19957APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY N
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19957
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILIXNGELCC7itICALPLUMBINGMECHANICAl
-y
Ca�lt�nao/a Name: Lk`�Na:
I OLL CD�,1GT�CTIOQ (
CATEGORY
CONTROLY
Arthltect/Engineer. Lk. Na
QIY ELECTRICPERMFr FEE
BUILDING PERMIT INFO
Address .GO —tSS b S
PERMITISSUANCE
�j O ❑ MECH❑
VAI
LICF.NSF.D CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under Provisions of c1haper9 (camanure,
ingwlth Setlbn 7000)of pvlsim3dtheeutlnesnand Rofeal«uCodq and
APPLANCESRESIDENIIAL -
JOB DESCRIPTION
Ilceneolain fullfoimandeffM.
PANELS ,
Limt. Clots Lica
Date Ge
7R.i P1�X
201-lo)o au
ARCHITECT'S
ARCHITECT'S DEcugnrroN
I underwnd my pbroehaObe used espublic remda
OVERIWOAMPS
SQ. Fr. FLOOR AREA
5/SQ, FT.
lav
Led Professional
SIGNSELICTRICAL
E D I N
..
OWNERexNLDER DECLARATION
IherbyaffirmthalIamexemptfromthed
U TER
SPECIALC RCUIT/MLSC
TEMP. METER OR POLE IN5T.
P.f WLicenseLw/mthe
following realm. L a p 70115, Burin®ard Pro pe , CMr. My dty or
pernR to ct, aitch p damolbh, or
muntywhine
l
J
p for Cosa
also re a lira
irm pursuattot he por such wilonsermte
mit to
any. Agnedu,tement he he
Ne a signM tlatertent the N b licensed pursuant to the proal Wv d the
Cuntndm"Lkeve law(Chapter9(mmmencing with Section 7000) of Divi-
idea 3 ofthe Business and Prdembv at Code) orthheir exempt therefromand
ROWER DEVICES DA
`/T
/ i
,t
SIMMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of SeGbn 70115 b/ any
applicant fora permit subjects the appeant to a elvll penalty d not mo rthan
OUTLPISSIVIICHESHJ(TURES
00
NEW RESIDENTIAL ELEC IZ SQFT,
Ove hundred dollars (55001.
❑ 1, as owner of the property, or my empbyeas with wages as their ante
STORIES
TYPE CONMUCT10N
cvmperaatlon, wW eto the work and thestmdure Is not intended or offend for
sale C�ec:70K Bualnas and Pudesebv Cade The Contractors License Law
U—N
does not apply to an ower of property who builds or improves therean,and'
who does such work himselfw
or through his on employees, provided that arch
OCC. CROUP
RFS. UNITS
Improvements are not Intended proffered for sale. If, however, the Willing or
Imp mens bsold wlhlnovyeare!<ompletbnthe owner4nilderwlll have
' TOTAL
Q'7
��.�rden of proving that he did hat bund or Improve for purpose of salt.>.
�[I I as owner of the property, am exclusively contracting with licensed
6ii Lctan to mvtroct the pmjcd (Sec 7014, Business and Pvfe®lom Code:
QTY. PLUMBING PERMIT FEE
I'FRM171�UANCE
E
PERMIT IWARAJN
FLOOD 7D
APN
The Cam naves Limine law don not apply to an owner d property who
Wilds or Improves thereon, and Who contnm for such plojeas with
93174+cior(s)11¢nsed pursuant to the Comrades's Lkeve Law.
LJ 1 am exempt under Sec B Mason6 P for this Mason
& WATER
SUMMARY
BAER FLOW PROTECT. DEVICEFEE
QIJTSIDEFCES
DRAINS FLOOR ROOF, AREA, CONT.
SANITARY Y_ N_
RECEIPT Y
,s p�/'WV
Owner - tle
WORKMANI have afti TION
Of hereby solum that 1 have o ire nca' o c sent b aeWlwrt, or a
artlllc to o/Worlan'Compenaati mfmunnttorsanifled mpythereof l$ec.
3800, Iib CJ
pp(.pURp� PER TRAP
SCHOOL TAX - Y_ N
RECERrT Y
OAS EA. SYSTEM -1 INCIO(IILEIS
PARKFFE Y_ N
Palley 9
RECEIPT
GAS FA. SYSTEM -OVER 4(FA)
CRy
BUILDING DIVISION FEES
Certified copy b hertbyfumWed.
CeN(IM mpyb Ned with the dtylrepectbn dlvlelm. -
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(rhb.eetk,n fiend not b<compldM Rthe pemdt bire one nanarea sonars
PAID
Date 'Recel tH
SEWF3YSAMTAAY SIOR.M EA 2OWT.
( 5100) or Iem3
N tha pe ra of thawmk fo b thla pemdt
Ill
WATER HEATER W/VENT/EIECTR
ENERGY FEE Y N
sot ehtl
erson i ct to ttd,
I ehaO not employ any peau b any manner so u b become wubjca to the
as to
Warkeu Cousepavatbn Iowa d G Warty. Date
WATER SYSTEM/TREATING
PAID
n
ApplicuNOTICE
NOTICE TOAPPLICAM:e after not Co the CerWbte1b Exemption,you
should become(eathsubject to the Workers' CorWensstlm pmvbis p of the Labor
Coda dare moat forthwlth annply with such provbbv or this permit still be
Date Recei t#
NEW RESIDENTIAL PLMB. SQFT.
']'O'FAI-:
BUILDING
dmnrd mesiad.
5EISMIC FE
CONBTRUC'TION LENDING AGENCY
IherebyafnrenthattherebamvtrudlonkMingage�uy lar the perfom,
ceoftherkforwN Uh pemdlbb M6ec3097,Civ.C3
Lewonder'.
TOTAL
ELECTRIC FEE
None
Lender:Addems
I certify the I have read this application and sonethattheabove Informatlm
QTY. MECHANICAI.PERMIT FEE
PLUMBING FEE .
MECHANICAL FEE
FEES PAID:
Iamrrm.lagree to comply wlthaO dtyand o>unty oMWnasand tlate laws
PERMIT ISSUANCE
relatingto Wlldingmumtru lon,ard hereby.whorlrartpretentatfvesafthb
'
dty to enter upon theaWvcrrcntbrcd propertyfor Wpectlon purposes.
(We) agree to save, IndemNfy an d keep har lese the City of Cupertlno
ALTFRORADDTOMECH.
Date Reeel t#
P
agaWt habWtlro,Judgrcw,c®nard expenses whkh rvyln anywayamue
n
agast said City In eonsequerem of the gnming this permit.
nrne,M "&�' sMNL(, 4,_ !y,
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
. AIRH,.NDLINGUNTT(OVER10,000CFan
CONSTRUCTION TAX
EXHALIST HOOD(W/DUCT
CONSTRUCTION TAX PAID:
Signatun.f Appllaant/Cbntrae'IBF 1441 Date
HAZARDOUSMATERIA sDl IOSURE
HEATING UMT(TO100,000BTU)
WRlthaapplkantorfuture Wedingoavpant rtareerNrdleha:aniau
raterial as dMlvd by the Cupertlro Mumdpal Code, Chapter 9.1 Z and the
Dare RCCCI [k'
HEATING UNIT (OVER iffy" BTIA
TOTAL:
Hnnith and Safety CMa Section 75532(a)t
TvYes��
Rl the appliamor tore Wlldingomupantuseequipmemmdevkea
which emit hararduuaib oantambuaa as defied by the Bay Arta Air
Management duktl�_
trOIIFR-COMP
Yes ❑ No
Ihave read the haamomatertabrequbb
emenunderChapter6.95of
the California
nia ealth 6 SafetyCurie, Sexrbv 25505, ZSS33 and 25534.1
undantaM that it the Wilding don not eurrently have. tenant. that it b my
reapovlbOlty to notify the oaaupant of the mcialfemema which most be met
VFN77LAT10N PAN LSINGLE RESIT)
ISSUANCE DATE
PAID.
r 'T
a
B OED' OR 100,000 BTIn
BOILMOOMP(OVERl00081L)
00,
NEW RESIDENTIAL MECN. SQ.Fr
,
priorto bnuamo da C<rtiliatc ofOnvpauuy.
of, MiTeitino
��ax��C'..t1je
ISSUEDBY:VS>S—IT•/Wil:'
Owner or authorlred agent Date
TOTAL
OFFICE COPY