
AIR HANDUNCUMTrovER10,000cF'hU
CONSTRUCTION TAX
g rc Applicant onto or b
HAZARDO SMATERIALS DISCLOSURE
Will the applicant orfuture buildingorcvpantsrore orlundlc hazardous
material as deRrud by the Cupertino Municipal Code, Chapter9.12, and the
Health and Safetycod�ri°n 75532(a)7
Yes No
ill the applicant orfutum building occupant use equipment or devices
which emit harardma.Ir contaminants as defined by the Bay Arca At,
Quality Management District?
Yes ® No
®riazardous materials equlrcmenH under Chapter G95 of
k Safety Code, Sect pps 75505, 75533 and 25536. I
a hollding docano nntly have a tenant, that It Ls my
fytheoavp rat the r' inonenlswhichmuatbeoctV
Cart fiat racy
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
_
HEATING UNIT(TO 100,000 BTU)
Date Racci tlf
HEATING UNIT (OVER 100,000 BTU)
TOTAL
.0
VENTILATION FAN (SINGLE RESID)
1$${��ICE,pATE
WF�I6�
n!f
�lT I/ 4 rj �QEFhp
1 a Y f1 GTC
aa� Cap �{aasaa
VI VI- Q646tm
ISSUEDBY:�
BOILER -COMP OHPOR 100,000 BTU) 8041
/ BO LER-CAMP OVER IW,000 BTU) 'L
0
NEW RESI DENTAL MICH. -SQ.FT
n or aulhorired agent ate
DTALa_As,
: W
OFFICE COPY