20483 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Praed Identification \ PERMITNO.
Building Addrcsa: c8 20483
as
ra ante: ��//)� ,I one:
jn_ CITY OF CUPERTINO-BUILDING DIVISION p
Co°J�'"°r N APPLICATION / PERMIT `5--3 I C
`O 1/'a `D'I.tS S� CATEGORY CONTROL 0
A hued Engin BUfLDINGELECTWCA4('LUMRING-MECHAMCAL
Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtss: UULI 11"J.1;
�at / PWWTISSUANCE pp
LICENSED ONTRACFo,P DECLARATION r
Ther Seib. 70lhatlam AJ 3.funder provard,o(Chapter9(mmmenc APPLIANCESRESIDENTUL jOBDESC ON
Ingwlth Sectian7000)of DlvlNon3o(iM1e aJ�easand ProfesalonaC°de,andmy
Iimnse Is In full form and died. { I ['a PANELS ��1
It. Chn Lk.M J o l—
Daiej�Z CLtr:;ctorf. UP TO 200AMPS
ARCHITECTS ECLARA N 201-IOOGAMPS
q�+oc Iunderatand myplansshallbeused aspubllcrecorda OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k�t, Licensed Prafeealavl SIGNS ELECTRICALpis D gL
<'a-Hall OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC r
owing aWrro5octio 70312, tfromihe Contractor's License Law fort he ��� ��
qqQQ fount)ngrcae°nuiresa nrmit tooatnemand Pimpoove, Code:Any dtyor �•7
O F'ry anus which Iresa permit TEMP.MEITR OR POLE INSf. //
Fq a
county requ pe galteq improve,demolish,arrepalr
any atmcturetatorroibhat he Isalso sed pur antro the prrislom of to POWER DEVICES
O Wes actor's statement that heLaw ter 9 licensed emcing t to the proWf00)of the
w� Mon
on 3 ofthLsins And Professions
Sedbnheref7000)of Divi. VALUATION
�Og theb.Mtfo theMleged Profembn. AnyCodeviolation that (fedi pttherefromand SWBdA4NG POOL ELECTRIC ��
the bran for the alleged exemtheap Any violation of na ltyo not m re any /�7 00
applicant OUTLEISSW1CHESFlXTURES
flue hundred dollars($500).pm NEW RM ENTIAL ELECTR FF.
�n ❑I,as owner of the ro —`� STORIES TYPE CONSTRUCTION
p pert.,or he employed with wages a their dole
compensation,Rasinu the work,and tom Code:
V not intended or cense Law
O dale(Sac.not apply
to alnowandf poapeby Code:The or Impdors Gcorue Law
doewhodonsuch ork unser ofpropehhiso Wim orimproveathereon,thatand such — OCC.CROUP RIS.UNITS
whoovementsa red Intended oroffe dowse.It,ho ea,providedibaig or
Improvementsarenotintenone carofcdpletioe.Il,however, llder ill have TOTAL:
improvement bwld wlthinoneyearofcompidlon,lheowner-bu0derw111 have
i1ig.4uAlm of pmving that he did not build or Improve for purpose ofdk.). QTy. PLUMBING PERMIT FEE FLOODZONE APN
LJ L as owner of the property,am exclusively contracting with licensed
contnctars to mrutmat the project(See 70K Buslnemand Profeasto sCode: PERMITISSUANCE - 'lel tom
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
WRde m ves themyr-s ct
who costras fee such pW"with a FEE SUMMARY
carp sed pu uant to'**Contndors License Law. BACK FLOW PROTECT.DEVICE
[am m un B A P C for M mason
Owner DRAINS MOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT p
WORKMAN COM SAT ON DECLARATI SCITOOL TAX Y N
1* ❑1 hereby affirm that I hav comf tate a(consent to self-Insure,ora RECEIPT a
cedlflcaL of Workers'Compematlon Iruuranceara certified ropy therm((Sec.
3800,Tab C.) GAS' PARK FEE Y_ N `
Policy a RECEIPT N
Com any GAS FA. BUILDING DIVISION FR[5
n Cedifled ropy le herebyfurnished.thecity
CREASE/W ASTEI PLANCHECK FEE 6Sa6
❑CedNed copy V tiled with the sty Ivpectlon division. aptE
CERTIFICATE OF O(EM PFION FROM WORK ERS' GREASETRAP PAID r-,3 — d
COMPENSATION INSURANCE
(TWssectlonneed not becompleted clthe permit t9fororrehundred dollar SEWER—SANITARY—STORM F.A.200FT. Date Receipt#
(fl unify that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
I cent employ
any pecram In an tmornerhe work sa as to
becahis me
ct to th, X 76 t"
I shall not employ any person In any manner n d to become abkct to the WATER SYSTEM/TREATING S (O
O Workcn'Compensation lawsofCalifornia. Date PAID a
Applicant DRte te Remi t#
Z 2 NOTICE TO APPLICANT:If, NEW RESIDENTIAL PLMe.after making this Certificate o(Exemptlon,you pOFT. _
Hdhmldbe...biMt.the W.r .'C.mpe.ati.s I,—..cam of the Gbor TOTAL:
f/1
Coon,you mw at fodhwlth'comply with such provlsiom or this perroilshall be ,0. •
j deemed revoked. BUILDING FEE
aNSTRUCFIDN LENDING AGENCY SEISMIC FEE
Ihercbya/ M1aNheotaamrutru on lendb agency for the pedorm TOTAL t ELECTRIC FEE L
Z once of the soca f (hic this vQrri t wed(Se 04/, fvort '�.{•`•
02 knee/a some ,iV a LandePLUMBING FEE
LL l— rs Addrcsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ha Imdifythatlt ap mtonan Yatethatthe ve Nformation
1 Iscorred.I agree to comply with all cityand munty onllnancea and alatelawa PFRMTTISSUANCE 'lxo6 FEES PAID:
>_ relating to building com uctlon,and hembyauth.neenpresentativd°fthis
I— city to enter uponthe above-mtioned pmpedy for lnspeklo"purposes. ALTER OR ADD TO MUCH.
U) en
rroDate RCCCI 1#
Z (We)agree to save,Indemnify an d keep hale®the City of Cu ped Inca P
against liabilities,judgmesta,coats and expenses which may In any way amme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
dirt City In consequence of the grantingntthis pemN4 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX V61,76
Signature of Applicant/Contractor Date EXFIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID;
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTUI Date Recci t#
rnatedzl m defined by the Cuppppppeeeeeedlno Murddpal Code,Cha)der 9.12,and the
Ilealth and Safety Cod M2(4? HEATING UNIT(OVER 100,000 RTU) TOTAL: a
Yee No
Ill the applicant°rfuture building ompa"t use equipment or devices VFNIILATION FAN(SINGLE RFSID) ISSUANCE DATE
which malt hazardous air conlambanta as defined by the Bay Arca Air
Qu lityManagement Distdn MOILER-COMP(311POR100,0001ITU)
4Yes
h e the M1azar duematerialsmqutmmentsunderChapter6.95.f BOILER-COMP OVQt100,000B U)
the un Health&SafetyCoesreatbns255h have
a3aad,that I lI1xC,Q ��� 199
scold hat tithe he gdart rad mrmnt)y have.tenant,that it met NEW RESIDFN77AL MIiCIi. SQ.FT. / 1
nponsl Ity to notify the or panto!the reyulrcmenta which must be cert
prlort uanceola e I cat IOc parry. City CW
43 F rllnnl(111 A
Owner or authorized agent Dat ISSUED RY:7dE� c
TOTAL: l�x
OFFICE COPY