26762O
Z Z
N
it -
W
IL CI
Z
U O
LL U
Ow
} y
A
ADDITIONAL PERMIT FEES
.rr.
Bth LDING PROJECT I DENT[ FICATION
VALUATION
FEE SUMMARY
BUILDING
OWNEP'S
HP ^�E j
�l PHONE
BUILDING
CONTRACTORS
LIC. NO
PLAN CHECK
FEE
r,ONT4ACTOR S
ABDPEU
PHONE
SEISMIC FEE
OTY.
- ELECTRIC PERMIT
FEE
4i
OUTLETS - SWITCH ES- RECEK,
1
LIGHTING FIXTURES
PLUMBING '
i
PPLIANCES - RESIDENTIAL r
PANELS -
MECHANICAL
^
SIGNS
TOTAL
SIGNS TRANS.
SPECIALCIRCUIT 7
"`_
TEMP. METER OR POLE INS.
PERMIT VALIDATION
ISSUANCE DATE
MOTORS - SEE FEE SCH.
SERVICE CHANGE
TOTAL
QTY.
PLUMBING PERMIT -
eLOC.
ELECr.
ItJ.
rLC�
MECI
ALTER -DRAIN & VENT -WATER (EA.)
BACK FLOW PROTECT. DEVICE
/1t'�fj �'i['�'•
k
tl
® '
P A,
us
- 3 1994
{/{i
YVI' byf-cn I IjvU
i
'
DRAINS - FLOOR, ROOF, AREA.COND.
FIXTURES - PERTRAP
GAS -EA. SV STEM- 11NC.90UTLETS
GAS - EA. SYSTEM - OVER 4 (EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS - 1 INC 5 V.B.
LAWN SPRINKLERS - OVER 5 (EA.)
SEWER - SANITARY -STORM EA. 200ft/
WATER HEATER W /VENT
WATER SYSTEM
WATER TREATING EQUIP,
QTY.
MECHANICAL PERMIT
FEE
^
ALTER OR ADD TO MECH.
APPLIANCE ..-
AIR HANDLING UNIT (TO 10,000 C F.M)
10=C.F.M.)
AIR HANDLING UNIT RDUCT
'
EXHAUST HOOD WITH 4
HEATING UNIT (TO 100,000 B.T:U.)
HEATING UNIT (OVER 100,000 e.T.U.)
VENTILATION FAN (SINGLE)"
BOILER - COW 13 H.P. or 100,000 B.T.U.)
BOILER -COMP IOW, UJITODO BTU) SEE
TDTA
µAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OFCUPERTINO B IL; C -ELE TRICAI.
DU OF C DIVISION APPLICATIOWPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENF'ICAT'ION
TI
PERMIT NO.
°
26762
BUILDING ADDRESS:
SANITARY NO.
AMT- ICATIONSUBMIDTALDATE
6 ZA Til LOT#
OW E S
CONTRACTOR'S NAME LIC NO:
N/C
❑
CONTROL#
RCHITCJ GINEIR: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY.
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
PERMITISSUANCE
El
❑mz
900
;66
Qz
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that l am licensedinderprovi siomof Chapser9(commencingwith
Section 901 Division 3ofthc Business end Professions Cade, and my license is in
full force it effect.
License Class Lic.p
APPLIANCES - RESIDENTIAL
PANELS
UP T0200 AMPS
JOB DESCRIPTION
a��
Llw\ �-�'11//
q6
7y^
Z
A t�s
Date Contractor
201. TWO AMPS
ARCHITECTS DECLARATION
1 undemtwJ my plans shell o uwA es public records.
OVER 1000AMPS
SQ. PT, FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
y
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT /MIST.
�yU
LL y
Oy
1 hereby affirm chat I am .exempt from the Contractor's Co License Los for the
following reason. (Section 7031.5, Business and Profeaaions Code: Any city or county
TEMP. METER OR POLE INST.
h ¢
!� }�
�i ,,, O
io�
5_m
.z¢
F 0
Y m°
y',3.
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires theapplicam fmms h pemtuo file is signedauitcment
but he is licensed pursuant m the pmvisiav ofthe Cimmuca 'a License Law (Chain.
9(commeneingwith Swdan70M)ofDivision3ofthe Rusinusand Professions Code)
orthat he is exempt therefrom and the basis far the alleged exemption. Any violation of
Section? 031.5 by wy applicant for a permit subjects the opplicenna acivil penalty of
a Nan Bve hundred dollua (5508.
ownerafthepropeny , mmyemployesswith wages istheirmiccompensation,
ill clothe work, and theswcture is not imendedorofferW onsde(Sec. 7044, Business
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FTKTURES
NEW RESIDENTIALELECIR_SQ. PI'.
STORIES
IYPF:CONSTRUCI'ION
and Proressom, Code: The Contamors License Law does not apply to an owner of
property whobuildsorimprovesthereon, and whodoessuch workhimselforthrough his
wnemployces,provided that such improsemenrsa enotiatendcdoroffered forsale. If,
OCC. GROUP
RES. UNITS
.p
however, the building or improvement is cold within one yearafcampletion , theowner-
builder will have the burden m pmving that he did not build m improve for purpose of
sale.).
❑ I, as ownerofthepmperty, amcxclusivelycontracting with licensed contractors to
Q
PLUMBING PERMIT
FEE
FLOOD ZONE
APN
construct the pmjcct (Sec. 7044, Business and Professions Code:) The Contractors
License Lawdoesnot applymanownerof poperty whobuilds or Improves thereon, and
PERMIT ISSUANCE
whocommew forsuch pmjicts with acontreetaEdlicansed purumt mthe Contractors
License Law.
ALTER - DRAIN &VENT - WATER (EA)
FEE MARY
❑ 1 am exempt under Sec. , B & P C for this meson
BACK FLOW PROTECT. DEVICE
'
'eita, Y N
Owns Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR. ROOF. AREA.COND.
RE .IPTil
SCHOOLTAK Y N
❑ ,hereby affirm that l have. cerificate of comsemmself -i ... m mucenificmeaf
Workers Com pensatianlnsuranceora ceniftedcopy thereaf(Ses. 3800, Lab C.) which
'lovers all employee's underthis permit.
Policy M
FIXTURES - PER TRAP
OAS -EA. SYSTEM -I INC.401YLES
REC Pfp
PARK FEE Y N
RECEI #
BUILDING DIVI ON FEES
Company
GAS - PA. SYSTEM -OVER 4 (PA)
PLANCHECK FEE
ev
❑ Certified copy ishcreby furnished.
GREASUINDUSTRL WASTE INTERCF OR
DING PER
[3 Cenitied copy is fled with the city inspection division.
CERTIFICA9'E OF EKEMPDON FROM WORKERS'
GREASETRAP
\))'SO!!4
FA
COMPENSATION INSURANCE
SEWER - SANITARY -STORM EA.2
PT.
�N
(This section need not becomplered ifthe permit is Income hundred dollars (SIM)
or less.)
WATER HEATER W/VENT/ELECTR
I certify shot in the performance of the work for which Ws permit is aided. )shall
not employ any person in any manner so as to became subject to the Workers
PAID
WATER SYSTEM/IREATING
Date Receipt#
Z
Q
ti
Compensetion Lawsof C.1homi.. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate, of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. S
TOTAL:
Forthwith comply with such provisions or this Permit mail he deemed revoked.
SEISMIC FEE
I A
CONSTRUCTION LENDING AGENCY
0
I hereby tiff rm thm,here is u construction lending agency for the perf.ce of
the work for which this Permit is issued (Sec. 3097, Cis. C.)
Lender's Ntime
TOTAL:
ELECTRIC FEE
QTY.
MECHANICAL PERMIT
FEE
PLUMBING ME
Lender's Address
ha
4
y
Z
1 certify that 1 have read this application indicate that the shove information is
cortect. l -greet- mm plywithallcityaad county ordinances and suite laws relating to
looddingcnnswaionculd herebyauthorserepreamactivesofthic city mrntutipon the
nose- mentioned roper , for inspection purposes.
(We) o ee to save, indemnity d keep hertnlaa the ity of Cupertino egdnst
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
liabilities' - nu.cosJe hinny ace agaimtad City
AIR HANDLING UNIT (TO IO,p GEM)
are of the grentin
7
AIR HANDLING UNIT (OVER TOMCFM)
S nat re of Applicant/ ontrartor Dune
EKHAUST 110013 W/DUCn
PAID
HEATING UNIT (TO $00,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will the applicant ar future building occupam store or handle hicumous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
TIL VENATION FAN (SINGLE RI'SID)
Code, Section 25532(a)^
11 yea 1:3 No
ISSUANCE DATE
Will the epplicantorf murebuildingoccupentuseequipmentnr Jeviceawhich emit
BOILER -COMP 011E OR 100,000 BTU)
BOILER - COMP (OVER 100.010 BTU)
saasdous air concentrations as defined by the Bay Area Air Quality Management
istricR
f^t pp
r cy 1
NEW RESIDENTIAL MECH.-SQ. PT.
❑ Yea ❑ Na
I have read the h.dous materials oupor scents under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.25533 and 25534. I understand that
If the building does not currently have a tenant, that it is my responsibility to notify the
a1/ ,
��
Cpp ai
V
occup.nt of the requirements which must be met prior m issuance of a Certificate of
, / (Jh
Occupancy.
rlV
ISSUED BY:
Owner or amhoriacd agent Date
TOTAL:
OFFICE