21107APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY ol- or 7
Building Projealdemifladar
PERh11T NO,
Bao 3 s V�, e U T- -7 z F}
2110 7
Phone:
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
`O _'_no
'l
C. ct«aName : No
A / r G, l �LI No:
L NA,ate
BIIIIlNNGELECfWCALPLU.f INGMFGHAMCAL
CATEGORY
CONTROL#
QTv ELECTRIC PERMIT FEE
BUILDING PERMIT INFOIC
Add.
PERMITISSUANCE
® ® Y LQ
LICENSED CONTR DECLARATIONWofhapt -
-
urodp
Iherehy hSedminnthatDiAai 3.ithe ual.a.d Pm ChJ..Cd,,.mc
in, ectbn7o,ce of DLvidon 3olthe Bsu�y�Nr''i�w�Ss��an'd�Plr�c1�W onaCadgand my
APPLIANCESRE9DEN7iAL
JOB N
oa, is o an Lie #
Lice Ch
have bin fir ddfetl�CI.A
PANELS
s�wL
-
Date Contractor
-1 AMPS
ARCHITECT'S DE RATION
IuMndand myptaroebllht.sednpubtcrtoad>
OVER IOOO AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTIUCAL
L{ ordiP .iorul
OWNER -BUILDER DECLARATION
I hereby affimn that l am e.empt from the Contractor'. License Law for the
foll ing reason.(Soctlon 703I3, Business and fhofesftms Cod e: Any city or
county whichrequires construct,• permit to construct, shier, improve,mo
delbh, or repair
SPECIAL CIRCUIT/1,419C
��,@,ME-fQt OR POLE INST.
any structure prior to Its buave, also requlrm the applicant for such pea -mit to
Ne s signed statement that he is Loaned pursuant to the provbbna of the
POWER DEVICES
SlVIdMING POOL IT
OU`ILM SW(TCHES!'!)\"fI1R6
Centimeter's Lbeme law(Chapter9(mmmencing with Becton 700()) of Divi-
don 3 of the Budneasand Profes fors Code) orthat he h exempt therefnomand
the bash d m
for the alleged! Any violation of Section 70315 by any
eppliant for. permit v.bjectsthe app"M to• civil penalty of not more than
VALUATIO�f
p (3O
I S�g7S
AEW RESIDENTIAL ELECTS Ff.
IT undred dollars %W.
I, as owner of the Property, or my, employees with wages a their sole
STORIES
TYPECONSLRUCITON
591 Q
oempevatlon, will do the work and thestrudure, Is cot intended or offered for
ale (Sec 70K Buslrme and Pmf.oma Code: The, Contractors Llama Taw
does not apply to an owner of property who builds or imp. thereon and
who doawcle work himself «wW
through his own employees, pred that such
OCC. GROUP
RIB UNITS
improvements art not Intended oroffered f«sale. If, however, the wilding «
bnprovemeN bsold within oneyearofemnpletbM1theowner-bullderwlB have
TOTAL:
t rdeo of leaving that he did not wild or Improve for purpose orale.).
oro
Lj L as owner of the property, am eael awely oantraeting with licensed
contractors to cenai the project (See. 7014, Businessand Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD IDNE
APN
PERMIT ISSUANCE
The Contractor'• Lice. Law don not apply to an owner of property who
Wild. or Imp. thereor, and who contracts for welt p,*1e, with •
Cgnll+deme)Iker.ed pursuant m the contractor. License Law.
LJ I am exempt under Sec B k P C for this reasonOUTSIDE
ALTER -DRAIN k VENT- WATER (Fl)
FEE SUMMARY
BAac Flnwl>ieorEcr. DEVICE
FEES
DRAINS FLOOK ROOF, AREA, GOND.
SANITARY Y_ N_
RECEI
Avner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby af(Irm than I have a «rtimate o! coraent to calf -Wort, or •
centlRote of Workere'C«npemNon I... «a certmted copy themo((5ec.
M3(3, Lab C.)
#
FD(NRES� PER TRAP
SCHOOL TAX Y_ N_
RF.CEIT'f #
GAS F.A. SYSTEM.1 WC4 OUTI.EM
PARKFEE Y_ N_
IRE[:FII'T e
GAS-EA.SYSITM-OVER4(Fit)
Comm gray
Co
BUILDING DIVISION FEES
ICertlfled copy h hereby fit ihM.
IL�J(CertNed copy is filed with the city Ituptetlan divhloo.
CREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
. CERTIFICATEOPEJ(EMPTIONF'ROMWORKERS'
PAID
COMPENSATION INSURANCEg}yER,SAMI.ARY-SInRM
(Thl..ectbn need nes be completed tithe permit b fa onehundml dollars
EA pig;!
n
Date R l QJ
WATER I-WnrER w/vEr1T/EI.EC'Tx
ENERGYFEE Y N
6100)«Int.)
Iadmy that tithe pcdomana of thew«k brwNch RNs pemttb Wiled,
WATERSYSIPM/TREATING
I.hal nm employ any person In any manner so m to become subject to the
Worker Compensationfaw.of Gil«nh. Date
PAID
Applicant
NOTICETO APPLICANT:I, after making this Certiflateof Esemp you
N R6lDFMIALPLMB. SQFT.
Date Recei t#
AIL
r 1
should become subject to the Worker: Cmnpereatbn provision. o(the Labor
Cade,yw=gforlhw hmmplywithwchpmvbbmorthbpemdt.hallbe
deemed newkM.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE . q
Ihembyafmrm thatthereb• mob dimlendingagemyfortMpedor
a of the work for which this permit h issued (Sec. 3097, CN. C)O
Lender's Name
Lender,Addems
1admythat 1 have read thhappllotbn and statethat the.1,ove4.ne.1 t
bcorrect. Iagrte to cmnply wlthal eltyand county ordWnm and tlate lows
TOTAL:;-7ELECTRIC
FEE r 0
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE O
MECHANICAL QQ
PERMIT NUANCEFEE$PAID:relatingtowildingconstruction,and
herebyauthoelaereprexntat hwiofthis
property(orlropetlbnpurpo.ea.
(We)agree toave, t demN and keep harmlemtheCity ofCupertlwgalnet llabWt dgeseem, Inde wit myir anywayama<
tin pemrt./�AIR
ALTERORADDTOMFCH.Date
Revel t#
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
HANDLING UNIT(OVER IotpOCEM)CONSTRUCTION
R
TAX
gnavrtof B UCanlr.ct« to
EXHAL?Fr HOOD(W/DL"
CONSTRUCTIONTAX PAI0. 'Z.
HAl RDOUS MATERIALS DISCLOSUR
1
HEATING UMT(TO 100,000 BID)
Will theappllart or future wilding o¢vpart store or landle h crus
material as daubed by the CupeAtemI!M Mudcipal Code, Chapter 9.17, and the
Ikallhand Safety CadtrvB.ectlm 2S53ib)7
❑ Ym LJ I'lo
Date Recei t
I-TATWCIINIT (OVER IW,000 BTU)
q
VENTILATION FAN (SINGLE RESID)
tum winants.covpantuu
WOenot
harard a the Bay A .devim
which eMttagerdoua air contaminants., neN.mdefinrd by the Bay Arta Air
CI$$�$�.[UQN�EaD313E
i1a 'tVli s
BOmFR-COMP OHPDR 100,000 BM
Quality Alavgement fH,trkF7
Ym ❑ No
is V
�bY
BOIL MMP(OVER 100,00) BTU)
have read the haaumlorusrMerials requirements underChapter G95 of
the Ullomia Healthk Safety Code, Sectors 75505, 75M.rd 75534. 1
#S(�,( Ls,FFgQ 1l
NEW RFSDFtMAL MECH. SQFT
undtand that if the building does ncurrently have a tenant that it ei my
mwot
��l
responsibility to notify the oav pant of the requhements which must he met
a
prior to Wuance a a Certificate of Occupancy,
ET
DIAL O
Owner or authorised agent DateISSUED
OFFICE COPY
1
'
� \ � •
,til .�.. ._•. t. i_ �
�Jv
/
1
I` µ
1