20753U]
`L1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification -
Building Address:
1 ✓'-LC ID612 �u.�r
PERMITNO.
,
20753..
_3
&A6
/2ff-3271y
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBING-MECHANICAL
�^A ,
1Z— W
°a aNan ,/�/�/p _�•y' ^/ Lk'
/ �'• " a'L' w ^ v r I
CATEGORY
CONTROL it
Architect/Englamr.. - Lia No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:�j _ �iJ(� .
❑ ❑
PERMITISSUANCE
ON
LICE SEDCON ACTOWSDECns
I hereby 7000) iDivisim3ofhe er Busirovland Pmfesem r9de,and e-
oiCh
Ingwith5ection 7000)of gvision3otthe Businessand ProfesdonsC-cads, end my
license la In full (a and effect. Q C
Liom lass �'t V Lk.p •J,,,s,_� �i
APPLIANCESRESIDENTLIL
JOB DESCfill N
-'
PANQ 9
ata
Data Contractor
AR
.-.
"
AMP5
OVERIO
OVER 1000 AMPS
SQ. FC. FLOOR AREA,
- 5/SQ. Ff..
Iunderstand my plans shall be used as public records.
shall records. .
Licensed Pmfeeekrul
SIGNS ELECTRICAL d"v
OWNSR•BUILDER DECLARATION'S
I herg gess n. (Sact o, 70313,
exempt from the Contractor's License LawfoAny cit or
o ywhidirequiecilan703 Wcomn c"t Profemve, e=le h,ycity it
tywhmph orlwiab vmt alorequimtheaprovntfor.bh,or ttr
any cture statement
it that ncgabore d pursuant to the provisions of t e
❑k a s ed &aliment that he b licensed pursuant to the provblom of the
Contracts License law (Chapter 9 (commencing with Section 7000) of Divi-
sion3ofthe memand Profemlam Cade)arthathebemmpttherefromand
the basisfor the leged exemption. Any violation of Section 7031.5 by any
s
SPECIALCR(CUIT/MISC
\p
111
1
•
TEMP. METER ORPOLE INST.-
POWER DEVICES t`
' 'l� 4 �
SW04MING TOOL ELECTRIC ky A (.�.'(`�
I ( VALUATION
applicant for a pe aubjectsthe applicant to a civil penalty of not rnrethan
five hundred dollars
❑ Las owner of the p rty, or my employees with wages ea their wk
comp ens atlan,willdothew andthestructure boot Intended or offered for
.1. (Sec. 7044, Budneesend assimit Code: The Contractor's License Law
doesnotapplytoanownerofp rty who builds or Improves thereon, and
who does suchwork himself or N his own employees, provided that such
Improvements are not intended orofk forsale. 11,however,thebuildingor
OUTLETSSWITCHESFIXTugpf; s
i
na C" ®
NEW RES(DEN'IIAL ELECTR _ SQ,FI':
STORIES
-
TYPE CONSTRUC7TON
- r� ` i� 1
_
�j `x" .
l`
���.� t
OCC.CROUP
RES. UNITS
'
improvementlssbldwithinomyearofco letloa•the owner-butherwlll have
_(`TOTAL:
fig-Eurden of proving that he did not bull improve for purpose of sale.).
u 1, as owner of the property, am exclus IF contracting with licensed
contomboatoccommatheproject(Sec7044,Bu eas and Profeasiors Code:
The Contractor's License Law does not apply to er of property who
builds or Improves thereon, and who contracts ( uch ploiects with a
ccacior(s) licensed pursuant to the Contractor's Liam aw.
LJ I am exempt under Sec. B & P or this reason
QW, PLUM INGPER a FEE
FLOOD ZONE
APN
PERMIT ISSUANCE F
LI 1 (�
ALTER -DRAIN & VENT- WA (FA)
- s
FEE SUMMARY
"BACK FLOW PROTECT: DEV[ E
OUTSI DE FEES
3 DRAINS FLOOR ROOF, AREA, COND. cx�
v
SANITARY Y_ N_
RECEIPT p
Owner Data
WORKMAN COMPENSATION DECLARATION
®I hereby affirm that I have a certificate of consent to self-inwre, or a
certificate ofWorkeri Compensation Insurance ora certifkd copythereof(Sec.
3800, Lab C.) �(
Policy p
FIXTURES PER TRAP -
SCHOOL TAX Y'
N RECEB'IT p '
GAS EA. SYSTEM -1 ING40UTLEIR
PARKI'EE Y N_
RECEIPT
GAS EA. SYSTEM.OVER 4 (EA)
BUILDING DIVISION FEES
-
'LjCertlhedmpybhereby(umished. I"
®Certified copy Is filed with the city Inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIHCATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thba' on need notbecompleted lithe permitblorone hundreddollan
SEWER -SANITARY -STORM EA: XIOFf.
Date Recei t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($100)or leas'
Icertify,Zd7nthe —,-of thewak forwhich this permit is lnmed,
WATER SYSTEM/TREATING s
I shall not employ any pens any manner ro as to become subject to the
Wak®s'Compensation Lawsof rola. Dare
PAID
Applicant -
NEW RESIDENTIAL PLMB. SQXT.
Date Recei t#
NOTICEco esubjettothe, oricefter rskingt rtifkrieof Exemption, you
should become subject to the Workers'Comperwt ovblom of the Lobar
TOTAL:
Code, you must forthwith comply with such provisions oftsail permit shall be
deerred revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
reby-ffirm that there aconatmctlon kodingageruy(orthe perfom�
sore o val, forwhtch this pmZ'1 b iaued (Sec. 3097, Cl¢ C)
Lender's Na
Lender's Addms
Irertltythatl havere tis appllationaM &atelhatthe above lnfomation
bcorrect. Iagreetocamplyvpl Il cityandmunly ordinances and nate laws
TOTAL, p
S leO
ELECTRIC FEE
PLUMBING FEE
QTY, MECHANICAL PERMIT FEE
MECHANICAL FEE '
^ ,.y�
J PERMIT ISSUANCE IL�W
FEES PAID:
relating to building construction, a rebyauthorizerepresintativesofthis
city to enter upon the abovcmmtioned p for inspection purposes.
(We) agree to save, Indemnify an d keep ha the City of Cupertino
against liabilities, judgments, mstsand expenses whit manywayaccrue
ALTERORADDTOMECIL
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
_
SUBTOTAL'
against said City in consequence of the granting of this pe
AIR IdANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Sigature of Applicant/Contractor Date
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fulore building occupant store or handle hazardous
-material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Cade Section 25532(a)7
❑ Yee N No
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
-
HEATING UNIT (OVER 100,000 BTU)
-
TOTAL:
VWEILATION FAN (SINGLE RESID) -
-
- ISSU#TE .
Will the applicant orfuturebuilding occupant use equipment or devices
which endt hazardous air contaminants as defined by the Bay Area Air
Quality Management District?'�
❑ Yes ® No
(have read the bazarclous materials requirements under Chapter 6.95 of
'
AU(i '
AU(i
BOILER -COMP OHPOR 100,000 BTU)
ll.1v
' BOILER -COMP 100,000 BTU) Q_
L
the California Health&Safety Code, Sections 75505,75533 and 25534. 1
that lithe building does not u otly have atenany that it is my
rmpomsibllitx to notify the occupant a( th�uiremenls which must be met
'
NEW RESIDENTIAL MECH. SQ17
,prior to suan aCerti at (Om ny
i O
ISSUED BY vV)-
.Owe rorau lud agent - to
TOTAL:
OFFICE COPY