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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY =
Building Projectldentlfk.tlunvN-OT
Building Addn : ��� /—-
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PER\ NO.
13soo rt�3� F
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. CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
p
�2 S
contvL .me Ll No:
CATEGORY
CONTROL
1!
BUILDINGS-D=CAI PLUMBINGM1)aIANICAL
ArehHM/Engl neer: Lle No:
QIY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PFRMITISSUANCE
❑ . ❑ ❑
LICENSED CONTR! S DECLARATION
I hereby Jflrm )ofam lkerueA heB"rovW dN feWpter9(commmc
under
IngwlthSeailon7000)of DlvWm3ofthe BuelnmadPNlesdoNCode,ad my
APIaT.IANCFSRF9DFNFfAL
JOB
Manxbin fuBlora and dfed.
PANELS
Lkxnx Cha Llc a
Date Cowador
UP TO 2DOAMPS
—
2714000 AMPS
ARCHITECT'S DECLARATION
I underatand my phro sWB be used u public records.
OVER1000AMPS
SQ. FT. FLOOR AREA
SIGNSE.tDaMCAL -
Lkmseddewb
PrNl
A L E D IN
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
Iherebya/
TEMP. METER ORIOLE ASI.
following.(SetIn7exemptfromthedProl ioUrtNeAwfathe
reaan. (Section 7(015, Buslnu and ProfembN Cade: Any dry or
munrywhkh rtqulreea pemdtromrocruct, alt., Mprove,drmolbh,orrtpilr
p TER
anye mmprbrtoita mgaborequh theappUmtfm.uchpem to
file a signed etalerrent that he b Ban.ed punuat to the provinbns of the
SER DEVICES
SWIMMING IDOL ELECTRIC
Contractors Lkerue, Law (Cha pler9(commendng with 5edbv 7000) of DM -
ebn3of the Business and Pro(embroCade)artlw Febe.ernp therefromaM
VALUATION
the bash for the alleged exemption. Any vloh0on of Scaibn 70315 by any
appll fit fora permN aubjechtheapplla ttoa dull peroltydrm moatthan
OU"ILE S.SW TCf IESFDCTURF5
NEWRESIDENTW.ELECTR SQFI.
five hundred dolbn (5500).
I, a owner & the Property, or my employe. with S. u then sob
- STORIES
TYPE CI�NSIRUL'1-ION
eumpenuttim, will do the wait and the struRurt bed W ended or offend for
-
. le 6ec 70K lhudm and Profaebns Code: The Contntoe.♦lame Law
TOTAL
do. not apply to a owner of property who builds or lmpmv.Ihenoh and
who doswch work himself or through M.own employm, in.ided that uch
Improvemew are cot intevded oroffend (orale. If, hove mr, the building a
ImpmverreN hnald whhinomyear&cmrpbtbn,theowmr-bulld.will have
OCCGROUP
'
RES. UNITS
raanofprawngthathedld rwtbundorimprw.forpurpmeofale.).
Lj 1, . owner of the property, am e.cbalvely omtnding -1. 1—
co
contracts. to construct ted projed(Sm 7014, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
P ERMD ISSUANCE
FLOOD 7DNTi
APN
The CoMndor's Ll oae Law does not apply to an owner of property who
Wilda or Improv. thereon, and who cordncb for audr p,jem with a
Baeaed puruant to the Contndoe. Lice. law.
am ea under Sec B 4 P C for thio w
Lj rtan
ALTSFDRAA4 VENT -WATER IFN
FEE SUMMARY
BACK FLOW PROTECT, DEVICE1
OUTSIDE I"'
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N -
BBC=F
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby 01min that I have a certtB.te of con.ert to self -Inure, or •
aNfiote of Worken'Com pereaNm INuraa or a oertlfied copy thereof (Sec.
3800, Lab C.)
SX7l1RFS PER TRM
SCTiOOL TAX Y_ N_
RECSIT E
CAS FA. SYSTEM -1 INC4 OUIIMS
PARKFEE Y_ N_
ky F
RECE17nr
GAS PA. SYSFF21-0VER � (FA)
�
BUILDLNGDMSIONFEES
lfiod ropy b hereby mrwhed.
Ned copy b filed with the city INpectbn dlvl.lon.
k
GREASE/ADUSIRl WASTE INTFICS"IL1RPLANCHECK
FEE
CRFA.SE TRAP
CERTIFICATE OF EXEMPDON FROM WORKERS
PAID '
♦ORM FA ]00Ff
COMPENSATION INSURANCEFR-SANlfyd2Y-S
(I'hLnsectbn need not be compldM if the permit b forom hundred dollan
Date RCCEI f#
WATFRFB'ATERW/VENT/ELECTR
ENERGY FEE Y' N
NIM) Nf...)
- Marti/ythatlntW performance of thewmk/or which this permit 1. b.ued,
WATSt SYSDM/TREATING
I sW B nor employ any persmr b any manner w as to becume ubjed to the
W.,lu,m Compenation haws ofC.11f.iu. Date
PAID
ApplimNOTION makingtee CtimptebE
NOTICE 70AI'1b)I
NEW RESIDENTIAL PLMB. SQFI.
Date- Recei t#
-
TOTAL
toT:U,ager
wbjhwith hawork Comp ofttbn,ym
Code, you is
Code, you rtuet forthwith comply with such provbbro or this permit nhall be
rovisinpmwlsFeoftW all be
BUILDING FEE
deemed revoked.
SEISMIC FEE -
CONSFRUCTION LENDING AGENCY
Ihcmbyaffirm Wtthert baconswdlon lendingageray forthe perform
anon &the work far whkh thio permit b Wued LSec.3097, Clv. C.)
TOTAL:
ELECTRIC FEE'
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
lender. N.me
1<ndere Addrea
ImrtirythatIWvereadthbappB tlonude tethatthe.boveinforrtwion
eromct lagreetocompfywhhall Wyand muntyordlnamandeatelam
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authortm repreaentatives of this
dtyto enter upon the abavo-mentbmd property for nnpedbn pu rpoe..
(We) agree to nave, W emrdfy an d ktep harmless the City of Cu pe tine,
agaWthaelltl.,ydg�w, mntaard aperun whbh nay in anywayacvue
against ale City In cmaquena of the gnmingdthls pemdt.
ALTFRORADDIOMEM.
Date Recei t#
AIRHANDUNGUMT(IL110,000CFM)
SUBTOTAL:
AIRHANDLING UNIT(OVFR lQ000CFM)
CONSTRUCTION TAX '
SIgNNnof Appll fit/Contndor fate
EXHAUST HOOD(W/DDCD
CONSTRUCTION TAX PAID:
,
HAZARDOUS MATERIALS DISCLOSURE
HFATING UNIT (70100,000 BTU)
Will the appB of orfutum building occupant atom or bundle havrdous
material an defined by the Cupertino Munldpal Cade, Chapter 9.17, and the
H.It ar Safety Code �1a�—S1�edum 75532(.)?
yee
Date Receipt
HEATING UNIT (OVER 100,000 B'CU)
TOTAL:
��
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
Will the appB onmfutune building onupart ux equipment or devices
whkh emit W.rdaue an contamina Naas defined by the Bay Arca Nr
BORER -COMP 0HP OR 100,000 BTU)
Quality MamgemeN Dbtrtd?
4Yn ❑ No
haveread the h no.,,oatMabrequinmennunderCWpler6.95of
e..
FC
BOILEPICOMP(OVER ID3,000BTU
the Calif.bi He." 4 Safety Code, Smt.. 75505, 75533 and 75534. 1
NEW RESIDENTIAL hfECH. SQFT
undrn rdi that If the building do. one currently have • tcNnl that it Is my
respoNlbWty to notify the amnpant&the requirements which most be mrt
a
prier bu...f. rtlffateofOccu/p)��r�Yq [{ �r q
1 /cY) 7 O"� /I
V';i 7 2 y T450
-
CI % of sine 'nry
Owner or authod>eda ent Data
e
ISSUEDB .
TOTAL
OFFICE COPY