19516 (2) APPLICANT TO FILL IN INFORMATION WITHIN RE_ D LINES - USE'BALL POINT PEN ONLY
Building Pm'ect Identification o PERMIT NO.
Building Add ress: L,-v
I 7-(p l,�(n�na LOA ne c„ -;moo CA q1;0 r4= 1951, 6
ppare � (1� hone: '
QPM Thr CITY OF CUPERTINO�BUILDING DIVISION
Contractor's Name: Lk.No: APPLICATION / PERMIT - 1 -1 Lk.No: —
Architect/Englner.
BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
- - " O
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
-- •' AHd7cai PERMInSSUANCE 00 �/ M .
LICENSED CONTRACTOR'S DECLARATION E4 —
Ihereby affirm that I am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of DiWsan3ofthe BusinessandpmfessimsC a,and my
licvIs in full force and effect. PANELSLens p -."-v
License Claes Lk. �j ;V\.. (r�Wp V
Date.Contractor
ARCHITECTS DECLARATION 2014000 AMPS
DCO (understand reyplansshallbeused apublic records. OVERIWOAMPS SQ.FI.FLOORAREA $/SQ.FT.
I�u Licensed Professional SIGNS ELECTRICAL
t EL�`7� OWNER-BUILDER DECLARATION
Z is I hereby afflrenthat lam exempt from the Contractor'sLlcense law farthe SPECIALCIRCUIT/MISC -
9y following reason.(Section 7031.5,Business and Professions Code:Any city or
O" µ9 TEMP.METER ORPOLE INST. -
�r Cd� cauntywhich nvrylresa permktocoriatruct,alter,Bnpmve,demolLsh,orrepalr
a anystmdorepr rtoltsbmame,aborequlmtheapplimatforeuch permitto POWER DEVICES -
r file a signed statement that he b licensed pursuant to the* provision of Poe; " .,\ Contractor's License Law with Section 7000)of Divi- SWIMMING POOL ELECTRIC
VALUATION
30 - slon3.fthe Buacessand PrnsofemloCode).rthathe Wexemptthe.fromand
6 the basis for the alleged exemption. Any violation of Section 70I1.5 by any" OUILETSSWITCHFAHXTURFS Q
CCL55509 applicant fora permit subjedstheappllcant to a civil penalty of not mom than o.0
p,o Endred dollars($500). NEW RESIDENTIAL ELECTR SQFI. RI TYPECONSTRUCTION
L as owner of the property,or my employees with wages as their sole
y. ro nsation,w111dothe work andthe structure is M intendedor°ffned for
'sag" O sale(Sec.7064,Business and Profession Code:The Contradots Liceae Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROIIIa RFS.UNCIS
who does such work hlmeelforthrough his own employees,provided that such 7�
Improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvenientbsoldwlthln oneyearofcompletloMlheowner-butWerwill have
tryt$aMen of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
IJ L as owner of the property,am exclusively mntracttng with licensed PERMIT ISSUANCE - 0 '
contractors to construct the project(Sec.7044,Bus Ness and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WAWATER[EA)
builds p - -or Improves thereon,and who contracts for such
(ojects with a FEE SUMMARY
�gp{(actur(s)licensed pursuant to the Contractors Llomse Law. BACK FLOW PROTECT.DEVICE
I_J l am xempt and r Sec._ B k P C for this reason
DRAINS FLOOR.ROOF,AREA,COND. SANITARY - Y N_
Owner Date RECEIPT If
WO FANG 1PENSATION DEC ATION FIXTURES PER TRAP .O V SCHOOL TAX Y N
❑I ereby affirm that I have a certlRcete of con est to self-inwre,or a RECEIPT M
3800,
ce00,La sof Woikers'Compenationlnurancemacertifld ropythereof(sec. ' GAEA.SYSTEM-1 INCA OUTLETS PARKFEE- 'Y_ N_
Pocky If p CJ S GAS EA.SYSTEM-OVER 4(EA) DING DI M
Co any - - BUILDING DIVISION FEES
ECertlfied copy Is hereby furnished. SE/N TOR PLANCHECK FEE
Certified mpy b filed with the city Inspection division. r 7 Zs 9
CERTIFICATE OF EXEMPTION FROMWORKERS' I G PAID_(—I
COMPENSATION INSURANCE I EI STOl OPT. Date Recei f#
(Thlsaection need nal be completed if the permit b foroe hubdred/dd� _
($lao)arleas.) �— - WAT. "iY; /Et.ECTR ENERGY FEE Y N
Icertitythat lathe performance o(thework(orwhkIssu
h this pe It is ed,
I shall not employ any person In any manner m as to become bject to{pe 1 W
Workers'Compensation Laws of California.Date L7 _ :r PAID
Z
Applicant - NEWAESIDENTLIL PLMB. SQ}T. Date Remi t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption'you
should become subjec[to the Workers Compensation pmvlaloruafthe Labor TOTAL:
cc Code,you muatforlovith comply withsuch prbvisimumthb permit shall be Y)
LLIL j deemed revoked, B L ING Z, 0
- CONSTRUCTION LENDING AGENCY SEISMIC FEE - - 1 0
�' I hereby affirenthat there b a construction lending agency for the perform TOTAL: pp q ELECTRIC FEE 0
once of the work for which this permit b Issued(Sec.3097,Civ.C.) p.Dry,
V
0j,
Leader'sName . - PLUMBING FEE - ••DV
LL'I— Lender's Address .- QTY.I MECHANICAL PERMIT FEE . MECHANICAL FEE .UQ
Ue W Icertifythat I have read this appileatlonand nate that the above information
IL isconect.I agree to comply with all dtyand county ordinances and state laws PERMIT ISSUANCE �„OQ FEES PAID:
relating to building construction,and hereby authorize representatives of this
F- 2 city to enter upon the above-crumdoed property for inspection purposes. ALTER OR ADD TO MFCH. - CD Y--`�—
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recel t#
V against liabilities,judgments,mks and expenses which may In anyway scans AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL
ag.; Id City le asequence of the granting of this permit.
I/ /7 p0 AIR HANDLING UNIT(OVER 10,x00 CFM) CONSTRUCTION TAX
now'6i pllcent/ ontrader JAL-^ Data - EXHA6ST HOOD(W/DUCT) _ CONSTRUCTION TAX PAID:
v HA RDOUS MATERIAIVIDISCLOSURE
Will the applicant or future building occupant store or handle hazardous, HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 912•and the
Health and Safety Code Section 75532(')7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 3 ,6
❑yes, u No "
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) :,,
which emit havrdous air comundro nts as defined by the Bay Area Air B'(•�fldf
Qua lily Management District? BOILER-COMP(3HP OR 100,000 BTU) ,
4Yo y�I1 No Jq
ha forcla ea th&Safety
materials Se reons 255 5,2553 and255Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) JAN Y 99I)
the Califodta Health Agaiety Code,Sections 25505,25533 a tenant,that
I .
understand that if the building does not mrrently have'tenant,that itbmy NEW RESIDENTIAL MECH. SQFT. -
- " responsibility to notify the occupant of the requirements which must be met Up! llf rllrlQ(tjBO
prior to issuance of a Certificate of OcmpanC�
cy. V
Owner or aulhoriend agent Data ,
" TOTAL: I9O
OFFICE COPY '
ADDITIONAL PERMIT FEES
♦N �
t BU I LOING PROJECT IDENTIFICATION VALUATION
ew LOINS
ADDRESS
105'U
P• L.
OWxEx 9 No.NE c�0 uc
ME
Jim F CQfo' LeAtIr_, PNOHE U7-4451- FEE SUMMARY
�K�
coxrxanroR s/� �/ BUILDING
�� ��M *�•�I
LZ-A ,NO. k0✓nQ.O PLAN CHECK
coxrnacraN S FEE
ADDRESS
PxoxE SEISMIC FEE
CITY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC iO
P ,
LIGHTING FIXTURES PLUMBING �s
APPLIANCES-RESIDENTIAL `�/o`er
PANELS MECHANICAL
SIGNS �J
SIGNS TRANS.
SPECIALCIRCUIT
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
Q SERVICE CHANGE
Z Z
1— 00 TOTAL
ISSUANCE DATE
LU O OTY. PLUMBING PERMIT FEE eLDc. EEEci PLc, NECK
o
Z) 2 ALTER-DRAIN 81 VENT-WATER(EA.) ❑ ❑
V O BACK FLOW PROTECT.DEVICE
O w DRAINS-FLOOR,ROOF,AREA,COND.
} n FIXTURES-PER TRAP
N
F ? GAS-EA.SYSTEM-11NC.40UTLETS
(J GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2001[/
1 WATER HEATER W/VENT /p
WATER SYSTEM
WATER TREATING EQUIP, PAID
.TOTAL J U;u 12 199U
OTY. MECHANICAL PERMIT FEE /s .{,
ALTER OR ADD TO MECH. r rl of Cupeirfino
APPLIANCE
AIR HANDLING UNIT ITO 10p00GF.M)
AIR HANDLING UNIT(OVER 10)300C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.) /A
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COMP(3 H.P.or 100,000 B.T.U.)
LER COMP 10—100,X0 BTUI SEE PEE SCR.
_ TOTAL •S i