20068APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
B.Imm Project Idendfle.tlon
Building Add.:
1 3 SO 0 C l -to pty
PLRMRT NO.
2 O O 6
elle• ase: ! oro:
J: V U UA lit Llb
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATIONS/ PERMIT
BUaDINC-ELECIRICALPLU.BINGMBCHAMCAL
LC a T
cmo-adar'. N.me:I Ile. Nee
V
CATEGORY
CONTROL
Architect/Engineer. Lk No:
"(---
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address 6 0 ,a '
PERMIT ISSUANCE
t", PLUMB
(�f ❑ 1:1 ElLICENSED
rLC
CONTRACTORS D .CLTI
ARAON
IherebyaHbm that Iamlicensed under provlelons of Chapter 9(mmmenc
ingwith Sec1bn7000)c f Dlvblon3 ofthe Bu0n s sand ProfesalmaCode, and/
roe
bceis in full bra and effe
License Clams Lk.0
Date Contractor
ARCHITECPS DECLARATION—
1 uadenund my pkes.hall be used as public records.
Licensed Pmf naso ul
OWNER- e WILDER DECLARATION Ht
I hereby.f lmnthat I am exempt !scam the Canrntore License Taw fee the
following reason. 5ectlmi 70315, Busher and Professions Calc Any city or
countywhichpq roup a e,mrorequaitch,Improve,demm&pe repair
to
any atrodum statement
rue,abensed pursuant t the prrsuchpemdthe
pursuant it the pmvhbro of the
Elsa altos statement that he b r9 (commencing
em.3ofContracthe Liceusinse Law ssandPCha feselo9(mmdRndng wtth5eebnherefof aW-
Cade) Orlluthef exempt 7031 S by any
tbbasis for
saed exemption.
thesee ache cep My daiadan of Section 1NI5 by any
the basis for the permit
appliant for a permR wbjeda the appBrut to a dull penalty of ria moa Dun
fthe p0.
tiv red ed owner of
I, as owner 11 the property, or my employee with wages u there dole
coe(See, 0K wRldothe wmk udthe sirude: h notIntendedm.&oe orofferedfor
mle (Sec 1614, Busbes. and Proferbro Code: The Coadndofs Ilam. Law
does not apply to u owner of property who builds or Improve thereon, and
who doessuch work himself or through hbown emplgm, Provided that such
Improvemenu are not Intended or.ffertd for sale. If, however, the building or
Imp meldbsoldwlthinone 3eahofccuosnnpplelbntheavner-Wllderwillhave
1� rcd n of paodng that he did not buff or Improve for purpose of ole.).
1, u owner of the Property, am Cr hu vely oontr ting with IlaeruM
1r�iestore to construct the prejni(S 7014, Business a rd Professions Code:
The Corrtndori Lkerese Taw does not apply to u owner d Property who
build. or Improve thereon, and who martnda for such pl" with
o7aq+do1(s)bcen.ed pua.uut to the Contndmi Lies. Law.
II I am exempB 6 P C (orrtthijs reason
APPIJANCESRETDENIIAL
JOB D N,
�' Yy. in S S 1
Gn ,
r vITILN< L let_ 1!L
PANELS
IDP- A.M
OVER 1000 AMPS
SQ. FT. FLOOR AREA
SK;NSELBCTIUCAL
TEMP. METER OR POLE INST.
POWER DEVICES
SW[?ANfINGPOOLELECIRIC
OLnLE7 SWTTCLa
- VALUATION
NEW RESlDN`nS
TYFE CONSfRIxT10N
QTi. PLUM
ROUP
KI
RES fA77'S
PFRMR LS6IlAN
ALTER -DRAIN A
PONE
AM ,
MARY
FEE SUMF_
BACK FlAW
'
DRAINS FTOOIR ROOF, AREA, COND.
Ref_
Owner A=7,— 1D T�JJ�/(r
WORKMAN COMPFNSAT RATIO
6 hereby •Elms that I lova a artnt to self -Ewes, or •
certificate Of Workewtl
s'Comperonlnwnnaaa certified copy thereof Qec.
3800, Tab CJ
peficy I
pp(.iVRES PER TRAP
SC1gOOL TAX Y N-
ta RGfE81.1
GAS FA.SYSTFAf-1 WC4OU7LE15
PARK Y_ N_
RFOFJP
GSEA.SYSTEM-OVER4IFA)
Com
BUILOWCDIV S
ISION FEE�iycd
ropy is hereby tumefied.
F-1Cemlied mpyb(kdi'with dr dry lropedbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINStIRANCE
(This section need not be completed lithe permit b for n
one hundred doBa
(5100)rtfy du
Illnor slut Nth. persounceofthework fors tohthiseemdtctlowed,
I shall not employ any pears f uy manner at u to become subject to the
WorkApplicant, eruatlonl�w. of Ulifomla. Date
NOTICE
NOTICETO AITWC t to the afire making is arsank Blare of iExemption, eL you
should become subject to the Workeas'Compevatbn prvvInbro of the Mbar
Code, You rtust farthwhh comply with wch provhbu orthb pemdt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I heaebyaf ro"hatthere, Ina construction lerding.gency forthe perform,
a of the work for which this permit b blued c 3091
ued (Se, Civ. CJ
Lender's "amu
I<nderenaarer
ladity Nat luvenadthbappUi tlonar ;i tethattheabovelnfornndan
Incorrect. Iagr tocernplywlth.Bchyud muntyardlnance,. andseatelaws
miatingtobuibin iutmdimr,and rebyauth«h npres Utiw.fthb
dry to mterupon the above-mrntbned property fa Wpedbn purpose.
(We) agree to i.vc, Indemnify an d kap hanNw the City of Cupedlna
agairetllabBiles,�idgmrnb,costaaMexper� khnuylnanywayamue
ago trot old CNy-i e� of the gnrding�'hb pemdt,�l�
I/a'�/'T^)'.—([-ins' �✓/L (L� •,j� 4
GREASE/WDUSIRL WASTE BJTFRCFPTOR
PLANCH CK FEE
PAID
Date Remi t#
GRFdSETRAP
SEWER SANTI'ARY STORM EA. 370Ir1'
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N_
—
PAID
Date Rete' tN
WATER SYSTEM/TREATING
NEW RESIDENML PLMB. SQ.FT
OT L:
BUILDING FEE
EISMIC FE
TOTAL
ELECTRIC FEE
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
MECHANICAL
PERMIT ISSUANCE
FEESPAID:
ALTFRORADDTOMECH.
Date Recci tp
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER Po,00ocFM)
CONSTRU ON TAX'
Sigratum of Appllrant/CUfttr—sesw• —J1 pat
HAPARDOUSMATERI LSDISCIOSURE
Wllltheappllcantorfuture building occupant stomorlundlo haradous
outerbl as deRne i by the Cupertino Municipal Cade, Chapter 9.12 and the
Ik,.hhand Safety h
Cade Sim7553](.)7
F1 ye, M No
Will the applicant orfuture building occupant use equipment wdevk
which emit hamrdous ale cmnrNVrds.a defined by the Bay Area Air
Quality Managencnt DI•trini
4Yee nn No havc read the haaai� materials requtremenb under Chapter 695 Of
the CaldornisHealth A SaletyCode,Sectloru 25505, 75533 and 25534. I
uadarauMt tlfthebu Bdbgdaero mntlyhave•ten.nLtlutlthmy
aep.rublli[y, to notify the oavpan of the requlmn nerds which must be met
pawl to hsu.nre of. CetlticakofQ panq.
ExtRUST HOOD(W/DDCD
CONSTR ON TAX PAID:
HEATING UNIT (TO 100,000 B71))'
Da Recei t71
HEATING UNIT (OVER T(!)
100,000 B -
TOTAL:
_
VENTI[ATIONFAN(SINCLERE5ID)
DISSUANCE DATE
A
.T 1(.j [k Jl]
t5
GitJ ('` CHCPTtino
t
ISSIIEDBY:4r
l
BOILER -COMP OFT OR 100,000 BM
6O1LER.CO1%IP(OVER 100,000 BTU)
-
NEW RESIDENTIAL MECIL SQFI'
Ovner or authohred agent Date
TOTAL
OFFICE COPY