19629 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prow Identification I PERMIT NO.
B"oafd35 N., tk�r-tai �vr, �e��n�ro , c�, RSOc� 19629
r. Phone: CITY OF CUPERTINO-BUILDING DIVISION
Contractor'.Naure
Lic.No: APPLICATION / PERMIT 2-7�f0
BUILDINGL
ELECTRICAPLUMBINGMECHANICAL CATEGORY CONTROL.Svs/
th / nee
N , _{ Lb.N« BUILDING PERMIT INFO
/.-7O 'v QTY ELECTRIC PERMIT FEE '
. Addrm,75 � f r PERNITISSUANCE1:1 1:1 [_1LICENSED CONTRACTOR'S DECLARATION
Iheceby Lffr utlam Bctnedurderprw msn Chapter9(commenc APPLIANCES-REsDENTIAL JOB DESCRIPTION
Ingwdh Section70W)of Dh .3ufthe Bu ..dProfe .Cadgand
license I.in full fd dfect. PANELS
re
Clam_{LLIc.,/. r 70 /7
Date /
DCantnctor S T
ARCHITECTS DECLARATION 201-1000AMPS
p�vOoum
Z IurdentaM pry plans shall be used&I public neovde. OVER 1000 AMPS SQ.FT.FLOOR AREA $/9Q.ET.
� Lleadi Proesl
faroT SIGNSELECTRICAL
«<�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M
Iherebyaffirenthatl amuempt fromthe Contractor'.Lic,r.Law for the
following mawn,5eafm 70015,Business a"Profeabru Code:My city or
F< TEMP.METER OR I
county which r qu Ince trug
a permit to coruaher,improve,demolish,or repair
K any atructurc prbrentthealwregt ptusuea to the fnalomof Jtb DEVICES
K � flee a stgned statement that k b 11¢nacd pursuant to the pro W bna d the
3µ Contracte.Lee.Law(Chapter 9(commencing with Section 7000)of Divi- NG POOL Q C
EO� elon3ofthe Buelneeeand Pmfemioro Code)orthd hee&exempttherefromand VALUATION
6 5
the baeb for the alleged exemption. Any violation of Section 70715 by any Ourm
O
applicant for a permit subjects the appBcadw
nt to a vR pelty, m ¢
d not othan OO�
0v��-h1,undred ddlan(1500).
'9..' LJ 1,ateownerofthepmperty,ormyempbye withwagesathe4wle NEVd D LELEC SOFT. SIORI6 TYPECONSTRUCTION
compertvtlon,willdo the work and thestruc urs,is not W e deel or offered for
k�O rile lSee 7014,Bu.inem ab Pm(embro Code:The CoritractMe LI¢roe law _ .
5� does not apply to an owner of propertywho bulldsor lmprovesthemen,and OCC.GROUP RFS.UNITS
whodoes wchworkhimxlforth.ghhi ....,ploy.,providedthateach
Improvements ace not Intended proffered for sale.If,havever,thebullding or TOTAL:
. Improvement e&edd wflhNoneyearofcanplelbRtheowner-bu0derwill have
tt�rdeo of prevby that he did not buua or Improve for purpo.e ofsale.). QTY, PLUMBING PERMIT FEE
L_j L ate cwnrr of the property,am eachrsHm
cly ntrMing with IbcruM FLOOD ZONE APN
contract.to construct the project(Sec.7064,Been.and PrafeaM ns Code: PFRMRI%UANCE
The Contractor.LI¢ne,law dm not apply to w owner d property who ALS-DRAW&VENT-WATER(FA)
Wilda or improve thereon,and who contracts for ouch project wth a
c'ITactmW licensed punwnt to the Contracto/.Lion.law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this recon
DRAINS FLOOR RODE,AREA,ODND. SANITARY Y_ N_
Owner Date RECEIPT f
WORKMAN COMPENSATION DECLARATION FIXn1RES PER TRAP 5C1-TOOL TAX Y N -
❑1 hereby affirm that I have a¢Mfkate of tonsent to seB-Lwre,a a =
certificee of Worker:Comperoatim Imuran¢ma certified copy thereof(Sec. RECEIPT s
3800,lab C.) GAS EA.SYSTEM-1 INCA PARK FFP Y_ N
Policy
REC13PTa
If
ray GAS FA.SYSITM-0VE7R 4(FA)
Com BUILDING DI VISION FEES
❑Certified copy bhedwhisreby me city GREASE/INDUSTRL WASTE INTFRCFPTOR LANCHECK FEE �J
❑Certified copy b filed with the city inspection division. '-I b
CERTIFICATE OF EXEMPTION FROM WORKERS' I/�t
cRFASETRAr PAID —7'qS'/1/2
COMPENSATION INSURANCE SEWFRSANITARY-STORM IIA poFT Date Recei t#
(rhe&aMbnneed nabecnmpleted ifthepemwl.feronahuna¢ddoilan ENERGYFEE YY N_
(f1 W)or les.) WATER HEATER W/VENT/ELEC7R
I¢rt#ythebthepedomen¢ofthewcekforwhlch Wapermhbbw , -
I hall not cmptry any p.In any rtunner w u to become subject to the WATERSYSIFM/TRFATING
w«ken'Cornpennuon law.of CaWornb. Date PAID �.-]-90 J�4//Z .'SQ•00
PP Dale Reoei t#
Z p NOTICE TO APPLICANT:),after making this Certificate of Exemption,you NEW R61DEN17AL PIMB. SQ Fr.
.hmbecome
ld subject to the Workers'Compenunt int pro leum of the tabor TOTAL:
CC N m
Code,you=9 forthwith comply with each provisions or the&permit shall be BUILDING ,S-
Z 00
.W 7 deemed revoked.
CONSTRUCTION LENDING AGENO' 5EISMIC FEE 3. 7Y
a LhercbyafOrm tlutthecee&a coommellm lending agency for the perfornF ELECTRIC FEE
Z anceofthewetkforwhkhthl.perm@bLwed(Sec.3097,Cie. TOTAL
U O lendar:Name PLUMBING FEE
LLI— Lender's Address QTY. MECHANICAL PERMIT E MECHANICALFEE
OW Iced".1,l have read thlaappBotbnaM teatethat the abovebformatlon
a e&mrrect.l agreetocomplywlth all cityand countyordbun¢sand Matelawa PERMIT ISSUANCE FEES? 7 9sy//2
N
PAI a.
} buy/y,/G-
relating to ilding mmtruction,and hereby wthorioe representattves ofthis J
F Z city to enter upon the a nnentbrcd property for inspection purpwes. ALTERORADDTOMECHL Date Recel t#
_ (We)agree,to suve,bdemN/y an d keep haemes the the City of CupertinoP
agaBut WbWtka,�udgmew,co.haM exile .whichnuyloanywayacxsue AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
t•dd Cit in ante enoe of the gat ngofthlsperedt.
1 &40 AIR HAN)LINGIINIT(0VFRI0,000CFMI CONSTRUCTION TAX
Slgrutu fAp ant/Contrstlor Date D(HAUS7 HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WI theappliant or future Wilding occupant port or hsMe harardm. HEITINGUMT(IO100,000BTU) Date Recel t#
material as defined by the Cupertino MunIcipal Code,Chapter 9.12,and the
I icalth and Safety Cade Section 25537(a)7 HEATING UKTT(OVER 100,(00 BTU)
RYes M No
ill the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE REED) ISS)
which emit! situs air roniandronts as defined by the Bay Arca Air
SIH Mev ntDi.trtctT B01111R-COMP MIT OR 1)0,000 BTU)
Yes geT No r a 1 19901
havereadthe haaa me matertae&requirements under Chapter 6.95 of BORI7t-COMP(OVER 100,000 BTU)
the C.11fornh Health&Safety Code,Sections25505,25533 and 75534.I `»
understand that if the building d not currently have a tenant that it 6 my NEW RMDFNTIAL MECH. SQFr
ro robillt to race Lfytheoccu t of the cequlrementa which at be met ^
p o nceofa Certificate Occupancy. (,.et-D �)l
OwVorrauthorimd agent Vie,
� 1'k `V
`-as,^"�"
IDTAL: ISSUEDBMJ
OFFICE COPY