19964 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Addreuuildln ProId B(btlm Do CST' PFRMITNO.
�►j -7 r PF- 19964
nets .: one:
CITY OF CUPERTINO-BUILDING DIVISION
• cmtado .Name: x.N« APPLICATION I PERMIT
ND BUILDINGELBCnCCAUPLUMBWGMECHANICAL CATEGORY CONTROL,/
Areldtee E6iBFsen «
BUILDING PERMITINFO
_ Q - ELECTRIC PERMIT' FEE
Address 60 ITURT 7T
PERMITISSUANCE ® ❑ ❑ ElLICENSED CONTRACTOR'S DECLARATION
IherebyafflrmthatlamlbenaeduoderP.Ed...f CI.Pm,9(.c APPLIANCES RESIDENTIAL OB DESCRIPTION
Ingwith Section70W)of D( .3ofthe Btol.and PmkvlornCode,and
Ike.b In full torte and effer PANELS
Lloenue Clea Lk.0 _
Date Contranor [•'�u ' t....
ARCHITECTS DECLARATION 1-1000 AMPS
0x I uMerateM try planaalWD be rued n public records, OVERIWOAMPS SQ.
.Ff'.FLOOR AREA S/SQ.FT.
UNwan LImnaN]hd®bvl SICNS ELEC]RICAL
that
IAn-BNLDEiI DECLARATION SPFCJALCDtCUIT t
71.., G Iherebyaffirm Sectiom31-5,Rn;linm I. eCo ehmir's Cave AnyLaw for he
o
following rearm.(Section 7m15,BuaNes and Pro(obro Cade:Any tlty or
r4 cauntywhkhrequbeapemdtrocorot Mu to ,Improve,de=n h,ormpalr E11P.ME ER OR POLE
anysvucturt prior to He bewrce,alwmrybn lheapp0ant for ouch pemdt to
POWER DEVICES
Me a tlgned mtement that he b Bayed punuant to the pmvbloro of the
Ow Camraole nae LkeLaW(Chapter 9(commeadnSection."Sen 7000)of Did-2 n3ofthe Bu Mneaaand Prdes th
CMe)orehebexemVALUATION
pttherefmmAdi SWIMMING POOL ELECTRIC
1- dod
yIt the haab for the alleged exemption. Any violation of Section 7MI S by any OUTLETSSWI7OH1SFIXTURFS r� G�
{jy�,�.•, appbantfor.peromeub)«v theapplinam too idyll penalty ofnn moa than eG�
five hundred dotlan(S50Vj, a
�j.. ❑1,as owner ofthe property,or my empk*e with wageastheirwle NEW RESIDENTIAL FT FCR SQFr. - STORIES TYPEOON.SRUCION
C rnmpevmon,will do the work and theatmdu m b cot intended or offeredfor
O
In Lee 70K Bu.b and Ptvfeebro Code:The Comndots LIaroe law
s$ don not apply to an owner err property who builds or lmpovn thereon,and
6 who donsuch Work hlmxforthrough hbownemplgee,provided that such OCC.GROUP RES UNITS
Improvcmenta art nrot Ntended oro(frrtd(m rale.IL however,thebuilding or TOTAL,
Improvemembwld withinoneyearo(cmrpletbM1theavner.bullderwillluve
Xenofpmdng that he did nawud or improve for purpo.e orate.). QTY. PLUMBING PERMIT FEE
Art al
as wvnrr of the property,aereluvey contra ng with licensed FLOOD ZONE APN
ore to corotmd Ne projed(See 7004,Bu,,oeA MPrdesbv Cede. PERMIT ISSUAIJCE
The Contadots I.1¢nae LAW dm not appy to an own,r d Property who ALTER-DRAIN 4 VFM-WATER(F.V
' hullde or fmpmvo thereon, and who commm far and pt'o)eda with a
oqn¢i,da(.)Baexd pursuant to the Cmtradnla Line.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt order Sec B&.P C for thio reams
OLMSI[)I.FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
S Owner .D - RECEIPT e
WORKMAN COMPFNSATIRATION FIXNRFS I'FR TRAP SCI100L TAK Y_ N_
❑1 hereby af(Irm that I have a oenffk An d consent to serf-byre,ora R��,F
aifia
rtte ofworken C.Ptneotlon Into rano ora artBkd copy theneaf(Sec.
3 ,Isb CI GAS EA SYSTEIIINCA 0UTLE75 PARK FEE Y N
Powy T CAS P.A.SYSTEM-OVER 4(EA) RECEIPT M
Cny BUILDING DIVISION FEES
omECertifted copy b hereby fumbled. GREASE/NDUSIRI,WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b flled'Mth the Illy Iropectbn division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEVER-SANITARYSTORM EA.31A'T Date Recd t#
ffNalinerthecompleted Rthe permit bfor ore hundreddoBan
(ElMal.es,).) WATER HEATER W/VENT/ELECIR ENERGY FEE Y N
I sthat bthe pnr oonaof the work for watch thiopemW Moaned,
I duo not ns,employ any person In any ob bme u ecoubje t to the WATER SYS VM/.IRIATING
warke�camw
petlnn law,or California.a.mtola.Date PAID
0 Z Applicant NEW RESIDENTIAL PCMB. SQF. Date Recei tk
Z O NOTICE TO AETICANT:H,after making tNt CertRlote of Enemptloq you
F
N
should bcmme subject to the Workeu'Comparoation provbbe of the Labor TOTAL:
� deemed!CMked.
kh recopy with such prwWoro orthb peodt ebatlbe
� ed rewked.
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a mrocrodlm kMing ageuy forthe perform ELECTRIC FEE
7 Z ance ofthe work forwMch thbpermit b baned(Sec.3 ,Cw.CI TOTAL
U O J. rdero Name PLUMBING FEE
ly I
F- CMer'e Addre.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcertlfythetltuvereedthlaappBa n.Mslatethetheabovelntormation
b Correct.I agree to comply with-11 dty and courtyon1tner.and Mate lawn PERMIT ISSUANCE FEES PAI D:
tea ' trial"to building Coetruction,erd hereby authorbe representative of thio
F•. Z dty to enter upon the abovireentiuned property for Wpenbn purpoeea. ALTERORADDTJMECH. Date RLYCI tk
_ (We)agree to save,iMerradty an d keep harrnl a the City of Cu pentW P
agabot Babibtkn,Ndgmenta,nnas a nd n penes whkh troy N any way.mue AIR HANDLING UNIT(TO 10,000 CFM)
agawt told City N Conwque.of the grandfiJ,of tlda prod. SUBTOTAL:
AgdU/h �ep -Zyzb �4� -Y �b AIR HANDLINGUNIT(OVER 1o,000CFM) CONSTRUCTION TAX no
Sigvtureof Appuant/a -ca-m `7-/ rl Date / EX USTHOOD(W/DLCO CONSTRUCTION TAX PAID:
HAZARDOUS MATER ALS DISCLOSURE
WBltheappllant or futurebuddingoecupantstoreorheMk haranloue HEITNC UNTTOO100,00013M D to RCCCI IH
rruterfel as defirved by the Cupertino M.Mdpal Cede,Chapter 9.12 and the
Health aM Safey Cade Sea1m 25532 W F FffATING UNIT(OVER 100,000 BM TOTAL:
Ye r]No
TY Bl the applicant or ftture building o pant um equlpmem or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
whkh emit havrdous air rents,Mrumea defined by the Bay Area Air 'I u
Quality Management Dbtrid7 BOILER-COMP OM'OR 100,(X9 BTU)
Yn n❑No
t Ilu,e read the haramous materials requirement,under Chapter 6.9S of BOILER-COMP(OVER 10,000 BTU) rs
theGluomla Health 4 ss,req'case,Sedloro 255(5,25537 and 25534.1 'Ity of CtIBP.r�inryJi
unrl Lard that if the building don not earrently have it tenant'that It b my NEWRESIDENIALMECH. SQ.FT
ro poroibility m natty the occupam of the requirement.which uA be reel
prior to bsuancc oft Ustifiata of Oce pa y.
Cwncrorauthorlaedagent Date ISSUED BY: Va...0—YIW\ Ct+
TOTAL:
OFFICE COPY