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CPIY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BNL.DINGEL CTRW MUMBING-MLCHANICAI.
Cj—1
Cmtruior'e Name: Lk. No.
CATEGORY
CONTROLI1Y
�l
AmhltM/F Lk
G"
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
A
PERIA"C IS6UANCE ' V�
® ❑
LICENSED CONTRACTORS DECLARATION IMreectionrmtlutlam Bcm.ed underprovLNons of Chapler9 (mmmmic
fice.h in forces Div Won3dtheBudnnsand ProleeMonaCade,and my
License Glu Lie/
Lacer le In fuB (Doneand d. 4
Date Contractor
ARCHITECT`S DECLARATION
I underhand my plans shall be used u Eni &
Licoru I'mfemloral
OWNER -BUILDER DECLARATION
Iherebyaffirmthatlamexemp fromthe CeMractari Llcanselaw(«the
following nason.(Section 70715. Butlnns and Pmfessbro Cade: Any dry or
Mprove,dersucla�rtpdr
�ntywhbh �b.a permit tom �d,alter�es the
an .lrodure [ertabwme, abo pu.ao Borst ro such of the
file a dgnea statement that he t B¢need pursuant to the pmNabns of the
Coni of usmnsad Prof ter9(mmmencing withe b, em bn70refof Divi-
Monaof the the xempt roCay orthe heb erempt therefrom and
the hseb for the alleged *a th m,. he violation of Section 7m15 by any
.ppewtfara prrndt sub(Mathe appBcant to•ddl pevltydna mon than
M ndred dol a ($SM.
so
1, uowner of the property, or my employ. with wj.ff,,d
mmpewrtlon, will do the wca and the slrurnrrela not Intendf
®le (See 7014, Business and lidemlors Code: The Contrac
not apply to an owner d property who bunds or Imprd
whodo..0chworkhUmetf«thwghhbownemploye.,pcit prwemewartwtlntended oro(fertd («eak. IL howev33a-�0—
provencndbsddwlthlnovyurdcampldbnthemvnn)ve tl�urdcn of proving that he did rot build or unrove!«ple.).
u I, .a owner of the property, am euhuively an.u.cting with 14xmed
mntracto. to mmtmd the project (See. 70th, Businem and Prof.io. Cotle.
The Comeamri License Law do. not apply to an owner d property who
huilda or Imp. thereon, and who mMnds for such p(ofeda with a
.pI[act.WB«nzd p...t to the Contndo'. Llreme law.
IJ I am evempt under Sec B k P C for this mason
.
APPLIANCESIff_SIDEMTALIrSwit
B N
ai I I L D
!!telad
D C
PANELS
201-IOOQAMPS
OVERIMOAMPS
SQ. FT. FLOOR AREA
I q V � �71
I 1111
�D ^
d
$/SQ. FT.
[ 2—
`�D
SIGNSELBCTRICAL
SPECIALCIRCUIT/ham
TEMP. METER OR TOLE INST.
p(hypJ(DEVICES
SWII MNG IC)OL ELECTRIC
VALUATION
OG
111 �O
Is EixMtFs
DLEMW'
NEW _ `''QfT'
STORIES
TYPE CONSIRUCIIDN
ti Aldon
/OCGGR011la
RES. UNfr"
QTY, PLUMBI FEE
PERMTI' LSUMCE
ALTER -DRAW k VENC -.WATER (EA) . DO
FT DT NE
AI•N
BACK FLOW PROrF1CT. DEVICE
FEE SUMMARY
DRAINS FLOOK ROOF, AREA, GOND.
FTXIVIffS PER TRAP Q
SANITARY Y N
R13CEBT o
Owner Date
T1ga WOR KMAN COMPENSATION DECLARATION
rcFyRlae of War4ens'Caffurn •omperoatimr Wunnt I have a ta«aaM(ied copytM1enof tsec.
3801, Tab CJ �r ,may
bikyY N(7J "of�' Oor,`Y/R
SCHOOL TAX Y_ N
L
R_
GAS EA. SYSTQW-D,
A-1 INCA
PARK FFP Y_ N_
GAS FA. SYSTEM-0VER 4 (FA)
Ca�m..pp++ny
BUILDING
BUILDING DI V ISION FEES
"Renified ropy b hereby furnished.
�Ccnifiedropy b filed with the city lropMbn dMMon.
CERTI]i OF IXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhleeeaad cad be eomplded Bthe permit bf«aro hundred delta.6105)«Im.)J nee
ImoutrtIfy thazbthe Pe performance thework for to I,co.this p bte Rothe
] shall not employ any person In City net m u m bemme ubJnt to the
Appb.r Compenutbn lava ofGW«nb. Daze
A T[CEt
NOTICE co e, xub) to
cher m.Wngthbgattonicre,toons oft
ate Of eLabor
Code, you must futhwdh comply with such provisionsorthla pemdt shalt be
deemed revoked.BUILDING
' CONSTRUCTION LENDING AGENCY
I hereby.(8rmthat then Is a mrotmdlon lending agency for the perform
ammof the work for which this pcmer b Loved Geo 3097, ON. C.)
<Meh Nam
L.enderi Addre„a
1 an By that I have mad this application and Mate that the above Information
Is comet. I agree to comply wiih.B eltyend coup ivncn.nd Mate laws
relating to building mrmrodlon,ud hereby„ o repmteotattvnd this
city to enter upon the.boveme Ito P�nopeny for pectic. Fury—
(We) .gone to ty a a keep ha ea the city of Cupertlon
ager Wrl e'coas eapen mayb.nywayacvue
.ger i .n ueroe of a gdthlspemdt'
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID I
Date Recti IM
?
J 6a
GRFASETRAP
SEWER -STORM EA. aTOFT
WATER HEATER W/VENT'/E].FC'[R
ENERGYFEE Y _ N
PAID
Date Recei t#
WATER SYSTEM/TRFAnivG
NEW RESIDENTIAL PLMB. _SQ ,FI..
TOTAL.
FEE
i TAG
_pp
5EISMIC FEE
ELEf-rRIC FEE
33.
_?8,
QTY. MECHANICAL PERMIT FEE
PLUMBING EEE
A
MECHANICAL FEE
FEES U 3y
. 0 (%
I%UMCE ,L,dO
' ALTERO DTO MECH. q
Date Refel (#
P
ArRHA 1
SUBTOTAL:
AIRHANDLI
CONSTRUCTION TAX
Sig roof ppndant/ tract IAte
HAlARDOU A IAL" UI"CLOSURE
WIIIthe.ppBcantorfutureb 0 occupant.t.mruftardkhavrdoue
material as dclined by the Cupertlro Municipal Code, Chapter 9.17, and the
fie.Nh and Safety Code Section 25532W7
❑ Yes Ii No
Will the �pplicaru or future building occupant see equipment or deviab
which emit hanrdouubmntambanbadefined bythe Bay Are. Air
+10.yyMoagemmt Dbtrict7
"O
Yn ❑F�I No
Iluve read the haaua rvtrdaLt requlrtmen.under Chapter 6.95 of
the CalBomla Health A Safety Cade, Sedloro 75505, 25533 and 755M. 1
understand that ifthebuilding dote not currently have a tenant, that It Lt my
responvlbjhtyto notlfythe occupant ofthe requirements which must be met
''prior to lauame da Ccdlfkete ofOavpan<y.
FJ(HAUSTH /DUG
CONSTRUCTION TAX PAID:
HEATING
HEATING UMT I MI)
Date p
100,000811J)
a 70
Vr2lATIO �AN(" .LE PJMD)
I rTc gA�T;
a7TJ7pr�
Ju
��Faa
r 3v)lw�
�•:+a/
(%T
ISSUED BY:V ;?_ 1lT
BOIL cR POFN OR O[D BTU)
BO ONP(OVER 100, BN)
RESIDENTIAL MECH. SQ.I'1'.
Owner«authorlud agent Date
TOTAL: D
OFFICE COPY
.�
46or OFevERT «o
INSPECTION DIVISION
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