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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldin Praiser Identlfkatlan
TNQ.
Building Addw:
235-00 CYLSTO L bY'
1
9 9 8
rcr. am,e ane:
Forum. Groi
n
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Q /
rte
Contractor's me: Lk No:
l co K-7-BLUfLDINGF].FCIRKALPLUMBINGkiE(:I
IA MCAL
CATEGORY
CONTROL0
ArthB / 1Y No:
—
�T (T '4_T
-
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
.D
Address 4 0
PERMITISSUANCE
® ❑ ,❑ 1:1LICENSED
CONTRACTORS DECLARATION
I hereby, affirm that l am beemed under prwWom of Chapter 9(mmmm
Ingwlth So dm`70B0)of Dr hdon 3olthe Butlnee.and ProfessonaCode, and my
APPLIANCES-RESIDEM'IAL
JOB DERRIT N
licenseliIn filart
foe and dletl.
Claw Lb. Y
PANELS
�F'i' F_ Port
U Yid er
Date Cic.a
Date
,� " U,:Mt
201-
ARCHITECT'S DECLARATION
- I understand my plana shall be used as public records
OVER I000 AMPS
SQ. Fr. FLOOR AREA
FT.
SIGNSELECIRICAL
Llecrsed Prvfmlonal
SPECIAL CIRCUIT/MLSC
OWNER -BUILDER DECLARATION
1 hereby,ffirmthat I am exempt fromthe Contr ctori License Law for the
TEMP. METER OR POLE INBT.
folbwing reason. betlim 711715, gualnm and Pro(esbv Code My tlty or
muntywhichrequbeapem wmr ct,alter,4 pr ,demo h,orrepalr
anyslrutlure prbrto lW huanee, alw requlrcthe appllant for ouch Pemr'lt to
file a signed statement the he la II¢rued pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC»w
0[IfI.E�WI�F�H%]iJR6
Contractor's License Law (Chapter9 (mmmendng with Section 7D= of DM.
lana of the Busle. and PrefeE IoCode) card at he exempt th,rafromand
the mala for the alleged exemplars. My vldelon d Section 7m15 by any
appllantlor. pemdt subjects the,ppacanttaativll penehydnat more thin
VALUATION
O � � � � I 1 t 0 D
o I
NEW RESIDENTIAL ELECIR SQFT.
five hundred dollars (SM.
F-11, as owner of the property, or my employees with wages as their sok
R S
TYPE CONSTRUCTION
mmpensetion, wal do the work, and the structure E not Intended or offend for
sale (See 7044, Busmen. rd Pro nabru Code: The Contractors License Law
does not apply to an owner of property who builds or impmo thereon and
whodooeuchworkhlmeeR orthrwgh hleown<mploym,provHed that such
OCCGROl1P
RES,TIS
improwam a¢notintendedoroffered!¢sale. If,however,thebulldingm
impmvxment beald whhln orcy¢rdmmplelbn the ownrrbu Alder will have
TOTAL:
Kme of proving that he did not Wild orimprove, for purpose of.ee.).
owns of the property, sem exclusively contracting with IkaneM
L asn m
t oto nelme the project (Sm 7014, Business and Prafes ons Code:
QTY. PLUMBING PERMIT FEE
FIGOD IDNE
APN
PERMIT ISSUANCE
The Contractor's Liaise law doe not apply to an oven of property who
wilds or improves thereon, and who centum f¢ such p(ojects with a
gngactor(a llmneed pursuant to th, Ccumeda • nee Lloelow.
LJ 1 am exempt order Sec B 6 P C th ¢
ALTER -DRAW 4 VENT- WATERrate
BACK FLOW
FEE SUMMARY
DRAINS -FLOOR, FLOOR
ARY Y N —
REC= Y
Z;
Pvn,r pat.
-WOR"ANO PENSATI IARATION
❑I hereby affirm that I have • ¢rti0a e f unseat to self-Iwre, or
¢rtl0ote of Workers' C¢nperwtion Insurance or a ¢eiHM copy thereof (Sec.
3800, Lab C.)
Policy Y
PLCIlIRFS PER
lir
100LT % Y_ N—
Y
GAS G.SYSTQ.f-1
PA Y— N_
RECEIPT Y
GAS EA. SYSTEMT OVRR Y (PA)
Com ny
� BUILDING DIVISION FEES
Certl(Iedcopy Lsherebyfumlahed.
Certif ed copy is, filed'Mth the chy inspection dlvlelm. '
GREASE/INDUSIRI, WASTE INTERCEPTOR
PLANCHECK FEE
C;RF.ASE TRAP
CERTIFICATE OF IXFI.IPIION FROM WORKERS
PAID
SEWFR-SAN)TARY-STORM E.A.X)()FT
., COMPENSATION INSURANCE
(This section deed out be mpem
mpletel if the Jt Is forum hundred dollars
Date Recel [#
FffATER w/vFxT/ELUCTR
ENERGY FEE .Y N —
'
($100)arless.)WATER
I nertify that In the performance of the work for which this permit V Issued,
WATER SYSTEM/TREATING
I rhea not employ any person M any manner so as to become subject to the
Wm)ers'Campematbn Lawsof CilBornla. Data
PAID
'
Appllant
NOTICE TO APPLICANT: IL.Rn making this CerBfleate d Erem, pflm you
NEWRFSIDIWEIALPLMg. 5p�,
Date Recei t#
TOTAL:
should become subkct to the WorkeA Compereatbn provisions of the Labor
Code, you must forthwith comply with such proviebro or this permit andl bo
FEE
deemed revoked.
EISMIC FEE
• I L
CONSTRUCTION LENDING AGENCYBUILDING
1hereby afOrm out there 0 a mnstmotion leading agency for the perform-
sore of the work for which this Permit Is loved (!S c 309'/, Civ. C.)
1<rdare N.rrc
icrder,Add.
1 cerflythat I have mad this appllatsenand stateth,t the above information
bmnacf.Isgrt<to complywithall tlty.rd muntyordlnanmand late laws
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relatingtowlldingmrutmction,and herebyautharice repre,entativesofthh
_
my, to enter upon the abovcmentbned property for hopectiopu
(We) agree to save, Indemnify an d keeps tamalethe CBy of pertW
ag,Wtaablatka, jndgmew, misaM experm which may ln.nywsyacoroe
agahatsaid Citylnoonseque�oftho gn am dthia permJL
�a,AA.. /-_O L,^ / vY li.,l
"7Y /.�`a/iL./�y-' V
ALTFRORADDTOMECH.
Date Recei t#
AIR HANDLING UNIT CFO 10,000 CFTO
SUBTOTAL:
3-
AIR HANDLING UNTT(OVER 10,O)D M
CONSTRUCTION TAX
F>oinusT HOOD(W/Dorn
CONSTRUCTION TAX PAID:
Siiggmltumoff'Ap`pbesnntt/ Ntee
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,OD00'Rl)
Date Recei t#
Will the appaant or future wading ary pant stme.r herdic havrdaus
material as defined by the Copan]. Municipal Code, Chapter 9.12 and the
Ekahhand Safety CodeSection 2S532W7
❑ Ye No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Q�r
VFNEIATION FAN (SINGLE RFSID)
ISSUANCE DATE
WWthe applioantoQture building ompantuu equlprecat or davit
which emit havardousalr crontaminents as defined by the Bay Area Air
Qualty Management Wtricti
4Yes No
havereadtheh m., material, requlrcmenbmule,Chapler6.95o!
the Gllfomia Heahh k Sof Code, Seer ions 25505,25533 and 25534. 1
^i
A. ��
BOILER -COMP OI [FOR 100,000 BTU)
SCB ER-ODMP(OVQ2100,000BTLD
NEW RESIDENTIAL MICH. SQFT.
u rdenta M that if the wilding does not currently have a tenant, that It 6 my
J
resporama By to notify the occupant of the requ hementa which must be met
prior to lsuaren of a Certificate of Omnpancy.
Cjhj (If r'I^ f9qY+.t
o
e--�,�QuP�er-tiynIo-
ISSUEDBY:_
O.vneroraulhMrad.gent - Date
'
TOTAL:
OFFICE COPY
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