20048 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY /
Building Project Id tlfbalm PERMIT W. '
Building Address: ` �3 20048 O O A4 8
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2 Com[
rrcr, ams: we:
P CITY OF CUPERTINaBUILDING DIVISION -• /'Cwtractor,Name: Lk.No APPLICATION / PERMIT 10 j CJ
BLnMNGELECnUCA I'L[IMBINGMECHANICAL CATEGORY CONTROL
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4
ArchllBtree y,rte` Z G " BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Add— O t E ^ PERMITISSUANCE ❑ E]LICENSED CONTRACTOR5 DECLARATION
Ihembyaf thatlamllcenaeduMerpr WwsofCbapter9(mmmm APPUANCES-RESIDEN17AL JOB DE`x ON
ingwe,I,totlon Imes,anDlvWon3dthe Budreaadl'rdeslw,Cade,and nn
li¢nx I,to luB for¢and effect PANELS - a—'1'T[.e/,
Llaerue C/s [�CoMraRor
Ka'Im�a�n�
Drt,� 22 Q P��3II1C31 UP TO200AMPS
ARCHITECTS DECLARATIONNE AMPS
pQ] Iundcratand my pWnehaube use upubuc remNa OVFR 1000 AMPS SQ.FT.FLOOR AREA f/SQ.Fp.'
d[j Licensed Pru(®bvl SIGNSELFLiWCAL
Q OWNER-BUILDER DECLARATION
I hereby aRm
hm that l am exempt frothe Contractor'sL¢ruelAwfathc S[aE{IAL CIRCUIT/MLSC
o9F� following¢aon.(Section7m15,BuainesandProfeskes Codc Anyettyor 'IP1fIa.METQt OR POLE INSf.
FvJ muntywhkh requlteaperMltomnwtl,ilter,Unpmve,dertnlbh,or¢parr
.nyshummprbrtolu Lau .allonyuln e.ppU.tfmauchpermftto POWER DEVICES
0Ie a Mped statement that he b hen.sed prrauant to the provisions of the
Contractor's License Lw(Chapter 9(comarmocing with Sectbn 9000)of DWI- SWAIMING POOL ELECTRIC,len3ofthe Bu. and Prdmlens Code)orthEhebexemptthercfmmard VALUATION the balls for the alleged exemptbo. Any violation of Section 7MI5 by any
.pphesntforapemdtwbie theappucantioaddlperoBydnamomtlun OII7LETSSW17C2iESFTXT[1RF5
0. flue hundred dolian(fW.
I,as ownsr of the property,or my employee with wages u their sole NEW RFSLDENTfAL FT ECTR SQ pT. STORIES TYVE CONSTRUCTION
7a mmpevatlw,will Bothe wmkandtMatructurelsmtlr¢ended or offered(or
Oask lScc 7014,Boxu=and Prdesbns Code:The Contractors License,Lw '
2 dos not apply to an owner of property who build,or Improves thenan,and OCC GROUT' R6 UNIT5
who dm such work hlm,eB rovn
orthreugh his own employees,pvlded that ch
improvements ue wt Intended oroltered fmaale.IL however,thebulldinB or TOTAL:
improvcm mntb dwithnomrarofcomplet mtheowner- Werwulhave
tFgIZurdenofpmdngtnatheddmtbuRdortmprovef«purpaeofaile.). QTY. PLUMBING PERMIT FEE
U4 as owner of the property,am erchufve ely contracting with licensed FLOOD ZONE APN
contract.to construct the pm)ect(See 7044,BWInesand Prdesba Code: PERMIT 15b11ANCE.
l
The Contndor,Lwo..Lawdon not apply to an owner d property who ALTEILDRAW k VENT-WATER(FIV
builds ve vmen, contracts ar Improthn,and whocontracts fm pk
such v),¢,with a
-w4sl-EWli¢nsEd punuat m the Cmtradvrrue.Lkelaw. BACK FLOW PROTIZT.DEVICE FEE SUMMARY
LJ[,am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT I
WORK MAN CAMP a malfiION DECLARATION FTXNRES PER TRAP 5CHOOLTAX Y_ N
01 Hereby mkc that I love•¢rturanc of cwsnt m opy-hw'n m a RECEIPT I
M,Lab of Workers CmnperoNiw]ruunn¢car.¢rtBkd oopythened(Sec.
3800.Lab CJ GAS F.A.SYSTEM-1 WU0II7L[IS PARK FFR Y_ N_
Pdkya 0610040779 RECEIPT
Com nv L9a11_S_3ll �EA.`'YSTEM-O�4(EA) BUILDING DIVISION FF:F.S
tedheci copy ls herebyumWed. - GREASEMMUSIRL WASTE INTERCEPTOR PLANCHECK FTE
Certified ropy ls filed Mth the dry Inspection div W w.
CERTIFICATE OPEIEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE
ls(coon,Hundred Bullae epeP
SEWER-SANITARYSIORM EA 200FT Date Rl tit
r(FFde sectbn need n¢he complete Rthe permit
(S1ao)a1ea..) WATER FffATFR w/vElvr/u.Fs.-IR - - ENERGYFEE Y N
I certify that In the pe l..mof the work forwhbh this permit is issued,
1 shad]not employ any person In any manner so as to become sub)Ect to the
Wohcrs CmnpensatbnlAwsof CaWcmxla. Date WATFRSYSTEM/TREATING PAID
ZZ Applicant NEW RESIDENTIAL PI.NB. SQFT. Date Reeei IN
O NDTICETOvesubjCAMhe W.,krs'C.uperGion pmluorx; th.Labor
TOTAL:
CC N ahmldbam most
sub�ectbthe Work en'C such
provisions
wpmvhis permit
a Labbe '7�
_ Cee,d nue,fmthwhh comply with each pmWbns or this pemdt.h.11he
� � deemed ked. . BUILDING FEE
III
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of im,that them ls a mnvtructlon kMing agency for the perform it b e3 ELECTRIC FEE
Z an¢of the work for which this permLssu (Sec. ,CN.C.) TOTAL
U O Leder.Name PLUMBING FEE
LL H I<eer'e Addrns QTY. ' MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certllythatl luvc¢ed tFdeappuotbnand statethattheabovelnfortMlon
b mrmct.1 agreewcomplywhh aBEM cc
tyauntyordlnannn
and state laws PERMIT ISSUANCE FEES PAID:
>_ N nlabng to building construction,ae hereby authorlss s
reprentattoesot thin
r Z city to enter upon the abode-mentbned property for inspection purposes. ALTERORADDT'JMEC11. Date RGCCI [it
_ (We)agree to save,Indemnify an d keep harm].the City d Cupertino
against uabWtles,judgment.,mraand expecte which may lnanyway.mue AIR HANDLING UMT(IO 10,0)0 CFM) SUBTOTAL .
.gaLut said City fit ort antbg d ton.permit. ALR HANDING UMT(OVOR 10,000 CFM) CONSTRUCIIONTAX
6—
S nature of Apphom/ ont or Date E(HAUSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDD S MATERIALS DISCLOSURE
Will the applicant orfuture building occupant atom or handle havrdoua HFATINC UNTT(TO 100,000 BTIJ) Date Recei tit
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
Fkahh and Safety Code Section 255n(a)? FBATWG UN3T(OVER 100,000 BTU) TOTAL: f
Yes .]No
Will thcapplimnt or future building occv pant uu Equipment or devlme VENTILATION FAN(SINGLE IESID) 1 ATE
which Emit luvMwealtcontaminants byte b
Bay Arta A
Qu]IX m
MarugeentWriel?Drk[7 BOILER-COMP OF4'OR 100,000 BTU)
Cal ¢ia the ealth&�we Corle,materialsSections 25505,25533
aChapl R. 1 of BOILER-COMP(OVQt 100,000,BTU JUN 4 6 1+90
the mtand t Heakh k Safety Code,Sedum 25505,ve a t ands,that. I
undmtandty,tohat nthe tifyth building does ofthereentlynsot,which
that It bony NEW RF9DINIlAL MECH. SQ.FT. �a�..as�
reponsibuity,to notify theowrpant dthe�(ulmmenu which rtuat be mel Mfal W Ik M.Iw
prior to Lsuanm da Grtl(katc o! parry. ` • VYVO�Lf�1a� •
G:zs-q
Her or authorlaxd agent Date ISSIJEDB
OTAL:
OFFICE COPY