24193 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm Identification
B.W Add :
PERMIT NO.
o r
24193
Owne,�
e .me:APPLICATION
G - ens
CITY OP CUPERTINO-BUILDING DIVISION
SUBMITTAL DAM
ryr
c 'r+a¢ Name: .No:
APPLICATION / PERMIT
�-
(�f� �J
BU]LD1 GELDCTRICALPLUMBINGMECHANICAL
CATEGORY
CONTROL,/
-
AmIdtectgineer. )Je Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Acta U
PMNdTISSUANCE -
❑ ❑ j ❑
L�]
', LICENSEDC NTRACfOR DECLARATION
Ihereby.ffirmthat lamlmm,adunderpr We eof Chapter9(m
Ingwlth5ectbn700D)of Div m3afthe BuMne dIhafntlon.Cnde d
Lilicce bInfu d e.0
License Cb. l��- (Comm
APPLIANCESRF_SIDENITAL
PS DESCRIPTION
PANEUP S
Date O Comm
—cue ��e�
TO
- AMPS
• U..H UE u
IuMenat.nd mry plaro,haBbe used npublicremmd>
OVER 1000 AMPS
SQ. FT. ILOOR'AREA $/9Q.Fr.
SIGNSELECTRIGAL
Lknnaea Professional
OWNER -BUILDER DECLAMTION
IherebyafBrm that l am exempt from the Con[r,eor', Lime Law for the
lolbwing reason. (SeNan71➢15, Bwinem.md Pnofe>.bro Code: Mydty or
muntywhlch«gWmion MImmutru4 alterlmptove,dende:Anyrt r
pry
/d P T E..�
�/G
SPECIAL ClRCUIT/ham
TEMP METER OR POLE INS!.
anymu mprbrto Ibbs ,aborLNUb he+ppll¢ntf¢.uchpemmto
file +Agnea .latement that he I, li¢ead npusu+nt to the ptovbbro or the
Contractors Uceroe Law (Chapter 9 (commencing w" Section 7DRq of Dlvl-
m
sn3oftheButlnessand Prd®ro b ToCode) orthat he exempt therefmmand
me DEVICES
cid
u�
ON
MING R70L ELECTRIC
the Web for the alleged exemption. Any viol.um of Sedmn 7m1S by any
bjemthe applmw ta, dull pevity dn¢nnrctWn
spears
OUTLETSSWTTCHESFDn URFS
NEW RESIDENTIAL ELFLTR SQXT.
fWe hundfar
Ove 1,..o dollars(SM.
(S
pr.
I, s. owner of the property, or my empbycn wage+, thio d
STORIES
TYPECONSIRLICTION
oomp❑ willdoth. w¢kand thetlrude: Is of m fo
oroffendfor
.leC _ 70K Prdabro Code:The
The contractors Lie. Law
rale Cnot
mp.rs
won not appy to an owner d property who build, or Improve thnm2 and
pply to. owner or
who doee.uchwork himself ¢through his own emplq¢s,provlded that eh
OCG GROUP
RES UNITS
improvements a¢ wt lnlended oroffered!¢sale. IL havever, the bulWing or
improvement bald wdhmoneyurofcmnpletbRtheawner-Wllderwill Wve
TOTAL
tl),juraen of pmwingthat he db not Wild or bnprove for purpose ofsale.).
LI L cue owner of the property, am e.huWdy contracting with licensed
corrasion to mronuct the projed(See 7061, Bu,lnes and Pro(mmrs Code:
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD TONE
APN
The Contractor'. Ll . Law does not apply to +n owner d property who
Wilda or Improv Merton, and who mmr.cts f¢ ash p,*u with +
oNlfactor(sl lieem .pursuant to the Contnd¢i License Law.
U I am exempt order Sec. B 4 P C for this reasonOUTSIDEHES
ALTER -DRAIN 4 VFN[ -WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, GOND.
FDnIJRFS PER TRAP' see"
SANITARY Y_ N_
RFLEPr 0
Owner Date
!WORK MAN COMPENSATION DECLARATION
fh (31 Hereby affirm that L have d
-
SpiOOL TAXY_ N_RECEIPT
, mnlB¢te consent to ,elf-Insert,u,
, .
oe
q, 0 G) aof Warken'Camperoatlanimur,n¢aa ¢rtifmd ropy thereof (Sec.'
CAS FA. SYSTEM -1 WG40UTIX S
PARK FEE Y N
;bb
I3b8fl/LCI 7 5-4�•
mY
RECEPT
GAS FA. SYSfFA1-OVER. (EA)
Certified cop 'ertbyfl5reLA�aavi
em110ed copy bfiled with lir dty lupe tmn divitlm.
BUILDING DIVISION FEES
GREASE/INIX151RL WASTE WTFRCE'TOR
PLAixJGHEGKFEE
CREASE TRAP
i CERTIFICATE OF E)(EMP ION FROM WORKERS'
COMPENSATION INSURANCESEWER-SANITARY-MR.MEA.2T0LT.
(fhlseectbn need n¢ tr cornpleted B the penN[ b(¢ ais hundred doB.ra
PAID
DatC Recei t#
alm)arin)
I ¢rtot'rnpilytthat he work. b ter p
Az TERW/�./�.�
ENERGY FEE Y N —
1.W 0 not empty any person b any rtanner. o u b icemen, subject to the
oy an perso in nary as to b) t. t1he
Compensation lAw+of Gll(¢nb. Data
A SYSTEM/TREATING
C
PAID
rat
Apphra
NOTICE
shoulWTICEco esubjGM:ll,.Ber makingthioatioe pteismsoftof teLyou
Code, you fueth to the plywit such pro isio provbbvorthe Lab or
Cade, you cost (¢thwith mp,py with,vch provbmro or this permit shall W
deemed re.-akra.
Date Remi t#
NEW RE9DFNTIAL PLMB. SQJ7
TOTAL:
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby+Hirm that (Feat b. mrotructlan lending ageuy (or the pedarm
an¢ of the work for whmh Nb pcmat b Loved (Sec. 304), CW. Q
ELECTRIC FEE
Lenaeri Name
Lenders Address
I reAtlylhat I have read this appliatmn,rd,tate that the above infornutlm
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
FEES PAID:
isro a .I.greeb... ytywahallcity+nd mu myridinanoes,nd"t.l. .
PERMITISSUANCE
relating to buildleg mmMmdion, and hemeby.uthortre rcpneenbtivn d thio
city to enter upon the abmv nncrtbrod property for Inspection purposes.
(We) agree to save, Indemnify an a keep harmlea the City o/ Cupertino
ALTER OR ADD TO MISCH.
Date RMCi t#
P
SUBTOTAL
,Salient wties, jndgmeru cost..d,.pe..e chmayb.nyw+ya.e
.g.' C Incros.uen¢d "ofthisperenit
AIRHANDUNG UFm(TOI0,mOcrm)
AIRHANDLING uhrrr rovER lo,Doa CFM)
CONSTRUCTION TAX
10 reof Appbrint I or
EKHAUST I IOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA TAR DOLS MATERIALS DISCLOSURE
HEATING UNIT aOI00,000 BTU)
Will the appBant¢ future bu0ding emmp,nt store or hard le havrdmue
material as deBeed by the Cupertino Municipal Code, Chapter 9.1 2, and the
Date ReCel
HEATING UNIT (OVER 100,000 BTIn
TO
Health and Safety Cade Section 2532(a)7
❑ Yee r! No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the zppllaed or future Wilding o Nnt us, equipment or devices
whmh crelt hazardous air mntamW ms as deRmd by the Bay Area Ab
BODER -COMP PTB' OR IW," Brll)
Quality Management DWric[7
Vn No
Qms
BOILEACOMP(OVER 1W,000 BTU)p
s
, I (have read the h v materials requirements under Chapter 49S of
the .m Ca19Tieahh4Sif&y Code,Seabm25505,SS33and2MM.]
W p
t
NEW RESIDENTIAL MECH. SQ.FT
Understand that if the building does not currently have. tenant, that it is my
maporobOBy to notify the accupam tithe requirements which must be met
Ct[`ss
SEP
precy.
'91brlomaua.d.Ccrtiflaw.fOrmp
ISSLIEDBY:,`=n.M1io
Owner¢authorlud .gem Date
TOTAL
OFFICE COPY