22363 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldendfka0m - PER!,UTNO.
Bu1WI33Z � . 22363
nrs Name, me:
CITY OFCUPERTINO-BUILDING DIVISION �f
Contra 's N.m: Lb.N. APPLICATION / PERMIT �Iw`
Anchtted/ BUFLDINGELECTRI PLUMBINGMDCHAMCAL GTfS,OftY CONTROCI
gfnv<n IJc Na
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtm: PERMITISSUANCE ❑ ❑ rx . ❑
LICENS EDCONTR under rDECLARATION
Ihth Sb Hbmt)atlamlkm3ofthe under prwWmaofOaprsGodesnmm< APPLIANCESRFSIDFMIAL rra �r -vmrvv„1 I�
Ingwlth tofull fX10)of d effa 3ofthe BualnmandPmfmlmeCode,and r<4 "�•-'�'/^y_w
Limn IC n full PANF]S
Date Cara ado, — � / UP TO 200 AMPS 0PIA 1'
AAC'HDECPS DECLARATIO 2II4000AMPS
�Z ]uMeretard my plana shelbeused As pubherands OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
SIGNS ELECTRICAL /Kw/L'+H ♦�MLkxnaed Pmfmbrol
OWNER-BUILDER DECLARATION
IhebyaflrtthatlameaemptfatheContetLnl.wfma SPECfALCIRCIR/MBC
oo following rtaam.LSMIm 70115,Bualntae and Rofmbro Cody.Any dry or
O z'� TEMP.METER OR POLE INST.
Fv� Aountywhich rtquBna pemdce,awomuirseatheact,alter, perc,demsuch,orch mitto .
q any atmrduretatemeprior to ltsheuaew&Isonsedp Neap to eet for theposolemsofte POWER DEVICES 2�
(Ile•tlgned statement that k b licensed pursuant to the provlabro or the '
Contractor's Lkense Law(Chapter 9(cmraamngwtlhSection N0))ofDIW-
F,E, alon3ofthe6ualneeaand Professions Cocie)orthrt heb evempt therchomaM SWIMMINGTOOL ELECTRIC VALUATION
�yl.. the baax for the alleged exemption. Any violation of Section 70115 by any
<. appbantforapemdterbjetbtheappBranttoAd lpenalty dn¢ OUTI.EISSW17CFffSEDCRIRFSmorethan LED 1
five hundred dollars(SW- .
yes ❑I,as owrar of the property,or my employees wth wages es their sole I NEW RE9DwnALELECTR P TYPECONSIRUCTION
mmpevatim,will do the soak andthe atru¢urt b rot LueMed or oRer&d roc
a O ale t5ec.90N,RuanrvaMProfmloro Co Wilds orimprofsthereon,
haroe Law
rjs$ docs nm aPchbrkhw lir frogh K[3b Aemplaym,pw Wt rc tand
Tu wnprowmuch Ann ocamaelfathroughlJeowale.It coveve,thhdilding i DI``�
impmvemente en rot intended orofremd(or ale.14 however,lh<buildin6¢ TOTALof :
Improvement beold within he did not
tfWild o imp, w for purpose
rposerwl111uve
tryE,kureenawer of theahedb,amexruevely wefor purpaeoforman QTY. PLUMBING PERMIT FEE
Ltr 4 as owner of the property,( erclu Rue mntrvcting with 11¢naN FLOOD ZONE '1PN
' mntrutms to mrotnrd the prokd(Sec 9011,BuaNm and Profmbro Code PERMIT ISSUANCE
'
The Corararmea License Law does not apply to an owner of property who
Wilds or Improae thereon,and who mrmam for sash p(o)eas wth • ALTER-DRAIN 4,VF -WATER(FA)
o7alpeor(a)liemed pursuant to the Coohada's License Law. BACK FLOW PROTECT'.DEVICE FEE SUMMARY
U1 am exempt uml,Sec B 6 P C for the reason
• Owner Date DRAINS.17.O014 ROOF,AREA,GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION ftECFR'F Y
"41 hereby affirm the I have A¢Moate of causes!to self-Insure,a a �D�PER SCHOOLTRAP SCHOOL TAX Y . N_
fig RECFR'I'Y
ate of Workm'Canpewtim lrounn¢aa certirkd ropy thertM(Sea. GAS EA.SYSTFA/-1 INCA OUMETS 'PARKFEE Y N
380Q Lag C.) _
1'dkyY _ GAS FA.SYSIT OVER4(FA)- RILFII'T
Com ny /Q�yE y $Gr BUILDING DIVISIONEEES
{{(��(��C++ertified eopy w fiertby�b M. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
PRCertNed ropy b riled with the mY iropedbn dNWm.
'��°O CERTIRCATEOFEXENIMONIFROM WORKERS' CRF ¢ - PAID
COMPENSATIONpermit
crnSEWEWSAN)T,ARY-SC)g FA 2XFT Date Recd t#
baedbn need notbe compldcd Bthe Fe emW bfaon<hundreddoBua
($1ENERGY FEE Y N
00)a Tess) WATER(TEASER W/VENT/ELECTR
I¢rtlly thrt In theparrornan¢o(0s awhfarwMct lMa pemW xbued,
1 shall not employ any person N any manner so u to become subkd to the
w�Tm srsmu/TRrknNc
wake,;canpen»tbn Law,or c.ur¢w.Date a PAID
0 Z Appilant NEW R®DFNI7AL I'llde. SAFE. Date Recti t#
Z O NOTICETO APPLICANT.B,after maWngtw Ce ifiaateol Exemption,you
should become subFct to the Wodrers'Comperovtbn provbbro of the Labor TOTAL:
CC T Cade,ynomutfmhw hrmnprywthsuchpmvl•bnorthbpermft•hallbe
> deemed revoked.
BUILDING FEE ag-
LLI p CONSTRUCTION LENDING AGENCY EISMIC FEE
d IhembyaWrtn thatthereba mru cimler ffigagemyfortheperfom
M Z once of the work for which thio perm!bry (Se,faed(S3041,Civ.CJ TOTAL ELECTRIC FEE
(.) 2 Indere Nama - PLUMBING FEE
LL f Urd,ea Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imre By that Ihave read this Application and state that the&low informatlm
4 bmmxt.Iagre,,tocanply with all cryaM county.,d nanmand state laws PERMIT ISSUANCE FEE$PAICr.
>. N relating to building corotrudim,AM hereby authM rep¢aent.0vesofthis Ayy
F Z mYto mteruPon the abwo-membrod property for Wpedbn puryoaea. ALTER ORADDTO MICH. mQ/l
(We).gree to save,indemnify an d keep harmless the City or CupeMro Date REYCI [M
V agerellabWtiee,led is costa ant expenses which may in any wm
ayaue AIR HANDLING UNIT(TO 10,000 CFM)
er lnet�.I it ne ue of the grantlogefthb pend SUBTOTAL
ag7 Z AIRHANDUNGUNUT(OVFR l0,0DOCFM) CONSTRUCTION TAX
Slgta pP t/c�tad Datuc�teef Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:.
AZARDOU9 MATERIALS DISCLOSURE
Wflltheapp amafuturt buliding oavpant&tort or laMie harardous HEATING UNIT CFO I0T,000 BM Date RCcel t4f
material as defined by the Cupertino Mumdpal Cade,Chapter 9.1;end the
Health and Safety cod, Ino 2553](A)1 HEATING UNIT(OVER 100,000 BT10 TOTAL:
RillY. /�f No
illtheappllrx.16Ru ,building occupant use equipment or devices VENTILATION FAN RINGLE RESID) ISSUANCE DATE
which enut havrdous air cmuaMvnta as defined by the Bay Area Air
Quality Management 7 BORER-COMP OHP OR I00,IXD BU)
Yn o
California
radthehva modexb eons 255nbundcand 2S534.I of BO LER COMP OVER 100,0008 )
theatt Heath kSurety Code,Sedbro75505,wat ands,that I _
understand that if ytonot bondingdoesaft em-gtleh matenan4lhat it is,my NEW RESIDENTIAL ME CIi SQFf
P. 0tty to not thlflcat a ooulertqubemcwwhich resort be met
prior Cc (flat Ocanpancy.
nererauth agent Dat ISSllEDB
TOTAL:
OFFICE COPY