19994APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project Idetagi.tlm
Bu�lding Addro,: M
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PP MT NO.
19 9 9
Kr. ams: l ` 'n one:
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CITY OF CUPERTINO-BUILDING DIVISION�n
APPLICATION / PERMIT
BIIRDINGELECIRICAL-PLUMBINGMECHANICAL
6 ��nTJ � '
contracte''Name, Lc. No:
CATEGORY
C NfROL Y
ArchRea/Fs�eer. IJc. N
QTY ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Addrt.c CgCq Kt—IbW S.
PERMITISSUANCE �lQ
LICENSED CONTRACTOR'S DECLARATION
I hereby affhm that l am lkmaed underprovhims of Cha pter 9(mm a
IngwlthSe on7(IOD)of Dlv Mm3ofthe Bualrce dP feaa Cade,and
Ranee ts In full force and effM.
Date Claw, Cont
Date Contractor
ARCHITECT`S DECLARATION
I urdertand my pl ro.ball be used a, publleresda.
Lkenatd Profeabnal
OWNERBUILDER D C TIONs o
1herebyamothtIuem fmheCm.eolLwthe
following on.(SeotmBueNmad Pmfsb,cCcd,:Anydtyor
tountyhlchrtquWapemktomeutruR, alter,Impmve, demolbh, orrepair
any atmotump term, ka tsauaroe, Womqui puha notes rm mzn,eof t e
flieCo a dgned statement that ha (Chapter Ilocns<d punuw to the provtsbna f the
(bn 3 of the Lkeret a"ProfLAw 9(mmmerMg a la SeGbn7000)ddv4
the b of the Butlnenaed Pm(edo exemption. Code)°natiohe f Seet ion 7Mmfsom and
the bat for the alleged nUthe.Any vldatlon d Sectbn rum m rm any
appllan( for • pemdt sobjemthe appllunt to • tldl penalty drum nnmthan
fit• hunereddollam%W.
IT as owner of the property, or my employee with wage as their sole
mmpena im,wRldothework,andtbestm=m tsnot Wended or offend for
vk C c. 7011, BuslMsa aM Prdesbro Code: The Condr.d.e. Lite. Law
doa rot apply to on owner d property, who builds or improve themo,and
who doom .6 work hlmmlf athrough his own employ., provided that such
Improvements am wt Intended or offered for sale. If, however, the bu llding or
Improvement issold wlthln one yea rofmmpletbM1 tM o merbuliderw111 have
tqLlIurden of pmnng that he did net build or Improve for purpose of male.).
Lj 1, as owner of the property, am eachnively contracting with Ikemed
coetrann oto mratmot the pmjed (Sec 70K BustrmMm
ss and Plom Code:
The Cmdnoto/s L iec me Law does not apply to an owner of property who
boll" or Improv thereon, and who mmnota for such pVieeU wW a
cQWfamdur(s) heomed p%mmant to the Contractor's Llee se Law.
U I am corpt under Sec B kCTP C for thim
APPI]ANCESRES[DENIIAL
JOB DFJCRErI7
-F-i7t �V/
11'" !"
-
PANELSLien
UP TO 2DOAMPS
—
201-1000 AMPS
OVERIOOOAMPS
SQ. FT. FLOOR AREA
LED
D I N
PTER
Q � /
5/9Q.FT.
SIGNeo ELECTRICAL
SPECLALCIRCUIT/MM
IEbP.MEIFROR POLE INST.
POWER DEVICE
DAIE
SWIMMING POOL ELECTRIC
OUTL�SW[IO FD(TURES
VALUATION
'
NEW RESIDENTIAL ELELTR SQFT.
STORIES
7YPECONSIRUCIION
TOTAL
QTY. PLUMBING PERMIT FEE
OCC. GROUT'
RFS. IIN[TS.
PERMIT 155UANCE
��-DRAIN k VENT -WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
rut, 1�rl
DRAINS FLOOR ROOF, AREA, COND.
F7X717RFS�IAAI'
SANITARY Y N
RELET T Y
Owner Date
WORIQ.UNCOMPENSATIONDECLARATION
ave . oeruff"m d cuent to self -Isom, or .
1-11 thereby affirm that I haso
mnlRoworker'me
te of Compensation luranas mnekd copy themof(See.
3500, Lab C
1'd4y Y
$Q-TODL TAX Y_ N_
RECEIPT' Y
GAS FA.SYSTEM-]soil OUTLETS
PARK FEE Y N
RECEDrI' I
GAS EA. SYSTEM-0VER 1 CEA),
Com any
BUILDING
BUILDING DIVISION FEES
CertNeropy ts fiemby(umWM. -
�Certifled ropy ts filed �Mth the d[y Impeotbn dlvlNon.
CERTIFICATE OF PTION FROM WORKERS
COMPENSATION INSURANCE
(Ttda etttbn rad not tr completed lftlw perMt ts faone hundred Malian
(Slm)al®')
work so as to b WapsubjealmM,
Imnlfy thatoy any
I slue net empe any pemon b any manner, at as to become ubjen to the
Waken' Compenaatbn Lasv. d Gllfomh. Date
Applicant -
GREASE/INDUS1RL WASTE INTERCEPTOR
PAID
Date RC i t#
-
GREASE TRAP
SEWER-SANITARYEA ZOFT
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Reoei til
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT.
NOTICE TO APPLICANT: If, after making tints CeNf{ate of Evemptbn, you
should bemm, subject to the Worken'CompemaHon provtsbro of the Labor
Code, you met farthwlth comply with such pmdabrtf orthis pemdt shall be
deemed invoked.
CONSTRUCTION LENDING AGENCY
Ihembyal1i thattheretsamnutmotlmkMing age for the pertorm
anmufthework mrwmmthlapemtltblamd(5,3097, Iv.CL
LLerml''. Name .Me'
.Addren
cemilythat Ct.IdgIhavomadthtsappentynaMgatyodthe.bovedn to pion
tsmrntt lagmeto comp)ywBA antltyaMmulm o rnanon aathatelawa
or i pectim ntstive °fritts
rebtl a to binding mrtrtmel en and hereby property
dt(Wenagreeon the to..e,boveromlyonedpropeetyfawpeCityofCuper
(We) agree to nave, IMemNty and keep hamdea the City o/ Cupertino
againdmidltb,judgmequer,mtfth ezpen.n whkh mayb snywayamve
agebat old City bmn.eque�dthe gradlngdtM. pemdt
'
TOTAL.:
WILDING
SEISMIC FEE
TOTAL;
ELECTRIC FEE
0 O
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PND:
ALTER OR ADD TOMECH.
Date Revel t#
AERHANDLING UNIT (f010,000 CFM)
$IJBTOTAL:
AIRxANDUNc uNrz (OVER ]0,000 CFM)
CONSTRUCTION TAX
Signature of Applimnt/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
WBl the applkadafutum budding °'upset nom or ha Mle huardoua
m ct 1asdeflrmdbytF Cupenlro M.NdpalCode,Chapter9.12andthe
Eleahh aM Safety Code Senbn 2S532(il7
MY. No
Willtheappliada turebuildingoavpantumquipmemordev
whkh emit luvrdoun W mntaMnaN,as delad bythe Bay Area Mr
Quality Management Dtstrin7
Y,.j�No
Nevercadthe h &S.f& Cle,S f..2menteunder Chaper G95 of
the GB/omh ]icahh k Safety Code, Seotlom 25505, 25533 and 255M. I
rosportaMyto that notify ullding don rot mrtentlyhaid. tenant thatb tsmy
rnprt ho,,yton . theca'p'er dthe requirements whkh mut be rtM
pr/lor/ty f®uanmda Certiflote o/ro Ota ruy.
EKFNUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HFATINGUhTT(TO100,0003IU)
Date Recti tit
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
O
VENTILATION FAN (SINGLE RESID)
ISM DATE
APR:! s t9s
^'
ISSUED BY:
BOILER -COMP Off? OR IW,0W BTU)
BOILQt{O.M'(OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ-Fr
$QFT
(TNic thorimd.gent Pate
TOTAL
OFFICE COPY