19835APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Huflding Project Idemllkatim
BuRding Address -
v� � 1
1'FTiMIT NO.
19835
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trae"or Na� .N«
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION if PERMIT
CATEGORY CONTROLy
.713 1 J
A L VQ/f�SS ISO ASA
/ A Lk N.
BIlf1AINGELECIRICALPLUMBWGMMIANICAL
QTY ELECTRIC PERMIT FEE
a
BUILDING PERMIT INFO
Address
❑ ❑ ❑
PERMTTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm00()hatl amlkan3 ofthe erpr,iaand dChapler9 (commenc
ingwlt`Sedto 7000)°Divlstm3oflha Bustnmamd Pro(eastoaCode, and
AI'PIlANCESItE_SIDF.NITAL
JOB N
,
14mr b In foil fo�E and d(cR.
LTff
Lbenx Cbae �j_Lle/�
PANELS t
Dale 'C'pD�_7� rtraRorL
1-1 MI
ARCHITECTS btEnAWN
I umdentsnd my pis _ - -li be used u pubbe rtmrda.
OVER IODO AMPS 177 p glit
1
FtrTN
$/SQ. Fr.
SIGNSEIEC RICAL O L a,
Licensed Pmfmional -
11
OWNER -BUILDER DECLARATION
Thereby dflrml License Lw fat he
^
�, ••
R
SPCCIALC RCUIT/MISE
7FA:P.ME177iORI'OlEINST.
following ream. (S ap 7 to Bu me and Pimp be, Code: My city or
icrm31.5, R.io.eComfensioa
mrntywhlchpe R,dtenapbvntfnaorrtpalr
9
(�
any at ruredatamtolbbuarre,.beAsed rtma ttothe t fmsulom of t e
tosaperedt oto re
floe a :Igoe° m t that lu b pursuant to the provbbm of the
POWER DEVICES
SWIMMING POOL ELECIWC
�E.��.C.ES�ES
nae, L r 9 (cord
Contractor's3 ofthLkeims and rofmi r9 Code)
witels Section 7000) mpttherefof and
h of the Businmond Prdmbra Code) orthat he b essmpt therefrom and
theivt-
m any
are bub for the alleged jecUthe a. Any Wolstbn of Sectinatty not room
ap:t o.dforapersubj:amthe applk:ntto•dvll perultydnot mon than
_ VALUATION
— l 1 (r a
5-5-16(n,
�J J (�
NEW RESIDENTIAL EI"F-CfR SQ'FC'
dollarsthe pr . '
fiU 1, as
❑ I, u owrnr of the property, or my employees with wage u tktr scab
STORIES
TYPE CONSTRUCTION
compensation, wit do the wmk and the azmcium b not Intended or offeredfor
\ 1
ale Ike 70K BueStru and Pmfmbro Code: theG
Coritraole License Taw
�/ _kJ
does not apply to ao owner d property who builds or improves thereon, and
who doeasuch work hlmeelf or thr«rgh his awn employeea, provided that such
OCC. GROUP
RES UNITS
impmv norm an not intended mattered fmsale. If, however, the bulldingor
neem lssold wlthlnoneyearofccanpldbn,tkovnerbuBderwlB have
TOTAL -
yt _7L_Improv
V
tfCIi+rdenofpmvingthal he did wtbulldorimproveforparposeofule.).
lvely ntro rg with liceruad
U 1 as owner of the property, am ettWem
contractors W matrod the project (Ser. 7011, Bualnm and Pto(mbru Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
AI'IJ
PERMIT ISSUANCE
The Co&ndarl Llmrm I.w does net apply to an owner d Property who
builds or Improves thereon, and who mMram for such p(ppots with a
cqaITac1or(0 Brensed pursuant to the Cmtrarme's Llmrue Law.
U 1 am exempt under See. B & P C for this rtron
ALTER -DRAIN& VENT- WATER TN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OOT91 DF FEES
DRAINSFLOORROOF,AREA. COND.
SANITARY Y_ N_
RECEIPT /
Pvvar Date
_ WORKMAN COMPENSATION DECLAMTION
F71 hereby affirm that I have a aerHffate d consent to x8 -Wort, or a
oerti(Irtle of Workers' Compematlm Inerranm ma mrtifled mpythemof (Sec.
3800, Lab
Paley/
- SATRAP
BCI -TOOL TA% Y_ N_
RFOEIPI' /
GAS lA.5YSEM-I INCA OUTLETS
PARK FEE Y_ N_
RECEIPT /
ens Fw. SYSTEM-0VFR 1(EA)
Cam ny
BUILDING DIVISION FEES
CeniRed mpy Is hereby furnished:
enRied ropy Is filed with the city leopeetbn dbAaim.
GREASE/PJDUSTRI. WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhbaeabnneed nothecompletedlithe b!moshundreddoWn
AID 'x
Date Remi ted a'[
SETVFRSAN)TARY-STORM E.A. 2DUFT
WATER HEATER W/VEVP/E].FLTR
ENERGYFEE Y N
0100)mlea.)
laertifythatlnthe perfomunmoflhevaorkforwM&th permRbtsaved,
WATER SYSlT2.f/TREATING
I ahau not.mPlay, any penin many manner n as to berome subjed to the
Worker(u
Compentbn Laws o(CGIRonb. Date
PAID
Appllant
NOTICE TO APPLICANT: If, after making thb Certificate of Excmptbn, you
NEW RESIDENTIAL PLMB. _SOFT.
Dale Recel ted
TOTAL:
should become subject to the Workeri Canpemathm pmwlalons of the Labor
Code, you rruat forthwfth comply with such pmWa. or this permk:hdl k
13VILDING FEE 61.00
deemed revoked. -
_
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
lherebyall'i hattheets mutmdimlMingagenryforthepedorm
anm d the work for whish this pemnn is owed Bee 30V7, Cl, CO
Ieedee' Name
Iendee.Add.
IronlfythAlhavereadthlaappllotbn.M.tethattheaboveinfor on
h onmxf.I.greeto comply withal dtyu,d countymd .r...d state lawn
- TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relatingtobuildingmvtrunion,and herebyauthorfurepnsentath softhis
dtytoenterupontheab,memmtbned propertyfor Wpmabn purp«xa.
(We).gee to save, indemnify an d keep harrrdca the City of Cupertino
ALTFRORADDTOMFCH. -
Date Receipt#
SUBTOTAL:
agml llab[htln,}rdgm nt;c samdexpena ichmaylnanywayamue
AIRHANDUNGUNIT(TO10,000CFM)
against sild City In mnsequeroe of the granting d this permit.
AIR HANDLING UhTT (VQt 10,000 CFM)
CONSTRUCTION TAX
Slgu prom/Cmtnotm to
E)CRAUSTHOOD(W/DUC)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCIDS URE
HEAT1NCUNTT(T0100,(00BTU)
Will the applicant or future bueding o pant mom rehandle ha—rdous
material as defir ed by the Cupertino Municipal Code, Chapter 9.17, and the
HealthandSafety Code c
ion 75537(a)7
lllthcappu.mwgmmbuddinga pantuuequipmerumdr oea
which emit havMoua air mob mbunb.a defined by the Bay Area Air
Date Recei t#
HEF FTING UNIT (OVER ioaxo BTO) -
TOTAL:
VENTILATION FAN (SINGLE. RESID)
ISSFYWATE
BOILER -CLOMP OHP OR 100,0(9 BM
Oua thy Management D'utdn7
ThaYn ,o
ve readlheha>s matedab rryulrtmenb underehapter G95 of
�.,ial\ wa 1 1990
BDILERIUMP(OVEIt 100,000 8711)
the California Health & Safety Code, Sectbm 75505, 75533 and 75530. I
undo: Mthatifthebulldingdon'natmmntlyhaveatevntthatitkniy
responsibility to notify the ar pain&the mquimmenb which crust be met
City Bf CBBertino
NEWRESIDENTIALMECH. SQ.Fi
prior to lauaroe da Certiflate d Oce puny.
ISSUED BY: Va O
Owner or autheried a gent Date
-
TOTAL
OFFICE COPY