22022APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE. BALL POINT PEN ONLY �(
- Building PPm� Identification �+ (}S� O�^�'
Building Ad �7 Irf-a �^" �.G\ i .
l�
PFJLMIT NO. 'a/1/ -/A/'�/1/
2 Y O Y 2
• .me: one:
f'Dax At
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BRILLDINGS ECTRICALPLRIMBINGMKHANICAL
AITLICAT
r L � o-9
`�T
Contntre.Name: Lic.No:
s
CATEGORY
CONTROL N
Athitet/Faglneer. Llc. No:
CITY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
-
Address
PEINBTI$IIANCe
El ® ❑.
1:1Ikya
ICENSEDCOT
LICENSED DECLARATON
t mbmdundereroWaoCamc
In hSebnf 00).iDtheBdwandofd.C.de,nd
IkeaselbInfuBforteanddffect.
CbsC.\J Lie/t
Date 11-Doo
APPIdANCFS.RFSIDFNAL
JOB ON
��
PAN
1-1 AMT'S
ARCHITECT'S DECLARATION
tundentand my pWushall be used n publlcrermin,
DYER toxo AMPS
SQ. Fr. Fl.00R ARFIJ
RETE,
f/SQ. Fr.
SIGNS FJ,ECTWCAI,
Licensed Profeslonsl
f-
RPL
OWNER -BUILDER DECLARATION
I herebyafirmth0I amexemptfromthe Coad oro Lia Lawfathe
lolbwing reason. Getlon 7m15, Buelnes and Prof�bns Code: Any tlty or
muntywhic requimaNe tomrercalter,bnpmve.demolbh,orreper
egzK9rTLIALCIRCUIT/MLSC
ZogS�
. ~.
TTMP.MEPERORPOLEINST.
_
anyetmture prior to In bsuaruq.bo requlrntheappecant (m ouch pemJt to
file a signed statement that he b Licensed! pursuant to the provbbru of the
Contratori License Law (Chapbc 9 (mmmencing with Boehm 7000) of Di".
•Ion 3 of the Bushes and Professions Code) or that he b exempt therefrom and
the h..tfor the alleged exemptica- Any violation of Setbe 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
POWF-R DEVICES -
_•
'
_ -+
SWatM1NG NOLflR
01_TLFI55WITCHES
' VALUATION
N[WRESIDENTIALEL6
fiv hundred dollar, (Stool.
NI, as owner of the property, or rtry employees with wages as their sole
-
Am.67ILWALS
TYPECONSIRLICI10N
compensation, will do the w.IA and the a csure b rat Wended or offered for
sale Gee 7061, Bou iws and Pmfessbn Code: Tlu Cordrator. License Law
UAIk
does not apply to an owns of property who build• or improve thereon, and
who dm such fork himself orthro ugh his own employees, provided slut such
RO
RES. UNITS
Improvement, are not Intended oroffered fasale. If, however, the building or
Improvement bsold within oneyearo(complebn,theowner-buiderwW have
TOTAL:
t refen of proving the he did net build or Improve for purpose ofsale.).
U 1, as, owner of the property, am exchulvely contracting with lken.ecl
cuntre,tas to came un the projet(See 7064, Buain. and I'm(eselon Code:
QTY. PLUMBING PERMIT FEE"
PERMIT ISSUANCE
FLOOD ZONE
APN
11r Comreci Limrue Lew don nest apply to e, owner d property who
builds or imp.. thereon, and who mM.M for sue], pAnjets with .
c�W�eten.)Ilanseel pe
urunttoths Cootr.dce.Lios eLaw.
IJ 1 am exempt ureterSec B & P C for this renin
ALTER -DRAIN & VENT" WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DR,V NS FLOOR, ROOP, AREA, COND.
SANITARY Y N
RECEIPT N
Owner Dee
WORKMAN COMPENSATION DECLARATION
F-11 hereby affbm the I have • artiflote, of conaent to self-biure, a a
nsa
tion Iurance a certified copythereof(Sec.
3 ,lab C.)
FD(71JRES PER TARP
-
SCIfOOLTAX Y_ N_
RECEIPTcertNcateofWorkers'Cmnperua
GAS EA. SYSTEM -1 ING40IJlLE15
PARK FFP Y_ N
RFLEITN
GAS F.A. SYSTEM -OVER 4(EA)
CmY
BUILDING DIVISION FEES
Cyned copy Is hereby famished.
CrrtNed copy b (Bed with the CRY InspMbn divieim.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(D1 tbn runt sat he completed If the pmdt b faore hundrM dollar,
PAID
Date Rccei tM
S8WTR.SANTTARY-STORMEA.700FT.
(d100) e,alcnJ
theperrsonIany of marrhe rk(orwMdicoro, subjecrmit ist booed,
lanot emplhe oy
I shag not employ any person b any ounner at n to become objet to the
WorkcCompensation lasd California.lifoia. Dee
WATERHFATFR w/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOT APPLICANT: R,.Rer wldry tMs CerHflcate of Exemptbe, you
shouldd become
come subject to the worker,' Compereelwu pmvbbns of the Iabor
Code, you roue forthwith comply with such proviebns orthb permit dull he,
deemed revoked.
Date RCoei IN
NEW R151DENTIAL PIMB. S-4FT.
TOTAL:
BUILDINGFEE
SEISMIC FEE
CONSTRR ION LENDING AGENCY •
Iherebyaflirmthatthereba construction lending agency for the perform
once of the work for which this permit In issued Gee 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
L_
Lender. Name
Lenders Address
I certify thin have mad this applleatbnand.tatelhat theabov'elnfomutlon
bm,,. l agreetocomplywith et cityand countyoNlnances and late law.
relating to Wilding construction, and hereby authortce relm entatives ofthis
QTY. I MECHANICAL PERMIT -FEE
PLUMBING FEE L
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID: yam.
`%\{N:
ety to enter upon the ab nentbred property for inspection purposes.
(We) agree to nave, inderradfy an d keep harmless Ne City of Cu perHro
ALTERORADDTOMECH.
Dale Recef tlf
SUBTOTAL:
against liabilitb,judgment,, costs and expcnrs which may in any way scour
ages Id City In mnseq.,. of the gr, rding d Wpermit.
_ lu c-,. I
70 V Lt*
AIR HANDLING UNITED 10,000 CFM)
AIR HANDLING UNIT (OVER ]O," CFM)
CONSTRUCTION TAX
rignatutre of Applicant ontracmr Date
EJ0HA0STHIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HFATINGUMT(T0100,0DOB11f)
'- Will the applicant mfuture building oavpantstore or handle herardous
maerialas deflned by the Cupertino MuniciplCode, Chapter 9.t; and the
Date RCCCI til
I -MATING UNIT (OVER IM,ODO BT -W
TOTAL:
Fleahh and Suety Codcr u�Seed. 75537(,)7 I
Yn f Na
Blthe appli.m or umr, building occupaM use equipment or devim
which rout ha ardous air mntaminsnts as cieflced by the Bay Area AIr
VENTILATION FAN GINGLE RESID)
ISSUANCE DATE
BOILER -COMP ORP OR IW,0(D BT(1)
Q.ulity Managcma. District?
Yes❑ No
o
have rd the haramous materials requirements under Chapter 6.95 of
HOMER -COMP (OVER 100,000 BTU)
the California lleaRh&Safety Code, Setbns2550.5,75573 and 75534. i
NEWRESIDFNDALMEOL SQFr.
understand that if the building don rot currently have atenant, that It b my
'
responsihdity to notify the oaupam of the ragWremew which rust be met
,
prbr io esuanceof a Certil cee.10.p.my.
"
ISSUED BY:
Owner or authorlred agent Date
TOTAL
OFFICE COPY