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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldl Pr. en Idemifintlm
Building Addman:
- PF1th9T NO.
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1.,'Sao C_e{Sto DV_ 3 3 s -r P
19970
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
'O SCJ
C-om7tName: Lk.Nce
lii{.I-7
BUILDINGELECiRICA1,PLUMBINGhfECHAI%rICAL
GTfS,OftY
COMROI.I
AnhRect/En nee
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrem (gyp IbU
PERM]TIS'SUANCE
1Q{ ❑ ❑ ❑
I�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lkerued oderpmvWweo(Chapin9(cvnnen
n7D00)oIDMkm3o/the BuMem dPmfen Code,and
APPUANCESRESIDEM'IAL
JOB DESCRIPTION
-
Brevetiesfu0 form and d"o"
PANELS
L4enac Clam Lk.a
Date Contnct.a
IMIQ2DO ANIPS
DUPLF�C
201-1000
ARCHITECTS DECLARATION
Iundenh niyphnahaubeu. pu Eciemds
OVER1000AMP5 -
C. FL�QaAQIA
s/9�. F[.
ELET:IWCAI, FiP
LkevM professional9GN5
EY
OWNEReGUILDER DECLARATION
thereby afRrmthat Iamexemptfrom the ('nnttdessio Clave Mwfor the
E R
SPECIAL CIRCUIT/MLSC :1
IFAIP. M=OR POLE IN
T��1
POWER DEVICES .' W�
folbwbgrearoclutesaprml5,BuMnm aM Nofeabv Cala. Mycity.r
county, whk pm wiaPera tomnateun,Wer,bnprwgdemolish,
su&pr to
any abueurepatement !sauces¢, abomrybnsuant t t he provisions of to
IRs a dgned !element that he tv 9 (cod pursuant to the tion 7 ) of the Contractor's lXense Mw(Chapter 9 (mmmendng with Section7000)dDivi.
abs and Prdsi.vC exempt therefrom and
/� /
SNTMMINGIOOLELECMC
-
VALUATION
aidsInBusNeu
theap haat for the alleged eeotsth a Any violation .f Saabs 7a3not m ne any
Any of
appli¢nl fora pearlt abjcvta the applicant to • civil penalty d not nnmtlun
OU17LE S-SWITCHES-FUCIVRES
f:�7
'Z'l I 3? 8
NEW RESIDENTIAL ELECTR SQFI.
fivr�h1, a edl owner of the pro.
i, u owner o/the property, or my empbyeea with wages u their sok
oornpevadon, wllldothe work, and theatvaum b not tmerdedor offered for
sale (Sec 70K Boll, and PmfesbmmLlano M
ns Cade. The Coons Law
ll J
SIORIFS
TYPE CONSTRUCTION
�, 1
_
N
does not apply to an owner d property who builds or Improves thereon, and
whodoessuch work himaU¢through hisown employee, provided thatuch
OCC.CROIJPs
RES. UNITS
Improvements... rest intended or.ffered for tale. If, however, thebtdWing or
Improvement bwld withlnorcyearofmmpietton,the owner -builder TTI have
TOTAL:
R-3
tpchaHe. of proving that he did not bund or Improve purpose of nab.).
I, a wvner of the Property, am ex l aively amtracting wish 11¢nad
t ¢a to mralrvct the pmjea (See 7014, Bovies®and Prdmbro Cade
QT -y. PLUMBING PERMIT FEE
PERMIT I%UANCE
FLOOD ZONE
APN
7T< Comraaor't Lksme Paw dm not apply to an owner of property who
IstOda or Improve theseem, and who contracts t¢ such Inepo, with a
oin"et¢W R¢vN pursoant to the Contraaara Live taw.
LII am e erupt urdar Sec 4 P C for thb reawn
ALTER DRAIN4 VET f -WATER IFJa
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FIODR ROOF, AREA, COND.
SANITARY Y_ N_
REfm't0
'
�p_.,...
Avner tie ate+
WORKMAN COMPENSATION 1` N
❑1 hereby af(bm that 1 have a ¢rtiB¢n ant to aeR Wane, ¢ a
mrtifiote of Workem'Compenutlon Ircuran¢ ¢a ¢nifbd copy thersof (Sec.
3800, Mb C.)
F n,6 -PFR TRAP
`.A100L TAX Y_ N_
RECEIPT 4
GAS TA. SYSTEM -1 INC -4 OUTLETS
PARK FEF Y_ N—
Poileyt
RECEIPT/
Y
CASEA.SYSTEM-OVER4(EA)
BUILDING DIVISION FEES
Certified copy is hereby tuMcity ID city Cci
rttled espy b (fled svlth the Ivpectbn divides.
CREASE/INDIISTRL WASTE INTERCEPTOR
PLANCHECK FEE
_
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
need eat be compiaed B!he pemdt b(ororc hundred dollen
PAID
Date RCCEI tic
SEWQLSANTTARYSIORM EA. 200FT
)ne Imo)
(f]ID)¢Iy that of Is
I ¢nor
WATER HEATER W/VENT/ELECIR
ENERGYFEE Y N
— —
oy anyhe erman, anye m neerwork w to beelapembjedit
employ to theed,
1 aldol nae empty any person b any manna ao u to berme �bjttx to the
n Compensatbnlawad UllfamU. Dee
'
PAID
WATER SYSTEM/TREATING
Applicant
ppli
NOTICE of Ferops to
should berme abFct to the Worten'Compewtbn provbbv of the laoo
NOTICE TOraesub Grote corarro Corcing pe saIlonf¢leislom o theL bor
Code,y.anuatforthwhhmanplywithuchproW m.rthbpermitshallbe
Date Rete! til
NEW RESIDENTIAL PLMB. SQJT.
TOTAL:
BUILDING FEE
12L4 1. t%
deemed revoked.
SEISMIC FE
CONSTRUCTION LENDING AGENCY
Ihertbyaork for Wt ht bamnstesissud(Sm3 g7, Civ. C.) perform
an¢ of the work for which tab perms b !cued (sec 3097, Civ. C.)
TOTAL
ELECTRIC FEE
heMerb Name
Madero Adores.
1 ¢rtlfythu I hese rtad <hbapp8¢tbnaM clots that the above Information
QTY. MECHANICAL PERMIT FEE'
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
eooncM. Tagreetoccmplywlthall dyard countyordlnanmaand suRelaws
PERMIT NUANCE
Matingto Wilding construction, and hereby authada mpreenutiveao(thb
aYtoentuupon the above-mentioned Property fee haps for purpme.
(We) agree to uve, bdemnily an d Iusp harmlev the City of Cupenino
agaivtllabWth,judgmenb,mMaaM espsve kh mayinanywayamue
agalvt said City in mnamuence ofthe gr min dthispertulL I
)WvSUBTOTAL:
N 6r*,VPr 4/
ALTER OR ADD TO MECH.
AIRHANDUNCUMT(TOI0,0)0CFM)
Date Rmci til
AIREUNDWNG UNIT(OVER la=CFhD
CONSTRUCTION TAX
Signature.. Appli.1/Guaaneter te
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATER ALS DISCLOSURE
BEATING UNIT (TO 100,000 IM
Will the applicant or tutur, building omvPart ltomorhardle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date Recei tis
HEATING UNIT (OVER 100,000 BTU)
_ TOTAL:
Healthard Safety Code Soaloo25532(a)i
I—I Y. M No
Ill thcappR .t¢ future building arvpirt use quipmem mdevlmt
VENTILATION FAN LSINGLE RFSID)
_ _--e
R ISSLSANNCE DATE
ntaae de(InM by 1M Bay Arca AU
Itpn cit -COMP PFB'OR 100,000 BTU)
QualityMahererdoueairrict?
M Mavgsmem W ]N7
Yn [�� No
I have read the ], z Woos materials mqultemennunderCha pter6.95of
�l
I U
EOTLFRCOMP(OVER 100,000BTI))
the Calilomia Health k Safety Code, Sectlov 25505, 75533 and 25634. I
and erata rhe that if the building does not currently have a tena est tlat it is my
City 0 C11"..iUn't%.t
NEWRESIDENTIALMECH, SQJT.
re�povlbllity to not ify the ocenpam of the requirements which neat be met
/
prbr to tauarce of a CertiRo4 o/Omapamy.
OILS
ISSUED BY:
Owner or aulhMved agent Date
TOTAL
OFFICE COPY