22360APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE, BALL POINT PEN ONLY J
BuiWl"X Project Identifkalon�� �iNE
Building Address: V
PF3Ih9TNO.
Z35wo 61 ro o A� c
Z 2360
e one
a P
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Con"cun'. Name: Lie. No:
BUILDINGELECTRICAl (PLUMBING -MECHANICAL
CATEGORY
CdNTItOLIt
A ft /Englrecr. Loc No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
P4RMITISSUANCE
❑ ❑ 1�( ❑
I+ V
LICENSEDCONTRACTORS DECLARATION
I Mnbyion 700D)Ofamt vWm3ofthesed udp ands CT.ptCod,andm
ingwithce..hSection 7000)ol Divfeot. he BuNneuand Professias Code, and
AP['[lANCFSRESmEMIAL
JOB RIIrf10N
license b in full d died.
License Lk.e 3
Drte Cerium .1 Yaa9.'7
PANELS
�� W,
il]-1000A.
ARCNITECTSDECLARATION
JOVERIUDOAMPS
SQ. FF. FLOOR AREA
f/SQ. F(.
Iudcrat.nd my plum elrB be used a a public moods.
SIGNSELECIWCAL
Licensed Profembnal
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that l am excerpt from the Comractorb License law for the
i`i i1L
f�
TEMP. METER OR POLE INST.
�
_
l my hrc re.(Sectioe7 wBwln®and Prof ionsemle: arr"r
tountywhich requimaprmJtmrovwa[, alter,lmprwe, demolish, orrepalr
anyatructum prlo W k, Uwarce, aim requires the appllont fowch permX to
Bk . signed statement that M it licensed pursuant W the provisions of the
s
Per M�
����
Contractor's Llcure Taw (Chapter 9 (commencing with Section 7000) of DW6
sion3 of the Buslnm and Profeslom Conic) or that he le exempt therefrom.ndLOO
VALUATION
the basis m
for the alleged exemption Any violation of Section 70313 by an
bjea the applicant to a civil d more ore than
applicant fora Perrot wdpenalty
O Ii1S
r
l�W Z
It wired dollars OLS00r.
L as owner of the property, or my employ. with wages., their wk
STOWFS
TYPE CONSTRUCTION
ompersatim w0l do the woh,and the strutlu , b not Wended or offered for
.In (Sac 70K Buvinm and Prdesbns Cade: The Ccumactols L1ame Use
'
don not apply to an owner of property who builds or improve thereon, and
who dmauchwor4hlmselfort1rough Msown employee, provWed that well
OCC.GROLIP
RES UNITS
Improvements an not Intended oroffend!cine. If, however, the building or
Mpmovement bald withinorcyesro(canpldbn,tMowner-0uildmMB have
'TOTAL:
t rdenofpmvingihathedid rotbuddorimproveforpurpoveofsale.).
Lj 1, a. owner of the property, am exchWatveoy awn —ung __lioeneed
mntrun loto mrstruct the project(Sm 70K, Business ad Prdesons lCode:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
MN,
The Contractor'. License Law don not apply W an ownm of property who
Wilds or Improve thereon, and who contracts for suchJun)oca with
cpUaclur(.)licensed pursuant W the Contractors Licerre Law.
L -J 1 am exempt udm Sm B k P C for this reason
�� DRAIN k VENT - WATER (FA)
BACK Flaw PROTII`['. DEVICE
FEE SUMMARY.
DRAINS FLOOR, RODE, AREA, COND.
SANITARY Y_ N_
RECEIPT R
Owner Date
WORIOvIAN COMPENSATION DECLARATION
I hereby affirm ifl
that I have a mr ate of convent to self -Lars, or a
Tote of Workers'Compemwtlm lrmnance oaaertlfled ropythenof Roc.
Iblky Y' �GZ��Y O
FD(TlIRFS PER TRAP
SCHOOLTAX Y_ N
RE= Y
GAS E.A. SYSTFDf-1 INCAOUTLM
PARK FEE Y N
RE{FS'C Y '
GAS EA. SYSTEM -OVER
Certlfi�copy'b7�4rcbyP WeS'
edlBed mpybflled with the dtylnspedWn dlNYon.
"•""����
BUILDINGA(PA) BUILDING DIVISION FEES
GREASE/INWSiRI. WASTEIMFRCEP'fOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OFEXEMPFION FROM WORKERS
COMPENSATION INSURANCE
(Ddamctbn need not be completed BIM permit b fo ore hundred dollars
PAID
Date ACCCI t#
SEWQ45AMfARY SNRM F.A. S>tQ"f.
R1ao rWys
ll or le thrt W the per(ormano of the work farwNch lis pcmdt b lswed,
I
WATER HEATER W/VENT/ELECIR
ENERGY FEE Y N
1 serol eat employ any.Lawn io any manner at u W hemme wbfcct toted
Woken Compersatbnlaw. o(CaWombDate
WATERSYSTEM/TREITIEG.
PAID
Applicant
Date Reaei Ht
NEW RESIDENTIAL PLMB. SQ17
TIC
NOTICE TO APPLICANT
IW: E, after making th6 CertBicate of Evemptbn, ya
should become subject to the Warken CornpensrtWn pwvlslom ofthe Labor
TOTAL:
Code,ydou okfwthwhmmplyMWsuchpmWbmorthbpemdte bedeeme
rev
1
CT AGENCY
CONSTRUION LENDINGFE
SEI IC E
Ihereby.ffire, that then 1, a constm otton lerd Ng agency for the perform
sem of the work for which this permit It Issued tSec. 3097, CW. C.I
I<ndele Name
1<nderi Addms
1 onifythat I have nadthbapplicatbn •d sslothrtthe above Infarmatlm
bcorms. I agree to comply with all cXy ad county ordinances and sate lava
nyp�
ELECTRIC FEE a
PLUMBING FEE A-
_ey�—u/
Ti'— J—
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:'
relating to bulWing mnstnuctlon,and Mnby.wholr rtpmenntatWnofthls
- \
-' a
dty to enter upon the abavo-mentbmed pmopertyfo inspectjon Purpose,.ALTERORADDTOMFLH.
(We) agree W save, Indemnify an d keep harmless the City of CupenW
Date Recei tX
SUBTOTAL:
agalmt WbWtb,ludnrs, coseand eapensn which myNtm
anywayaae
agalm IdC granting dthb pemdt.
AIR HANDLING NC DNIT (T010,000 C
AIR HANDLING MIT OVER IO,(00CF.N)
CONSTRUCTION TAX
SlgvWnaf p ant m
E(HAtzI FIOOD(W/Ducn
CONSTRUCTION TAX PAID:
URDOUS MATERIALS DISCLOSURE
HEATING UNIT CIO 100,000 BTU)
will thea. cant or WWre building oacupantatonor handle h—rdou,
material as definsd by the Cupertlro Municipal Code, Chapter 91], and the
Date Recti tN
DATING UNIT (ovER ifloxD BTI()
TOTAL:
Health and Safety Codep4dum 75531(a)r
nYn fANo
VENTILATION FAN (SINCLE IiESID)
ISSUANCE DATE
..
El the applicant ceReurebu0ding occupant use equipment «devim
which emit havrdou, air nmtamlnsmds, a drfived by the Bay Arca Ab
BOR.FR-0DMI'PER'OR100,(1(q BTU)
Quallty Managemed d7
Yn � ((``�3����QQttr��Nb
95 of
test wt mode,
neons
BOILER-COMP(OVFR I03,000 BTU)
California Health Se 2555,2553caC 255M.
Code, Sections 25505,25533 Satandt,tI
NEW RIDDFN77AL MEIN. SQFf.
ur emuurd
undoniolfty to 11 building tI1
that it Is my
building don ndarequirmnts
notify
notifythe occupant dthe requlrcnrda which must be met
which
mistto
ua c
prbrto uanmd rti t panty.'
,
ISSUEDB
erorauthorf gent Date
TOTAL
OFFICE COPY V