21988APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldl ProM Identlfkatlm a
BuBdlog Address:
PEIUATNO.
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one:
C/Itzey,�/TIV,t//��! / aQ
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICATION �WMI I I AL DA IE
'3 �— .I
Contredor's Namr. Idc.Ner
BUILDING-ELECTRICkl PLUMBINGMEC MCAL
CATEGORY
CONTROL#
Archlted/Englver. Lie Na
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
miLh❑
Address
PERMITISSUANCE
❑ ❑ �
LICENSED CONTRACTORS DECLARATION
I hereby affirm that lam lleenad under provblons of Chapter 9(commm
IngwlthSeRbn70M.f Db .3.fthe Budrcssand Pmfes .Cedgand my)D
APPLIANCSRESIDEM7AL
BD6CRBTION
Ilam is in fun, (or¢ and dfed.
License Cha -LI, I
PANELS
^
Ditto ContractorContractor/G"
Date
UP TO 2DOAMPS
����
M"
ARCPITECFS DECLARATION
I understad my plsm.lull ne used an public read•
OVER1000AMPS
SQ. FT. FLOOR AREA
$/9Q. FT.
SIGNS ELECTRICAL
Linseed Ndmbnal
SPECIALC T/MISC a
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the G
Cordraorn Llcerue law for the
dry or
cwnrywhfcl, requBesa Enron, tomrutsud, ilbr, Improve, demoW h,
following reason.(Schon 7031.5, Business and l'rofeabrs Code: AJ�ch
any aimdure pdotoltafaarce, aoensed ursuaapplfantfowch
/0e a signed statement that k h Il¢need pursuant to the pnvvbbof
IA'70 C
Comme tes License LAW (Chapter 9 (comnroneng wBh Smbn 7000
don3o(the Buelnm andPrtmbrsCede)orthai heb ettmpt the?
VALUATION
tFe basis for the alleged ezemptim. Any Wdatbn of Sedbn 701Lny
eppheam for a permB wbjecia the applfcant to a dull penalty of not an
1A I
O FIXTURES
R® TR SQFT.
flex hundrd do"($500).
1, as owner of the property, or my employees with wages as thek
STORIES
TYPECONSTRUCTION
cvmpenutimn,willdothe work, andthe structurt b not Intended or ofes
sale (Sec 7014, Business and Professlom Code: The Contractor. LTawdoes
rot apply to an owra d property who bunds or improves thend.00C.
Who doosuchwrkhlmvelfeethrmgh Msownempl/en, preVidd drImprovements
GItOIIP
RFS UNfIS
are not intended orofferd forvle. If, however, the buTOTAL;
hold wlthinoneyearofmmpletbn,theowner-WElder
th,,-La dm of proving the, he did not bund or improve lar purpose of v4.).
aWely radeding with licensed!
Lj L as owner of the Emptily, am exchalt
mntncton to construct the project(Sm 70K Burin® and Professions Code:
QTY. LIN BING PERMIT FEE
F100D7DNE
APN
PERMIT NSUANCE y.(J0
,l
The Contndur'. Liceme Law does not apply to oro owner of property who
Wilda wm
da or Imprei thereon, and who rdraes for such oWpu With a
Banid pursuant to the Conmdw: Urns law.
L j I am exempt under Sec B 6 P C for this ream
ALTFA-DRAIN & VENT WATER (EV
FEE SUMMARY
BACK FLOW PRO.I.BCI,.DEVICE
DRAINSFLOOR EA, COND. ROOF, AR
SANITARY Y_ N_
RECEIPT
Ownn Drte
WORKMAN COMPENSATION DECLARATION
❑1 Fereby affirm that I have • artlliate of comart to self -inure, or
mnlBate of WarkeWCompevdmlmuanm as artifled copy thereof (SK-
38W, lab CJ
Policy 1
FDnIJRS PER TRAP
SCITODt. TAX Y _ N_
RILOPT
( GAS EI. SYSIFM.I INCA OUTLETS (,D
PARK FFE Y _ N
RE(:m'1' i
G'�PA. REMOVER 4 (EA)
Ce n4,
BUILDING DIVISION FEES
ECedifi`d copy b herebyWith nbad.
❑Cenlfled spy b /fled with the dty inspection, divWon.
GREASE/woUSIRL WASTE INITRCfPTOR
PLANCHECK FEE
GRFAStE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA WIFE.
COMPENSATION INSURANCE
(0)orI bn red nU be compktd lftW parmB hfurore hundred donan
Date RCrei t19
WATER rffATIR W/VENT/ELL=
ENERGY FEE Y N_
PAID
(5100)orfy that
Irertny employ any pterion iaofthework n as to bthise, sabbbad,
I wrist mat employ any person b any owner m u to become wbjed to the
W«ten' Comperoatbn Lawn o(G Wama. Date
WATER SYSTEM/TRFATING
AppBant -
NOTICE TO'APPLrkNT:If, after ouklog this ceMlate of E,emeptbn, you
Date Recei tq
. NEW RESIDENTIAL FILMS. SQ.FT.
TOTAL:
should become subFat to the Worttn' Compemailan provisions of the labor
Cede, you eno t forthwith nomphy With such pnuvbbv or this permit shall be
deemed revoked.
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that then ba eonutrudlm lending agency for the pedorm
anm of the work for which this permit b laud bee 3097, CW. Q
TOTAL: -
ELECTRIC FEE '
QTY. MECHANICAL PERMIT„ FEE
PERMIT ISSUANCE
PLUMBING FEE
, 0
Lendee.Namr
Iedee.Addnesa
I certify that I have read this app"tbWve
n and nate t the aboWomm
atl
Is correct. I agree to comply with all chy, a d nan®
county ordland sate laws
MECHANICAL FEE
FEES PAID:
retailing tobuIlding corutmetim, and hereby au,horioe npneenatives of this
,
city to enter upon the above-mantbned property foe WpeGbn purposes,
(We) agree to save, Indemnify an d keep he-mlm the City of Cupertino
against liabilities, judgmena, mnsand expenses which may in any wayaaue
agakto City in eon rano he nta tHs permit.
ALTIRORADDTOMECH.
Date Rescel tic
AIR HANDLING UNIT OO 10,000 CFM)
SUBTOTAL•
AIR HANDLIIiG UNrr rovER lB,lnocF`f)
CONSTRUCTION TAX
Signature ofA ant Contractor Date
EXFIAUSTHOOD(W/DUCT
CONSTRUCTION TAX PAID:
HAZARDOUSMATERIA ISCIASURE
HEATING UMT(PO 100,000 BTU)
WaltheappnaMorf.wr Wuding tst morhaMlehavolms
material as deRned by the Cupert l m Mused I Cede, Chapter 9.1 Z and the
Fkafth and Safety Code Saleetion 25537(a)7
Date RecCl [i(
FIFATING UNIT (OVER 100,000 BTU)
TOTAL:
/
VENTILATION FAN(SINGLE RESID)
ISSUANCC DATE
WultheappBantor fu W. Wllding.pantuseequip.m.rdevicca
which emit haadma W dmaMnaMs an denrKd byline Ray Area Air
Quafty Metagemera Dearer?
Yes ❑ No
Wva read the havNous materials requirements underChaper 6.95 of
,he Ca Ofomh Health h Safety Code, Stolons 25505, 75133 and 25534. I
understand that if the building does net currently have a tenant, that itis my
PAID
APR ���
BOIUFRmMP (31D OR 100,000 BTU)
BOUT-ER-COMP(OVpI100,0008111)
NEW RESIODMAL MECYL SQ -FT.
respo el,flity to notify the oaupant of the rrqulrements which moat be met
,
prior to Issuance d • CertlOam of Oavpaney.
d no
ISSUEDBY_d VL
Owner or wthemed agentDate
TOTAL
OFFICE COPY