20005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Pro en Iden1 .1 PERMIT NO.
gnBa2A 20005
eine: me
CITY OF CUPERTINO-BUILDING DIVISION
Cortndor's Name:
Lin,Na APPLICATION I PERMIT
BIIfLDINGp,ECIRICA41'LUMBINGMECHANICAI. CATEGORY CclkiTilol,Y
A et Engineers No:
�-'
/^ QTY - ELECTRIC'PERMIT FEE BUILDING PERMIT INFO
� -
Add. 8 � ` S r PERMITISSUANCE ❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION
Inrtby affirm that lamlken d under pmvldmuofOupler9(avnmmc 'APPLIANCESRFSIDEMfAL JOB DFSRQTIDN
Ine,u,e Sed/onto.afDivLdon 3otthe Buau:eeand Pm(mlaruCode,snd my
Borns,b e fun for¢and died. PANELS
Lienee Ct. ("36 Lk.# 227 62 -
Date_6 /')O /nn c.ad,ador UP TO 200 AMPSP✓1 1 '1
ARCHffECI'SD 11C81 201-1000 AMPS
NO ZpO I understate my pluu shad be ue<d a pubnc rtovda OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k (/ Li¢ned Pmfceelorul SIGNS ELECTRICAL0
<<�61 OWNER-BUILDER DECLARATION SPFLIALCIRCUIT/MISC ✓ �' I
zF' � IherebyaHlrmthatlamesemp[from the CurrtraRorb Lkerue Lw(wthe � � a.� +
p o loaowing rcanon.(Sedlm 7L015,Busher and I4o(eabna Code:My tlty or K
FZC muntywhkhrequroapem totnMxua,alter,lmpm ,demolbh,ormpalr �P.ME
OR IDLE IN
anyetr mmpMrtolbfe me,aMrequbalheappnantfaraudipe tto POyERDEVICES
O file a signed statement that he Is nonmed purauant to the provisions of the
w -
C..Mmr',Lice.Law(Chapter9(comewaded
ng with San 7000)d Dwi- VAIL
30�^ sion3ofthe BusinemandP mbroCWe)orthahebe therefromand SWIMMING POOL ELECTRIC LUATTON
O ted dab for the alleged esemptbn. Any vldatlon of Setbn 70015 by any OVILEISSWITCFIESFIXMRIS
appBcamJatfora pebjedatbeappB ttoadAlpevhydn¢montha
Me unof dred dollen(5.500). NEW RESIDENTIAL O.ECTR SQFT. SIORI6 TYPECONSTRUCTION
cv I, s owner the property,or my employees with wages as their sole . .
mpewtlm avW doth,work and thearumnre b rot mt<need or offered for
OBale]Sec 7014,B ao era and f bro Code:The C fin provet Li¢nu I�w
does red apply to res owrcr of throngproperty who builds or improve thereon,and
who d«aauchwarkhimxNorthrough his own emplvyees,provided that such 'OCC.GROUP RES,UNITS ,
Impnevementa are not Intended oroflered(ornate.If,however,the building m TOTAL
impmvement bmO mthinomyearofcomplelbn,theowner-bullderwnl hove
tFTn-�1rdenofpm"thathedld rotwudorimproveforpurpeneof.ale.). QTY, PLUMBING PERMIT FEE
_I L as owner of the property,am excluaively cvvtrti
ang with licenced - E-FLOOD ZONE AIW
I_
mntraeton to mradrud the projed(Sec.7044,Bushes and Profmaoru Code: PERMITISSUANC.E .
The Countorb Linc Law dm not apply to an owner of property who - ALTER DRAW kVENT12100
-WATER O+NN
Wilda or improve themon,and who mmram for such p,jee,wkh a - -
c1,14ad.n.)ll¢naed pumnnt to the CmtndoYr Lice.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I sin exempt under Sec B k P C for this TenonOIJTS I DF FEES
. Owner - p� DRAINS FLOOR ROOF,ARFA,GOND. SANITARY - Y_ N_ .
��,a(( WOR"AN COMPENSATION DECLARATION Y
/I}3L hereby affUm that I have a aertifi¢le of consent to eeB-Were,or a FXR5��' SCIiOOL TAX Y N_
*¢¢kit AFCE11`T 1
Ificete of Workue'C¢nperurtlmlruuranoema¢elfkd copy, (Sec. GAS LA.SYSTE1i-1 WC40UTLE15 _ PARK FFE
Y N
3glyib CJ "
Palirya ] GAS EA.SYSTEM-0VEtd(EA) RINGDIECEIPT A
Com rev __ BUILOWGDMSION FEE9
reified ropy b heed wide the
- - GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy b filed with the city Inepeelon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP' PAID
COMPENSATION INSURANCE S�"R-SANTTARY-STURM EA 3f10F1' Date Rest t#
O'Nnee tion need not be IINSATed NtINSURA is fmorc hundred dollars
est 00)¢fytlu WATERT-IEATERW/VENT./E1J=t ENERGYFEE Y N
I¢nor thatinthe person
of thework no sa totiCitaeemJteIn awed, —
I shad rev[employ,any penin In any manner m u b become subjed to the
Workcrn'Compmvatbn l�wa of Gllfomla.Dere WA777R SYSTEvI/TR['ATING PAID `
PP NEW RESIDENTIAL P[MR. SlQFT.
A lion[
Z OZ NOTICE TO APPLICAM:grker making this CetNlnbof Exemption, Date Repel t#
.hauls become eubjeetto the Worken'Campewatlon provbbv oftha Lbor TOTAL:
N Cade,you rrustforthwith oomply with such provbloru or this pemdt shall be
W G deemed revoked. " BUILDING FEF.
d CONSTRUCTION LENDWG AGENCY SEISMIC FEE
I hemby aferm that th m b.m�man leming agency for the NffaroRIC. ELECTFEE
Z an¢of the work for which thio peradt b fawed(S..3097,CW.C.) TOTAL. O3O
Q O,, Lenderme,Nay PLUMBING FEE
LL lender.Adore„ QTY. MECHANICAL PERMIT FEEMECHANICAL ITE
O W 1certify that]have read thla appBratbnand aatethettheabove Wortvtton
ie lagreeto complywkhali edy,nd muntyordaun¢e and late laws PERMIT ISUANCE FEES PAID:
} a relating to Wilding mtutrudion,and hemhy.uNorlu repre.entrtNes of thio
F Z cry to enter upon the above-mentioned property for lrope ion purpoes. ALTER OR ADD IO MECH. Dale - ReCei t#
_ (We)agree to rove,Indamnify an d keep harmless the City of Cu pertNio
rg.but BabWtles,},dgnrm.,meeard eaper.which y,In anyway..e AIR HANDLING UNIT CM 10,000 CFM) SUBTOTAL:
inert said City Nniumque ottheuing ofthls pemnit.
�`. AIRHANDILNGUNTT(OVERI0,B CFM) CONSTRUCTION TAX
•lure of AppNont/Contra qq - Date DGIAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HA2ARDOU511ATERIALSDISCLOSURE -'
Will the.ppNsa est or future building oavpat atone or hand le haardou HEATING UNIT(TO I00,0D0 RM
nDate Recel t#
aderlal as defined by the Cupertl no M.r idprl Cade,Chapter 9.13,and the,
r Hex lth and Safety Cod a ion JSG'a3(id? HEATING UNIT(OVER 100,000 BTU) ' TOTAL: Q
Yes No
WBltha epplkant re WildNg ocupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUAN-CE DATE
whkh emit haardou.aU connmLUMn as defined by the Bay Ams Nr k`!'9I Lea
Qu Ihy Marugenrnt IXa 0
7 BOILER-COMP QFIP OR I0g0(U B'TU)
11Ye No I [� ff'' ( 1
hawere.dthebaa smdeda requ remnnbunderChapter6.95of BOILER-COMP(OVFR IW,"BTU) JUIN 2 (/ IJJV
the CGBlomla Health k Safety Code,SMIom 25505,25533 and 25534. I
underst.nd that lithe budding dace not evrrently have rtenant,that it is my NEW RESIDENTIAL MECFI. SQFT
responsibility,to nottfy the occupant of the requirement,which rniust be met
prtortobwarmcfa Certitkatco! panty. CIpJ VI LB[JQIUnD '
Owner or autheadined agent Date
TOTAL ISSUED BY:���'t�
OFFICE COPY