20204APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pra'M Identiflratlm
Building Add. �u t� tLl, l S -� 8E F
23so o GP��, e 1
PE]NffINO.
20204
res ams: l�—pL(JV� me
� ��
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUE.DING-E.E{TRICALPLUMBINGMECHANICAL
APPLicArMTMVFM`A
c °rt ams: ��—' Lte.Nre
CATEGORY
I
CONTROL X
'
Arddtees/Engiraer. Llc Na:
,QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address
PERM[TISSUANCE
t� 11 PLUMB si�
❑ KZ E] ❑
LA`j
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc
Jngv,hlice. is I. fon Jame and eff m3 olthe BuNnessand ProfeWon.Code, and my
Lice is I. full Jame and effect.
Date Clan ie.cunt
ARCHITECTS DECLARATION
I understand my plane shall be used as public record&
Llcenrd Professional
OWNER -BUILDER DECLARATION
I hereby affimn that I.m exempt fromthe CoM.esorileroe Llaw fm the
fOlbwing¢ason.f$MIon70.715,BusnmaMPmfmbn Codr.Anydtyor
muntywhkhrequWapem wmvt Maltm,lmpmve,demolbh,orrepalr
any.b mmprbrtoi"a ante,aborequbestheappilantfmauapemdtto
file a signed statement that he b Bmrued Pursuant to the pmvbloro of the
Contractors Lienee l-,v(Chapter9(commencing with Section 7DO(f /Div1-
pon 3Of the Business and Prdnebro Cade) orthat he b exempt therefromand
the lasts for the alleged exemptV Any violation of Section 70315 by any
appfiant fora permit subjects the applicant to a civil penalty of no mum than
Bee hundred dolls. ($500).
1, an awner of the property, or my employees with wage as their wk
cmnperoatlon,wllldothe work and the.truw¢bnot WeMedor o(femd/or
vk 6ec 7011, Buaircss and Prdmlons Cade: The CoMraesars LI¢rue haw
don applytonnO mrofpmpertywho Wlld.orimprovathe.ORand
whodce.suchworkhimaelforthwgh Meownemployeee,pr Ldedth.tsuch
Improvemew a¢ rot Nimded oralfe¢d (weak. IL howesar, thebulklingor
Imp cmcMls wfthnome rofcomplmbn,theewner-WiWerwW have
t4L4rdenofpmvtng that he did
"L as wvner of the property, am ..tori sly mntracting whh B¢nued
oanmaetm to construes the project(See, 7Dly Businm aha Pro(esslons Code:
The Com.nor's Lkenee Law does nes apply to an owoer a property who
Wilds or Improves thereon, and who contra for, suets plojec'b with a
O licensed pe ..t to the Cmt.dors Lleense Law.
I am exempt under Sec B 4 P C for this .w
an
APPIIANCE RESIDENTIAL
JOBD
PANELS
M-1000 AMPS
OVERl000AMPS
SQ. Fr. FLOOR AREA
A L E D I N
P U TE R
f/SQ.Fr.
-
SIGNS ELECTRICAL
9TF_pLCIRCUIT/Ml
.�,M�DRP�INST.
_
LOWER DEVICES
SWIMMING IDOL ELECTRIC
N
OIJTI,ETSSW77CF�SSFDCTURES
NEW REtiTDFNLI FLILTR SQA'
STORIES
TYPECONSLRUCTION
- '
TOTAL
QTY. PLUMBING PERMIT FEE
OCC.GROUP
RES.UNTS
PFRMITIMlUANCE
ALTER-DRAIN4 VENT- WATERS
FLppDZONE
APN
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y— N—
RECEIPT Y
Osvrar Date
WORKMANCOMPENSATIONDECIARATION
❑I hereby affirm that I have • oertlBate o/ consent to self -Uva., m a
¢NBote ofWorke.'CompensNlon lrouan¢ ora ertfted ropy thereof(Sec.
3000,LbCa
Y
$Q{ODL TAX YN
—
te, Y
GAS EA. SYSTEM -t INCTLET
YOUS
PARK FEE Y N
RINEBTX
S
GAEA. SYSTEM.OVER4(EA)
Com Y
BUILDING DIVISION FEES
Centlfied ropy is hereby turrdehed.
f'OCcrtlfied ropy is filed with the dty inspection dWislon.
��Y CERTIFICATE OF IXFTIPI'[ON FROM WORKERS'
COMPENSATION INSURANCE
(Thee sorrier, need nes be completed If the permit Is lm one hundred dollars
RI00)efyth
lanot employ
o the performain an the m werixmanner so wMob ca e, mW la issued,
I ork nes employ any penin b any manner at u to become abject to the
Wonlicant mpenatbnlawsMGWomla. Date—
Applicant
NOUCETOAPI'LICA .M,aftermakingthio CenBkateof Exemption, you
ehald become sub)" to the Workers' Compensation pnavisbro o(1M Lbor
Code,you
seecoked. dh comply with wch pnvvLabro orthb prmWshallha
seemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebya(ftrm thatthe¢ba constmctlonkodingagencyfortheperform
ane of the work for which thio pcmdt b hued (Bet 3097, CW. C3
Lenders Name
Lender. Address
1 ¢rti(ythat I have ¢od tMs appliatbnand etatethat theabwe Womutlns
uoam.Iagreetoc plywtthaneyand=ntyordlnanc detatelaw.
relatingtobandingcoratr dim,ahaherebyauthoriserepr mated ofthio
city to enter upon the above mentbnM property for Wpealbn purposes.
(We) agree to save, ird emodfy an d keep harmless the City o1 Cu pertW
agabut liabilities, judgments, "..od expenses which may In any vay...
ages Wt Wd City In mr sequenee of the granting d this permit.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recti ted
CREASE TRAP
SEY.,FILSANITARYSTORM P mp,T.
WATER HEATER W/VENT/ELECL'R
ENERCYFE•E Y N —
PAID
Date Re i ted
WATER SYSTEM/TREATING
NEVRFSIDFNIALPLMB SQFT
TOTAL:
BUILDING FEE
SEISMIC FEE
7ArAL:
ELECTRIC FEE
_
QTY. MECHANICAL PERMIT ITE
PLUMBING FEE
MECHANICAL FEE
PERMIT M-LIANCE
FEES PAID.
-
ALTER OR ADD TO M3M
AIR HA NDLING UNIT (TO 10,000 CFM)
Date Recd [aY
SUBTOTAL'
ALR IUNDUNc uNrr (OVER toaaB CFM)
CONSTRUCTION TAX
Signature Of Appliant/contocter Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applloM m Mtu¢ WBding occupant store or handle haurdous
madenui as defined by the Cupenim MuMcipal Cade, Chapter 9.17, and the
IlNo
lI �alallIth and Safety Code Section 75531p)i
devices
RHI Blmt appndous2 tu¢WOdbg acapantuby equipment Area
Mich shat Favrdous air contaminants as defined by 1M Bey Area Air
Wy Management Dbirlct7
Yes Q No
haveread the h. cuss materials¢qulremenbunder Chapter 6.95 of
the California Health S.Safety Code, Sectns io75.505, 25573 and 75531. 1
uunderstand that if the bullding don not comntly have a tenant that It b my
r.ponsID1111y w ramify the.pantOf therequirements which noun be met
ncu
Phar uao(a Cent tcof pa
eA244
Ela-IAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
I -SATING UNIT (T0100,000 BTU)
Date RCYei ted
-
HEATING UNIT (OVER 100,000 BTW
_
TOTAL:
VENTILATION FAN 6INGI.E RESID)
,ISSUANCE DATE
PAM
-
1 7�7
�„ O Ts9�
^
1/1
Cllsr Of424d
ll �J}n�ertino Ove
X' � �_ls[�� l%' `( t
ISSUED G'ri-- �
BOILER -COMP OI -B' OR 100,0(0 BTU)
a ROMERCOMP(OVER 100p(I0 BIL)
NEW RERDFNIIALMECII SQFT
netout arivN agent Date
TOTAL:
OFFICE COPY