19968APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ect Identification -
Building Addreu: trr�
*a:3s00 E en v I, I I J z3 Z� -rYP�
PENT NO.
19
re came: one:
F -L WuR
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILINNC-MEC RIC LUMBINGMCCFIAMCAL
A
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Cm Ror'e Name: Lk. No
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L` C-0 G••rVW L
CATEGORY
CONTROL 0
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A¢hN / glrcer,yu
' = G O
Qn ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add— 6 `d� ♦
PERMITISSUANCE
El 1:1 11LI
ENSED CONTRACTOR'S DECLARATION
I he,rebyaRirm that l an, lkmecd under prowhiouof Chapter9(commenc
Ingwlth5ectbn7000)of beinim3ofthe Bu.iwaandProteabruCade,and
Born. la In hull to. and dfc
Lice. Class LfcY
Date Contractor
ARCHITECT'S DECLARATION
I understand my plana shall be used u public ramda'
Licensed Pro(esbnal
OWNERthat I an, exempt x NLDFR DECLARATION
(wing ..affirrFcdi.731.5,Bhroets.m the Contractors License AnyrByLaw for he
foliowingrch requinesitprmitto Busin®aMPml.sbu Codc:Mycityor
cvuntywhkh requir.a pnNttomrutmct, alter, Improve, demoLLsh, orrepalr
anyetmcturc pdotolu d�rancc, aloraryL.the appBcantf«odupmJt to
file a edgned at itement that he b I tuned pureuant to the provbiaru of the
Contractors Liceme, Law(Clupter 9(co.ocing with section 700D) of D(A-
nlnn3 oftbe 8uainas and Professioru Code) or that he It, exempt therefrom and
the hula for the alleged exemption. Any violation of Section 7m15 by any
apph.etfor. permit objects thcappBart to a civil penalty d not mo re than
five hundred dollars CIW— .
�I, aeowrcra(the property,«n7 empbye. wkh wages utF<b ole
compensallon,willciothe work, and the Mructure in not Wended or offered for
n,le i5cc. 7044, Busb and Profesbm Code,The Corrado. Limn. Law
don not apply mm owrcrof propertywho bulde or Improv. therm., and
whodoesochwork himself orthrough hLsownemployees, Provided thateuch
improvemewaremtlntendedoroffered forsale. ILhovever,thebudklingorTOTAL
rov
impcmcMhseldwehinomynrofcompletbn,tk erbwWuMerve
Xrdenotproving that hedd notinild orlmproe, fxrpurpo.ofsale.).
I, as own.. of the Property, am exchsively co—a—, wlth 1—noted
I an to mrutruct the project (Sec. 7044, Boameeand Prdealoru Code:
The Contractor'. License Law doct net apply to m owner of property who
hillan or I.P. thereon, and who contracts for .&Ex jecta with a
ob.dor(a) home c] put mart to the C®tractors Lku
ee Law.
we I am exempt under Sec. g & p C�4r this rearm
V4 If 9,, a/n<=Fjy_ /�— II -1�
Ow
WORKMAN COMPENSATION N
❑I M.bbyy affirm the I have • certificate t to .If -Lorre, « a
certificate ofWorken' Comparoatien lnuranor«a certified copy thereof(Sec.
3800, Tab G)
Peaty,
� It
APPLIANCES RESEDENTALeDE]CRIx170N
,
f'� / �+�/
V V �X
PANES
2m'I000 AMPS
OVER1000AMPS
SQ.
T E R
"III
^74,
S/SQ.FT.
SIGNSELECTRICALPP13
9'ECIAL CIRCUIT/MLSC
TEMP. OR POLE INST.
POWER DEVICES
SWIaUING IDOL ELECTRIC
- OUTLEfSSWITCI IESFIXTURES
- VALUATION
I 00
e
- NEW RESIDENTIAL FLECIR SQ -FI'
.SIOR16
=CONSTRUCTION
,
1
QTY. PLUMBING PERMIT FEE
OCC.GROIIP
{J _�
V�
R65. I1NTf5
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTE4 DRAIN 4 VENT- WATER (FA)
BACK PROTECT. DEVICE
FEE SUMMARY
OLUSIDE FEES
S. FL
DRAINS FlAOR BOOP, AREA.ODND.
SANITARY Y—N
RLCEPr
FD(TLJRES MR TRAP
SCIIiOOLV Y N
REGEPI
GAS EA. SYSTEM tA`C.40[1TLEf5
PARK FTE Y N
RECEIPT'
GAS E.A. SYSTEM-0VER 4 (FA)
a y
BUILDING DI VISION FEES
eci
�Certifled copy is herebyth the city
❑CZ cdcopyb Iled'ndththecity Inspect Lon division.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION"becom INSURANCE
(D) or I Ion need na h completid B the prmlt V hoorc hundred dollam
($1DD)ENERGY
IorrtdyUutbthe pedormance ofthew«kfor whlclu this permNla lesrM,
I shall nut empby any person many, manner o u to becomes injectto the
Worken'Compcnutbn Lawaof CalRornla. Date
Applicant
GREASE/NDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCCCI HI
GRFASETRAP
SEWER SANTTARY STORM E.A.20 1'
WATER FIERIER WNEM/EFLTR
FEE Y N
PAID
Date Recei O
WATER SYSTEM/TREATING
NEW RESIDENTIAL ELMS. SQFr.
L after making this atsze ote of Faemptbn, yw
NOTICETO APPLICANT: to the
.Amidoumu forth tothe Workers' Compensationprnvhbmofthe Irbor
Coda you neat forthwith comply with such provbbv or this permit .lull be
aromas revoked.
CONSTRUCTION LENDING AGENCY
It ... by
hereby aBLm that there 6a mrtntmrtme lending agcmy for the pdormm
.norof the work for which this permit h.e,ei bee 3097, Civ. C.)
Tender'. Name
I.ender.Addeas
I ordlfythat I havered thio applic tbn.nd aetethat theabove Infomutimu
iscorrect. Iagree to comply with all city and county ordinances and state lawa
relating to building mrwructlot, and hereby authorize rep.acntative of thin
city to enter upon the abovt mentioned property fee Inspection pu rpon..
(We) agree to nave, Indmol
e/y.n d 1,ecp Karen. the City of Cu pertW
agaWt llabiBtf.,pdgmemn,cont e..d exposes whleh may In any way amue
agalut std City btan.equerior o/the g.Ming of th prmi j�
Signawreof AppBcent/Cent ami Date
HAZARDOUSMATERIAL,SIA URE
Will the applicant or future building occupant store or handle hazardous
material a defined by the Cuprtiro Municipal Code, Chapter 9.11, and the
t❑ Y. Safety Codr,s i=25532(a)7
No
Will theappli.rt«future Building.,.t u. equipment or devkos
which emit hazardous air comarmuMs ae definN by the Bay Area Air
Q..My Marugcment District?
Yn ❑No
have mad the havmlou,, mutedale requirements under Chapter 6.95 of
the Gid.m Health4Safety Code,Sectbm25505,75533and255M. 1
understand that lfthebuildIng don not currently have a tenant, that It is my,
imporaWBBy to nalfy the occupant d the requLement"hO uvst be met
Prior to Louance of. Ceriifeate ofOavpancy.
TOTAL:
OJILDING
SEISMIC FEE
- TOTAL:
ELECFRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTFRORADDTOMECFI.
j7d[C RCCCI [li
P
Alit HANDLING UNIT(7010,000 GEM)
SUBTOTAL:
�s
AIR FfANDENc UNIT (ovERlD,ivacthd)
CONSTRUCTION TAX
EXFiAUST HOOD(W/DUC)
CONSTRUCTION TAX PAID:
FIFATING UNIT GO iffy" MIA
Date RCCCI tic
U
HEATING NTI(OVER 100,000 BTI.
TOTAL:
VENTILATION FAN ISNGLE RFSID)
�l4R� ISSUANCE DATE
-j
0 13��
'
1
Of CIfOP,r L rl1(}�.
ISSUEDBY: ba_(� ��•'s-�/�`
BOI.ER.COMP PFI' OR IWXM BM
BOILER COMP(OVFR l00,0008iU)
NEW RESDENTIALMEIN. SQFf.
Ownerorauthorizedagent Date
TOTAL
OFFICE COPY