20202APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building PmKq Idemlfkatlon 1 W Ia-I-C �� O
Building Add.,: - V I _J o
PERMIT NO. n/
Z
23 Seo tcv-`bTn 6
Z O O Y
Iturne.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
4
con d �• •nc Lle-NP
I
BUfIlNNGE1HCDUCALI'I,IIMBINGMECJIANICAI.
CATEGORY
CONTROL/
AmhimetfEngineer. Llc No
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PFLth9TIAUANCE
❑ � ❑ ❑
LICENSED CONTAARLA
OR'S DECRATION
I hereby dorm that l am licensed under provbioa of Chapter 9(a rru me
Ingwith Sedlon7000)of Dlvl m3ofthe Buslnes dProfeWi Code,and
APPLIANCES -RESIDENTIAL
OB �iCRll'CN
�'i^�.]J \(1 F1..4� 1 1
License b In full force and effmt.
PANELS
l I 1 `�' V I 1 T"✓
Glas Lk..
Date d
Date Condor
UP TO 2DOAMPSpu
P
201-1000 ANTI'S
ARCHITECT'S DECLARATION
Iundentad my plaashall be used as public ecard..
OVER 1000 AMPS
SQ. FT. FLOOR AREA g/ .FT.
SIGNS ELECTRICAL
Lkenxd Pmfewbeal _
LED I N
ST'IGAL CIRCNT/MIS[
OWNER -BUILDER DECLARATION
IherebyaffirmthatIam exemptfromthe Co e,masieLicense Lawfm the
collowing untywsawn.iresapion rm15, Burines.d Profmba Code Mycltyor
musty white requires alter, Improve,
o conalso
r repmit,
P T E R
IFl✓3. hfEfTR OR INST.
spcmdu
any ebucturttatemeprior to ttheuanceaboreed puruam,rea, the W onl(m anions of to
ro ui t for su& permit, to
!ib • dgned statement that he b handed purwmt b the provblDm of the
POWER DEVICES
f/ ,
SWIMIVING POOL ELECTRIC
ContractsleLite. Law (Chapmr9(comnendng with Seth.. 7000) of Did- b
an3 of the Busirmand Profesloro Code) orthat he is ertmpti herefmmaM
xxxxxxx�
VALUATION
the beat for the alleged e.cmptlon. Any violation of Se dlem 711315 by any
appecantfoe apeed(SW. the appucmltoadull pevhy door mort than
O SSWDC}DSF7)<NRFS
NEWRESWENY71ALELECIR SQ,FT.
Mdhundreci weer of he pr).
1, m owrcr of the property, or my employen with weed• (kir dole
STORIES
TYPECONSIRUCTION
w1E do w«F, and the Codes Is ot r or
Intended or offercerin,
,
B.inethe
.k 5,cc,ompeou7DKftion,
(exec alnowss adf Cor
Code: The CoMndors
he L w
nae Law
TOTAL -^
77, 4
rl property
don not apply to an owner of properly who build• or Improves thereon, and
apply to he
who danwchwork hlmreB«thmngh hi. own employeee, provldedthat such
ver, theulNing or
improverrenis art not Intended oroffertd forrale. If, howeb
OCG GROUP
AES. UNITS
Improvement lawld wlthinovycarofc«nplctbM1the«vner-bulldnwW have
I rdm of proving that he did not bund or Improve for purpose of dale.).
4.. owner of the Property, am x.humvely �t ading with Ilrended
mntrad«d to mmtrud the project (Sec 7DN, Ruenes•rd Profmloa Cady:
QTY. PLUMBING PERMIT FEE
FLOOD Z-0NE
APN
PERMIT ISSUANCE
The Contractor's LI«nae Law don not apply to m owner of property who
es therm., and whmw
build• or improvm o ac for .0 p,*cts with a
qal[ d Ws) Banded purwant to the Contrader's Licena<Lw.BAIX
LJ 1 am exempt under Sec B k P C for thio meon
ALTER -DRAIN VENT -WATER (EA)
FEE SUMMARY
FIAWI'ROTFIT. DEVICE '
DRAINS FIAOR ROOF, AREA, CONS.
SANITARY Y_ N_�
BBC= a
Owner DNe
WORIUHAN COMPENSATION DECLARATION
❑I hereby all that I have a certlfio e d Gauen to aeU-bwrt, or •
certificate of Worken'C«nperoation Iruunnce or a cedlfW copy thereof (Sec.
38W, lab C.)
petky a
F l sPER TRAP
SCHOOL TAX Y_ N_
RECEIPT R
GAS EA. SYSTEM -1 INCL OUTLETS
PARKFEE Y_ N_
RFLEIPE a
GAS EA. SYSITM-0VfA /(FA)
Co�^ +ray
BUILDING DIVISION FEES
I I Certl(Ied ropy b herebyfurnished.ed.
dj��LCertiBed ropy b flled'Mth the dry Iapectlon divides.
GREASE/INDUSIRL WASTE INEIBZEPTOR
PLANCHECKFEE
GRFASETRAP
. CERTIFICATEOFEXEMPEIONFROMWORKERT
PAID
COMPENSATION INSURANCE
(Mastt oneed not hecompleted If the permit b fmonehundroddollar
Date Reel IN
SEW,Ea-SANITARY-STORM FA 700FT
WATER HEATER W/VENT/ELDZ1i9
ENERGY FEE Y N
(SI I or really that
]art ms.) Nthe pedormanceo(the work for wNchthio pemd(bLwed,
WATEASYSIEM/TREATING.
I shall not employ any person In any manner w ax to became aeb)ect to the
W«ken'Comperuatlonlaw.of C.Ilfomla. Date
PAID•.
Applicant
NOTICETOAPPLICA-.U,.fleerakingthio Certlfkateof F.cmptbn,you
NEWRE&O,a ALPLMB. SQFT.
Date Re I tN
should beme subj d to the Workers' Compeneatlo, pmvbloa of the Labor
co
TOTAL
Code, you next forthwith comply with..& provbiom orthb pemdt.ball be
deemed nwkn].
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IherebyaffirmtFutthesbamalrudion lodingagency lorthe perform
arm of the work for which thio permit Is Lined (Sec -3D97, Cl C)
1<dee. N.
Lasd.e.Addrem
I artifythat I havcrtadthbapp0catbnad •tate thalthe.bove Nformrtim
bmned.l.grn to comply with all dryad county o.IWnm and date Wes
TOTAL
ELECTRIC FEE
.L7
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
slating to building mnxtactim, ami hamby.whorlu reprcaentat Wesof this
"
city to enter upon the abxr,mentiorcd propertyfor Wpectbn purpaes.
(We) agree to live, IMemdfy an d keep haren]. the City of Cupertino
ALTFRORADDTOMECH.
Date Recci tit
SUBTOTAL:
egalrut lbbWtles,Ndgmerda, code and expcaes white m.y In any wayacaue
ATR HANDLING UNIT CTO 10,000 CFM
agairw mid City in corirequenm of the gra dlay of ted• permit.
•
AIR HANDLING UNIT(OVER 10,DD)CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
.CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNITED 100,000 TEU)
WOltheapp"mmfummrt ildingoaup.ntdortorhadbhanrdcud
rtnterbl as defined by ted Cupertino MuNdpal Code, Chapter 9.17, and the
H❑Yes Safety CodeSSMloon 755374)7
Date Rccel t7l
HEATING UNIT (OVER IOD,000 BTL.
TOTAL:
a
VENTILATION FAN(SINGLE RESID)
ISSUAN9T DATE
A fryryr
L
WBl the•ppllnnt or turn building occupant useequipment arde
whfrb emit hanrdous air eontamirunts as defined by the Bay Area Alr
Quality Maragcmeot DWrict7
Yea ❑ No
BOILER -COMP OH POR 100,DM BTU)
IW," IW,BN)
vateriab requirements under Chapter 695 of
I ave read the hard asm
the California Health k Safety Cade, 5cVbru 25505,75533 and 2153/. I
/ 177 , tGnO
1 J
NEW RESDFNIIAL NISCH.-SQ-F]".
.M.tadttutifthebuUdingdonnottunentlyhaveatenant,thatltbmy
responsibility to orally the ouv pad d the requlrem nda which nwxt lora met
Prior to uane d. Certilkee of p y�
/ice nt �
�a.
City Of PflnprNno
DE Rw�luyc.�;
ISSUED BY�
Owner aht Date
to
TOTAL;
OFFICE COPY