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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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1 23405
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Cchor 3 Namefs/-==� o
fe
BI1ffDINGELECTLIJM
RiCAPLBINGMECHANICAl
CATFLORY
COMROL.
eci/En eros . Llc Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
A d SIE
I'FRMIT I3sT1ANCE
❑ _❑ ❑
LICENS ED CO. ACTOR DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmare
Ingwlthg n7000)ofDMkm3o(the Budneuand Pmfeas Code,and
=1 bC N ^o dLlc dtexf y
LI¢n a /� J� Y 710
APPLIANCES-RESIDEMIAL
DESCR�iION
w
PrIH Y
PANELS
-
ei
N)1-1
-Co—
ARCHITECT
]uMerland my phro stun be used! nPublic remrda
OVQt 1000 AMPS
SQ. PC. FLOOR AREA f/SQ. Ff.
SIGNS ELECTRICAL
Licensed Prvfesslanal
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby afOmnthat I un exempt fmmthe Contraaorb Lkerue Law f¢ the
.MET[Or OR POLE MSf.
following reason.(Setllon 7m15, Business and Profabra Code: Any city or
u nwhkh requires a permit m
my dtto remoct, alter, Improve, demolish, or repair
Al
D '
any mrumere prise to its Issas me, also require the applicant, fee weh permit to
fife a signed statement that he h Ipursuantued pursuant to the provisions of the
Contmdoe& License Lew (Chaptn 9 (mrmrcncing whb Seabn 7OOM of Divi -
ebn J of the Business and lidesbroCede) orthrt he b exempttherdromand
- POWER DEVICES
LUATION
SWIMMING POOL ELECTRIC
the bash for the alleged exemption. My vldadon d SeGbn 7QI15 by any
app0antforaperm bjeutheappLa ttoadvilperokydnmt mthin
OUTLEISSWI CHESFDCIURESD
n�
7
NEW RESIDENTIAL PT R SQFT.
nfjwnarta dollars MM
I, a owner, of thehepmperty, or my, employer with wager u their doleNEW
STORIES TYPE CONSTRUCTIONLf
Bothew¢kandthestmciureh rotIMeeded
mm(So,7
Kwdl
sale tree. me Law
Lee. w
Band Profmbro Code The CoMnroves
o
don resroessuey torn owrcrdpropertywho buHdpl y.,movided that and
he
apply totheme,
whodonsuch work hlmseB through hisowne provided that
OCGGROUP
RES UNITS
a . 14 how,
however, thebuilding ve
g or
Improvementl are net Intended proffered r¢sak. the
Improvement b sold within orae year of<ompidlon, tk vvner-lou Ilderwlll have
'
tlg.tlurdenofpmvingthe l old notbuBaorlmpmvefmpurproeorule.).
"1, as owner of the property, am evchulvely mntracting with ifs, uM
mntraeon to mntroci the project(See 70K thodeesud Pmr®bra Code:
QTY, PLUMBING PERMIT FEE
I
PERMIT ISSUANCE
Fl"DDD ZONE
APN
The Contnnor's Lkxnde Law doe net apply to N ownn of property who
builds or Improve s the eon, and who coomsefee such p(Djem with a
ryNrietuee) hemmed pursuant to the Contract¢: License Law.
U 1 am exempt under Sec B 4 P C for Nb mve
anOUTSIDFFTFS
ALTER-DRAINAsVEM-WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINFLODROOF, ARE.
S R A, COND
SANITARY Y N_
RECEIPT tFIXTURE&
Owner
KM
WORKMAN COMPENSATION DECLARATION
E
❑I hereby orfimn the I have • oertlfiate of emesent to epythsurt, ¢ a
¢mNab ofWorFeri Canperuationlrouan¢¢a¢rtBkd mpythereof 6ec
3.00, rise,
PER TRAP
SCHOOL TAX Y_ N
RECEIPT
CAS FA. SYSTEM -1 rNCr OUTLETS
PARK FEE Y N
RECEIPT e
GAS EA. SYSI EM -OVER l (EA)
ComF
BUILDING DI VISION FEES
TMy Illed ropy is hereby fumished.
❑ Certified entry b filed with the a ty 1ropeGlon division.
GREASE/INWSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF FXDY[PTION FROM WORKERS
COMPENSAT]ONINSURANCE
(ihb se tion need no be completed lithe pepermJe Islm hundred dollars M1undd dolla
PAID
Date Recd tp
SEWER-SANTEARY-STORM EA. 2(X)FT.
(f100)mlesJ
Iartify that tithe pedomun¢of th<esmkforwMch this pemdebhomed,
I shall rat empty person lo any runner u b erbjeci to the
W¢kera'C Ca e
WATER HEATER W/VENT/FIDCTR
ENERGYFEE Y N
PAID
WATER SYS[EM[TREATING
Applies, //
NOIIC i T'ZfC�CJ C lateof Exemptlon,yvu
Date RCcel tN
NEW RES[DEIMAL I -LMB. SOFT.
ehmld become subFct ten the ork<n'Compensatbn provisions of the Lebor
Code,you =9 forthwith comply with such provisions orthb pemdl &hall be
deemed revoked.
TOTAL:
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaff"m Hatthhemhammt dimkndingagerRyfort perforrr,
ante of the work for wch this Permit h Issued Sec. 3097, Cl C.I
TOPS
ELECTRIC FEE
Lender's Name
I<aaera aaati,.
1 ¢rtlfythat I have read thh appllotbn and muethm theabove In(orrrwims
[ten -1 .]agrea to comply wltha0cityand munry ordbunre and late laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
refelog to bulk(Ing a mtwGlon, and hereby authorlu mpresenuuve o(thb
dry to enter upon the abovcmrntbrcd property for lropenbn purposes.
(We) agree m save, bdm
erdty an d keep barred. the City of CupertNo
Date Recei [q
P
ALTERORADDTOMECH.
SUBTOTAL:
agobut Wb1ill" dgrmru,mis and ex Per. whiel, mayl any wayamun
.ala ren „¢perk gnMi this
_
AIR HANDLING UNIT t0,WOlR+M)
ALR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
gn wmaf Ppuam/ Date
EXHAUST HOOD(W/DLCT)
CONSTRUCTION TAX PAID:
HAZAR SMATERIALSDISCLOSURE
HFATWC UNIT CID 10(1,000 BM-
Wllltheappllo M¢futumb adingo pantuomorha lehav s
material es defined by the Cupertim M.Mcipal Code, Chapter 9.17• and the
Date RCCei f
DATING UNIT (OVER 100,0DD BTU)
TOT
Health and Safety Cade Secilon 2S532(j)7
❑ yesN No
VENTILATION FAN SINGLE RFSID)
ISSUANCE DATE
illtheapplloM mfuturebuildingmvpantumequipmem¢devlm
whkh emit hamrdous air cmnumlrorets as deflned by the Bay Area Air
BOILER -COMP OI1P OR 100,0(D BTU)
Quality hLragereent District?
4 Ye 9W
have rudthe hart s rrmeriab requlrerrcnb under Chapter 6.95 of
n A' D
P' M
BOMIR-COMP 100,D00 BTU)
the California Health h Safety Cede, Sections 8505,]5533 and 75531. I
NEW RF5IDFtJ77AL MECFL `SFT
underurdyi.nthe building donnot cvrreMlyhave
ore
M.a haM,iha b,mey
whkh rw.k be naY
MAR 12 1992\
Po eta uay eat Codi utcontdtherequlremeMa
prior to hsuarre d • Certlflate or Ocaparcy.
dQJ
CII Y ry
ISSUED BY:
Owner or eahorlved agent Date
TOTAL
OFFICE COPY