22794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proee Identification PERMIT O.
Build ing Add reo: 22794
I Y 6 Z C�Tr1 t�tN/Ji-��9 !�/`�
w r lime:
e'�TR12/ N ✓r/P` 2�-? CITY OF CUPERT[N6BUILDINCDIVISION Q �j
contra .r'uName: ' Lk.No: APPLICATION / PERMIT —l^Z�""—►
BUILDING-ELECIIUCALPLUMBINCMFCHANTCAL CATEGORY CONTROL s
Archil./Enginser. Lb.No:
,,.- ..- ,i _ •M _' :.'BUILDING PERMITdNFO_
;ELECTRIC PERMIT t - :FEE t' 'I
Add.. PERMITISSUANCE E:1 ❑ TLY El
CONTRACTOR'S DECLARATION �J
I hb ffirm that I am BcrosedwWo provkdmsufChapter (comeroorc. APPLIANCES-RESIDENTIAL JOB
�DFS_CnR`E
s
110N
tngwithSon7OofDi (theOuYseandProfnmaCode,andm
licamlsmfuillormandeffed. PANELS
Cho ic.N
Data _
—
colnuct. UPTO200AMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
^QZ I understand my plans shall he used as public records. OVERT AMPS_ - - � `.4.FI.FLODRAREA $/SQ.Fr.
Cleansed Professional 9CN5 ELECTRICAL
Q�^'l OWNER-BUILDER DECLARATION I� r'
ti R SPECIALCIRC T/M6C ✓ r, l
p., Iherebyalflrm that lamexempt from the Comnctor's License Lawteethe _ 0
Cz following reason. 70315,Businessand Professions Code:My city or TIIMP.MECER OR OLE)NSC.
F i"' muntywhkh rcqu4oapemtitromrmtruff,iller,lmpmve,demolbh,orrtpalr
�� < anyrtmuciure pdorto lisbsoante,also requbeatheapp0ont far each permitro HIL' .)
V file a signed statement that he is licensed pursuant to the provisions of the POWERDMC7S
�3�� Contattofs License law(CFupter9(commencing wkh Section 7000)o(DIW SWPtMING IDOL ELECTRIC -
sbn3ofthe Buss mmd PmofmWm Code)ort nhebeumptlhemfmmand VALUATION
g the hast for the alleged...mptlm. My violation of Section MIS by any OUTLETSSWITCHESFDMAIES
applicant for a permit subject the applicant toa cue penalty of not morethan
g o (Iva1 lndreddollar(5500). NEWRM ENTIALcr ECTR Q�p. STORIES TYPE CONSTRUCTION
g.. (����1(�yJJy,,
..L ..of the property,lir my employees with wages as their sole
2< c�nptrwHon,willdothe work and thestmeure brei intended or offered for
O v�iee dee 70K BusWseand P.9dal s Code:The Cantae e.Ll¢m Law
$ does not apply to an owner of property who builds or improv¢theme,and OCC.GROf1P RES.UNITS
doessuch work himself or through hlsmvn employees,prwlded that such
Impurvementsare not intendedoroffered forsale.ILhow,mr,lhebulldingor - TOTAL
Improvement iswldwithinomyearofcampletbgtheowner-bullderwUI have
thg,purden of proving that he did not build or improve for purpose of sale). QW. '. PLUMBING PERMIT, '.t '.FEE. FLOOD ZONE MN
LJ L as owner of the property,am eachrsively cormoUng with Il¢ved PERMIT ISSUANCE
to construct the project(Sec 7016,Business and Pmofesslons Code:
TM Cantncte r'a License law does rat apply to an owner a property who ALTER-DRAIN 4 VENC-WATER(EN
Wilds or Improves th. , and who contracts fee such pnojam with a
onpt(dor(s)limned pursuant to the Cwteaeoes License Law. ^�FE E'SUMMARY';,.>k'',�q;;;.
151 am exempt under Sea B k P C (or Ihb reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT
s
(_]I hereby affirm that I have a certifloh of comm us elf-Insure,or a FIXTURES.PER TRAP SCHOOL TAX Y— N_
diat of Warken'Compemd..Immun�¢¢a¢rt1led copy thereof(Sec. RECEIPT e
cen
3900,UbC.) GAS EA.SYBIkT1.1 PIU OITIT.ElS PARK FFR Y_ N—
Policy a RECEE'C e
Cam any GAS EA.SYSTEM-OVER 4IRA) BUILDING DIVISION FEES
ffCeelBed copy b hereby furnished. CREASE/INDUSfRL WASfERJTQGFFTOR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MEET ! Date Recei NF
CThlssectlon need not becompleted lfthe pemdt I,forom hundred dollars
(9100)otifyth WATER HFATERW/VENT/MMTR ENERGY FEE Y_ N_
I¢rtifythal b the per(omn¢
uolthe wanM
k forwch this permit Is leaved,
1 shall not employ any person In any manner so u to became subject to the WATER SYSrE M/TREATING
WmkxWCompe.wm.. awso(CaWomb.Date PAID
O Z Applicant NEW RESIDENTIAL Pl.48. SOFT. Date Recei ted
_Z O NOTICETO APPLICANT:lf,after maldegthb Certlfi¢teof Ew ption,yvu
should become subject on the Worker'Compensation Provlalo o of the Labor TOTAL:
WN Code,you neat forthwith comply with such prervlabm or this permit shall be BUILDING FEE
> d¢med revoked.
CLO CONSTRUCTION LENDING AGENCY SEISMIC FEE
[hereby a(Orm lhattherebaamstruction leadingageneyfortheperfomv Tan ELECTRIC FEE
M Z ance.ftheworkforwhlch this permit is issued bee 3097,CIv.C3
0 O tander'a Name �1v PLUMBING FEE GL
LL I— Lenders Address y.•:�,.2%? co
MECHANICAL:PERMIT',m`: _ FEE�$I MECHANICAL FEE
O W 1 mad.lzalwvenadthbappudty. nd ratylyd L.e..a d( t.lian
Ismrrtato :grtero comptiandtyandcaunty¢dWn¢sand Yat slaws PERMIT ISSUANCE FEES PAID:
} a relating to building construction,amd M1ertby,authorize representtivns of this
FN c t.c.mru heaWvrmentbnsd f¢W ion ALTER OR ADD TO MECH.
" 2 H !;pety pee p"rpOper Date Recei [p
(We)a cave,IndemrW(y an d k¢p ea the City of Cupertino
CI agalmtihbll dgment,caYw dezpe Ichmsymitrywayacttue AIR HANDLING UNIT RO 10,000 FM7 SUBTOTAL:
ago Wt vl n em of the gra at this permit.
NR HANDLING UNIT(OVER 10,00006M) CONSTRUCTION TAX
g of AppBont/Contractor Data D(flALST HOOD(W/DLCO CONSTRUCTION TAX PAID:
NAZARDOUSMATE ALS DISCLOSURE
Will the applicant or futum Wddln pant stone or handle haaardous HFATLCG UNIT(T0100,000 BTU) Date Recei ted
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Codrler Section M32(il7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
No
Wilt the appliam.,future building occupant use equipment or deices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eedt haeardous air contandnsnts as defined by the Bay Area At,
Quality Mansgemem District? BOILER-COMP QHPOR 100,000 BTU)
4Yes ('J No PAI®
havereadthehua'r..mateialsrequirementsunderChapler6.95of BOILER-COMP(OVER IN,000 BTU)
the California Health k SafetyCode,Seelans 25505,25533 and 25534.I SEP
undentandtistifthe Wlldingdoonatanentlyhaveatenanithatltbmy NEW RESIDENTIAL MECH. SQFT. s� 4 �pQ�
responsibilityto not ity the occupant o(the requirements which must be meltLVEr r 2 Jaz
prior to onuan¢of a Certificate of Olio panty. !��IJ,ss{Q�u
Owner.rauthoHaTOTAL:
edagent Date ISSUEDBY: V lJGi 'I�/Va�����
OFFICE COPY