20009 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm Identlf d® O PERMIT NO.
Building Addma.:
2000.9
rcr• 2ares: - P_ H G O 0 0 n
one:
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ci_��'P CITY OF CUPERTINO-BUILDING DIVISION
C as•M�S•N^am�e:/Qm� N APPLICATION / PERMIT G —2 - B
r v .y, t /let 3V( BUTLDINGELECIIUCALPLUMBINGhfEC11ANICAL CATEGORY CONTROL♦
Amhkea/EnglKe -� 1 'L
_SFQTY ELEC[RIC PERMIT FEE BUILDING PERMIT INFO
Add- 6 o i PLUMB MECIt
I'ERh9T1gT1ANCE ❑ ❑ ElI�if
LICENSED CONTRACTOR'S DECLARATION JAI
I hereby affirm that l am licensed under provLdoro of Chspmr9(comment, APPLIANC6RESDEMULa�}pgp RQ71ON
Ingwlth5e n(7OM)of Divblon]ofthe BualrQu dPmfeWma a,and t \ t
tice� PANELS
H
DNe /�CHITCCI'S DECLARATION ��� 201- Ahfl'S SQ.Fr.FLOOR AREA S/SQ.Ff.
MPS
roz lurdmttami`Vmyplamshallbeu wpubllcrecceda 1
q�+ °C OSIGNS ELECTRICAL [7, �sp,�
lv Z'(� Llmnaed Professional �\VE Al E D
�< WNER-BIBLDER DECLARATION L5[aECTALCEtCI1R/MQSC, 1\V/'
Z' F' fOW6 grecs (5. dim7m15BualnaaMf®bro Codr.Anydtyor Ihereby affimmthat lam exempt from the Contractor's License Law for the a n PVT E`
,
O ❑ TFla�.METER OR POLE♦NSI.
FE counrywhmpmrtolU eatltroaroregLalttheap Rv tfwolbh,orrtpto
any.wcturtpamment that
he ,a4orecd puree at to the forsuchpemdte POWER DEVICES _
04 a signed laterrcnt thrt he b I¢nuM punuanc ro the pmWloro of the TE
gu,l- Cmm�ctn/e Lkeroel�w(Chapler9(mvurcndng with 5ectlon 7f10W of Dlvl- V
F-�O.J] ,bn3of the BualnmaM Pmlmbrm Code)orthat he l,eumpt thenfmmaM
SWIMMING IDOL FIECIWC I
the basis for the alleged exemption. My violation of Section 7015 by any
�« appBontfora pemdt sub)erf.theappBc,nttoa cidl penaltydna montlun OVILETSSWIICIIESFDKTURFS
c. Iv hundmddollan CiW. NEW RESDFNTIAI,E.ECIR
..�n 1,as owner of the property,or rrry employee with wages as tholr sok SQA. STORIES TYPE CON5MUCTION
C < mmpewtlm,wlldotle wmk,.nd thestrutlurt is not Wended or offered for
a O sale l5ec70M Bu,l..M Pmfeabro Code:The Contraaora License law
psi doe not apply to an owner of property who luRds or improve thereon,and OCG GROUT' RES.IINTTS
Cut. who doessuchwork himself orthwgh wovenes
employe ,provided that such
imprownrew art not Intended or offered for sale.If,however,the W llding or TOTAI,-
t4LluruIenufpnm,Ingth9hedW mbuildorlmprowforpurposmofsale.). QTY. PLUMBING PERMIT FEE
LJ L as or of the property,am excwlvely mntrictIng with Ifren,eti ET'ODD TONE APN
contractors to construct the project(Ser.7004,Bualnem and Professions,Code: PERMIT ISSUANCE ,
The Contractor's License Law dm not apply to an owner of property who ALTER-DRAIN La VENT-WATER(FA)
W lids or Ire sews th. , and who contracts for sucin p1o)em wnh a
oqpl(+aor(o)lhe Frumsu ttothe Cmttradm'.Lln, Uw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec B(a P C for this mason
• Owner Data DRAINS FIDOR,ROOF,AREA,GOND. SANITARY Y_ N_
RECWORKMAN COMPENSATION DECIARATION �4
hereby affirm that 1 haw a certificate of consent to self-Nsun,o a FTl(Tl1RF3I'ER TRAP � •TAN Y_ N
e note of Worken'Comperoatlmtvsunncee•certRled ropy thereof bee REZ'ERTa
'n GAS EA.SYSTEM-1 INC4OULEIS PARK FTE Y_ N_
Pak?a ) I �Y RECE�P 9
Co�m y GAS EA.SYSTEM OVER 4(E1) BUILDING DIVISION FEES
CJ`M ` `O� e nua `d' cRFASE/INDuslRl w,�slE wrFxcErrOR PLANCHECK FEE
CertNed copy b flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANCIARY STORM EA X)�rl' Date RCCCI tM
(rMa section need ed not W completed!If the permit b fora¢hundred dollars
aomarfytit WATER HEATER W/VENT/EECTR ENERGY FEE Y N
cert less.)
1 t In the perfomrunce of the work forwNch this pemNc b Luted,
P shall not employ any person Pre any runner ro as to be..subj d to the WATER SYSTEM/7RFATING
Workerv'Cmrpso.tlon laws.(Califomla.Date PAID
pp 5QF-p, Date Rccei [p
A um,t
Z Q NOTICE come..KAto the .rko.'fter bng tut Certsn pro is Exemption,aLobo NEW RESIDENTIAL♦'LMB.
should become aub)ect to the Warken'Compereatlon provisions of the Labor TOTAL.
N Code,you mntforthwith mmplywlth such provbbroorthh,permit shall be_ BUILDING FEE,
W ] dmmcd revoked.
CL O CONSTRUCTION LENDING AGENCY $ IC FEE
I hereby affirm that(hors b•mrotmMan kMing agerry far the perform ELECTRIC FEE
� Z ance or the work for which thI32=b leased(Sec J09'7,Civ.C.) TOTAL:
02 Lender's Name - PLUMBINGFEE
LL F Lenl,r',Addreaa _ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O Q
OW Imnlfythatl l�vemedthb applotbn,M tlatetluttheabv,<ln(orounton /fir
CL ismrrtct.lagrt Wcomplyw hWdcyandmuntyordlnanmandnatelaw. PERMIT ISSUANCE I�_w FEES PAID:
} N relating to Wilding mrotroctlm,and hereby authorlae reprtaentatWe of this
F Z city to enter uPon tk abovcmenUorud mperty for Wpectbn purpo,n. ALTER ORADD TOMECFL Date Recei ((1
_ (We),gree to b 13, hared he City of ct, iro P
agalrntllabNt ret., ave pe muyN any w,yamue AIR HANDLING UNITE(TO 10,000 CFM) SUBTOTAL:
agave(old segue of gars pored(.
AIRHANDLINGUNT (OV 31IQ"CFM) CONSTRUCTION TAX
Si tutu of Applfont/ ontnctor Date EXHAUSTIIODD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
Will the applicant or future building oovpant atom orhand4 havrdoua HFATAG UN7T,(TO 100,000 B'Dl) Date Recei t#
material as def"by the Cupertim Municipal Code,Chaptcr 9.IZ and the
I lealth and Safety Code Ion 2S532(a)7 HEATING UNIT(OVER 100,000 BTU TOTAL: 0
❑ Ye
Wlllthoappilod Nm Wilding omvpant use equipment m devim VENTILATION FAIN(SINGLE RESD) - 'ISSUANCE DATE .
whkhemithavrdous contaminants as dell"by the Bay Area Air . ' L
. Iky Marugement rkt7
BOILER-COMP OIiP OR 1(IO,Om BTU) �a1 WIYe
lose read the Fiv amrter4b rtqulrtmenb under Clupte 6.95 of BOR-ER-C'Oh'd'(OVFiR,00.0pp BRn JUL 311.790
the GWamhlleahhk f Code,Saalbro 1550.5,TiUJ and 25574. ♦
undmtand that if Ildingd mrrtntly haveate rel tlutiw my NEW RF5IDFMIAL MECH. SQ.FI
noporoWllityt the rpt the rtqulre.1.a neat be met
prbrtoba aCenl pauy. 7 s !4tvoTtiP(1
.71 RV
e authorfrMd agent Date
TOTAL:
OFFICE COPY