20037APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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Buildirift Project IdentlfbHon - -
PERMIT NO.
Budding Addmc
�ssoo. G2�S'To R = aR,. U49t't% t Pe k
20037
r. >m ene:
SaZu2ov p
CITY OF CUPERTINO-BUILDING DMSION
APPLICATION / PERMIT
O']
Contrador's Name: Le. No:
BUIIDINGFI,DCTRICALPLUMBI MECHANICAL
CATEGORY
CONTROL Y ;
gi.x- Tn G Lk. No:
ArchWg �- -S31iS
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QTY " ELECTRIC PERMIT' FEE
BUILDING, PERMIT INFO
r�
Add. Go 4Sc. lvQ ST 5 t r
PERMITISSUANCE 12 �Q
❑ � ❑ Ll
CONTRACTORS DECLARATION
I hereby affim that l am licensed under provision of Chapter 9 (mmrrsat
ingwlth Sectbn7IX )of0iv m3oftheBuWrc dPmfe .,C.de,andnV1
Timms la In full farm and effect -
APPLIANCES-RESmF.M'IAL
�gCRB�ITp
Ly7� OVP�
L-. KI x
PANELS
LteenseClea, Lle. r
Date or
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201-IODDANUS
ARCHITECT'SDECLARATION -
TaMerataM mypWnahnBbe usM as publlcremN.. " .
Llan. ciProfeadorul
OVERIOOOAMPS -
SQ. Fr.
Fr. FLOOR AREA
I (V
f/�.Fr.
SIGNSELDCTRICA'L
SPECIAL CIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby a(lirmthat I am exempt !moths C.ntrx[or's Llmrue Irw fm the
P
TFMPMEITRORPOLEIN5r.
^--
POWDEVICES OATS
following reuan.(Setlfon 70315, Buenas led Pmfeubna Cade: Any dry or
counywheh relfubrsrm
a peXco demo, or repair
torutruct, alter, Improve,n,
anyetruRumpAwtolbEe me,aleorequU theappBcant for such permit dt to
file a aigned statement the he b Licensed pursuant to the pmvEdam of the
!,
'
SWIMMING POOL ELECTRIC
Cnetrenor'e Lice. Law (Ch.pter9 (mmmentlng wkh Seaton 7001).! DM-
don3 ofthe Bastes and Pr&ubru Code)or if, he b exempttherelmmand
VALUATION
'how for the alleged exemption. Any violation of Sedlo.7MI5 by any
eppllcantf.ra perMteubJe tithe appBrant toativil pevlty ofntl roam stun
flv�undsedner of epro
I, as ower .f the property, or my employees with wages as rheU sole
OUTLETSSWITCFHESFIX1TlRF5
F
NFWRESmENTIALELFCTR SQdrr
STORIES
TYPECONSIRUCTION
_
O
w Predes m
.1,IS, 70KItuilintheand s Code: reThLenotbdeam'.otane.Law
- TOTAL: bc%'3Q
dwapplywwowerofpmpertywounsorimpesterennod
w.dowhw.rkhmBmthwghNwnemplvyn,proddthatwdri
Improvementa are wt Intended m.fiered!.sale. If, however,the building or
OCG GROUP
R-IS UNITS
Impwvementbaold Mlhlnomy arofcmnpletbn,thewvvr-bullderwlllhave
-
tl)gk.rden of proving the he did raw baud or improve for purpose of we.).
Wty contra -8
LI I, as owner of the Property, am ercslventra-8 wkh Iarn
contranors to aorWrud the project (See 7014, Bualneaa.ed Pr&mbv Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD IDNE
APN t
The Contractor'. Woe. Law does not apply to e, owner of property who
bu Oda or impcontractsou
thereon, and who contrafee ch Mjem whh a
c gBlrwtm(a) ilmowd pursuant to the Contradda License Law.
UI am exempt order Sec B k P C for thh mown
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ALTERDRAW & VENT- WATER tTild
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FEE SUMMARY
W,
BACK FLOW PROT= DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANHARY Y_ N_
RECEIVE Y
Owner Date
WORKMAN COMPENSATION DECLARATION
F-11 hereby afHnn the I have • mrtlflcate of commnt to self-Inwre, or a
mrtiBote.f Worker"' Comp<roadon Ine rano ore mnifbi ropy thereof (Sec.
3900, Lab C.)
HX7l1RES]'ER TRAP
SCITOOL TAX Y N_
RECEIPT r
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GAS EA. SYSTEM -1 INC4 OUTLETS
PARKFFE Y_ N_Poli-
Y
RECEIPT r
CAS EA. SYSTEM-0VFR 4 (EA)
Comcy
y
BUILDING DIVISION FEES
wim copy to hereby filed the ea. -
rib led copy la flied with the tlty Ivpectlon dlvlWor%
GREASE/INDUSrtt1. WASTE INTElsFrroR
PLANCHECK FEE '
GREASE TRAP
CERTIFICATE OFU MPr10N FROM WORKERS
PSD
ER- SEWSANITARY STORM FA 200T
COMPENSATIONINSURANCE
(rHaeetlion need rad b complded Rthe perm![ b fororc hundred dollars
Date Date Reeei t#
WATER HFATFRW/VENT/ELECTR
ENERGY FEE Y N
($10(l) or le:.)
1mrtRys.) Intheperforrvnmo(NewmkforwhicA thl. pemdtEbved,
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WATER SY5ITIM/TREATING
I .hall am employ any person In any manner w as to become object to the
WerkeriComperuatlonl.a .of Caltfurei Date _
PAID
Applium
Date Recei t#
NEWRISIDFNT7ALP 11. SQFr.
NOTICE TO APPLICANT: If, after madding this Certificate of Exam too, Y.
cow
eboeld beme bFmpens
ct to the Workers' Coat lot proviebn ofthe Labor
TOTAL: -
ode;you nuet (odhwlth amply with wch pmvl.bv orttJ.s pemdt dull be
d
doomed revoked.
ILD ING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyefirmthat them 6a mvtmetion lending agency forthe perforre,
ance of the work s for whish this permit Is laed LSec- 3041, Clv. C.)
iOTAi.:
ELECTRIC FEE
Ot 10
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QTY. MECHANICAL PERMIT FEE'
PLUMBING FEE .
Lender. Name
Leaderaadd.
I artifythel have read thla apphmtbnard a eatharthe.bove Informelan
Is correct.lageee to comply wlN all tlty.rd county.edleanoesand state law.
MECHANICAL FEE
PFRMIT'ISSUANCE
FEES PAID:
relat ng mvtvdlm, and hu ntatNee of the
o enteru upon
tlty W,).g.to she, milrmentbmd propertyfmas'the tin purposes:
o propertyfee Inspection
(We) agree b ave, IMemrdty an d keep harMese the City of Cupertino
ALTER ORADD]O ME}L
Date Recet t#
SUBTOTAL:
agenat lied City in eameef e.teard eapenag whloh nay In anywayamue
aga Wt Bald City In con.equersm of the granting & this Ferrell.
AIR HANDLING UNIT (TO 10,000 CFA!)
AIR HANDLING UNIT (OVER Io,000cF'A)
CONSTRUCTION TAX
Signature of Applicant/Contractor Data
EXHAUSTFTOOD(W/DLrD:r
CONSTRUCTION TAX PAID:
HA]ARDOUSMATERIALSDIBCIASURE
"
HEATING UNIT(ID 100,000 BTU)
Will the applicant or future building oneupantstore orhandle havrdoea
anterial e, defined by the Cupertino Municipal Code, Chapter 9.17, and the
Date Recei t#
HEATING UNIT (OVER 1m,00) BTU)
TOTAL:
q30
Health and Safety Code Senior 25532(a)7
❑ Yrslr�-,1 No
Will the.ppBcant or f m building omrpant use equipment or devlas
VENTILATION FAN (SINGLE REM)���GE
DATE
which emit hanrdou, air mnW Mvnta as deRvd by the Bay Area Ahr
BOILER -COMP OHPOR 100,000 BILI) -
Quality Marugement Dlstre.t7
Yes ❑ No
have read the ha.rT material, raqrc
uiernts under Chapter 6.95 of
A P
APR �O
19gu
BOILER-COMP(Ova Im,0006IU)
the Califonia Health A Safety Code, Stolon 255115, 25533 and 25534. I
urd anrarad that if the baBding does not co rrentty have a tenant, that it 1. my
C1 .
NEW RE5I DFNIIAL MECH. SQ_FT
re.pon@Bityto notify the o pant&the requftementswhieh at be met�f
priortotauerue&a Ce hear'"cee Pa
/11!10.4
'rtfBo
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ncr or authortred "gen[ Date
TOTAL:
ISSUED BY��F
OFFICE COPY