20049 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
builkiieR Prom Identifitation IPERMIT NO.
B.Rdddre.: 20049
one CITY OF CUPERTINO-BUILDING DIVISION �^� C1�
Conlncior's Name: Lk.N. APPLICATION / PERMIT i�(�
BUIL.DING-ELECTRICAI.['LIIMBINGMF NICAL CATEGORY CONTROL 0
AmhLL En seer. o:
Z
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add-a.
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I'ERMITISSUANCE
I hereby affIrl heenard rprovWou ofCh.pttr9(m,mmuc AP'LIANCISRESmENTfAL
IScct107=)of Dby3ofthe edB/D6rRRT10
11.ifln hull fore and dfeet. PANTOS N
R-4—=>e
Lf¢ns Cb. Lk.I 222562
Dated CaMaetar Kalman MpcEanical up TO 2DO AMPs
ARCHITECT`S DECLARATION 201-1000
M'Z IuodAre.d my pinbshaubeued au Pubhemeods OVER 1000 AMPS SQ.FT.FLOOR AREA S/$-FT.
O
Liceved Professional SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SI'EtGlCIRCUIT/MIST
Iherebyaf .thatl amexempl fromlhe Contraetorb Ll¢rm lawforthe
pp following reason.5edlon 70315,Buenas and Profess ons Code My city or
muntywhkh rtqulrn.Perritt to mvtuct,alter,Improve,demoW h,ornapak TEMP.METER OR POLE 13457.5
anywuctum prior to W issuance,also requires theappllnnt for such permit to POWER DEVICES
Oµ file,a algned statement the he Is B¢nxd pursuant to the pmvbbv of the
Contractor.lkarue Law(ChAp r9(commencingwhh Steffan 7000).(PHDivi- SWIMMING POOL ELEC[ELECTRICOS abn3ofthe Burnes.nd ProfesbruCede)orthrhebexempttbemfromaM - VALUATION
y.' the bleb for the alleged exemption. Any Wolatio.of Steffan 70315 by any
applleant fora perMtsubjecbthe.ppliceat.a civil penallydn.t morethn OUTLEISSWITCHESFIXTURES
f Eundrtd n ddW ($SM. NEW RESIDENTIAL ELECTR `"Q'ET' STORIES TYPE CONSIRLCTION
u I,as owner of the property,or my employee with wages u their wk
��� comperwtlon,willdothewakandtheetrunvrtbnot Intended or offered for ,
Osab(Sec]ON,But.lrcm and Profesion&Code,The Contrad.e.Lice.Taw
doe mt.pply to an owner of property who bullets on Imp.themcRand OCC.GROUP RFS.IINRS
0.0. whodoeswch work hlmdfathwgh hbown employees,provided thatuch
Impmver¢w are rot Intended proffered fm ule.11,havexer,thebulkRng a TOTAL
Improvement lasddwkhlnomye...fcompletbn,th..,-builderwlU have
t LJ Lrdcnorpmvingth.thdWnctbulldorlmpmv fapurpouofs.la.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am eechulvely mntnding with licensed
mntradon to comtud the pmjed(SLI](K Bualnes and Pdealom Code: PERMIT ISSUANCE �y�
Th Cc ntndoro Llet.law does not apply to an owner d property who ALIFR-DRAW 8 VFM-WATER ff.V cn
W13,16 or imp.Hereon,ant who mn
rt ets for uch P'"wIN a
cWII�or(s)B¢nned p,n..m to the Cmtrad.r.Lice.law. BACK FLOW PROTECT.DEVICE FEESUMMARY
LJ I am exempt under Sec B A P C for thio w
rean
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N_
• Ownrr Date RECIUI'I'I
WO.
Rm the COMP ENSATION DECORATION FD(TURES.PER TRAP SCHOOL TAX Y_ N-
®1 htrtby.Rbm that 1 have o certificate of consent to a Ytiterem fS a RFLETpT
art,L te bC Worktn Comperurlvnleunn¢¢aartRkd copy themed Fee. GAS EA.SYSITM-I INCA OUTLETS PARK FEE Y N
Polity# C) �j nQ Q -
Co Ad RR4II�S171$. RECmrI's—
Comy ray Lam— GAS EA.SYS'IV]N-OVER/(EA) BUILDING DIVISION FF.L9
IAl ecertl0ed ropy b hereby with
efty GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b Red with the mY I¢pectbn dlvWm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
(Thb.edlon need
COMPENSATION
OMPENSATION INSpeUrmitNbCE . RCi toSEWERSANTTARYORMEA2(K)FT Date
hundred doUan
aro)¢l .') WATER HEATER W/VENT/ELDZTR ENERGY FEE Y N
1¢rtuymr tithe perr.m,.n¢oHhe work brwMthtwpem,r bUued, — —
I net employ any Peron In any rtunner u u to become object to th
werak)c mn
ers'e.mpen,. law..f California.lifo . Daft WATER SYSTEM/TREATING PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Rccel til
Z 2 NOTICE TOA subytNT:eW.fl,Ilem,maklompe CeonlPro of Exempla Lada
should you
mine wbjed b the Workers'Compensation pmvhbm of the Lbi a TOTAL:
F N Code, must forthwith comply with such prwbbru orlhb pemdt aluilh
deemed nwked. -BUILDING FEE
W CONSTR(JCTION LENDING AGENCY
CL Iherebyefimr that there b a mvtrudlon kperform,forthe perforSEISMIC FE
2
ELECTRIC FEE
(Qan¢ ork forwhkhlh6penNtb Lined Fee 30Y],CIv.G) TOTAL PLUMBING FEE
,) kndar'.ere Nawine
LL H L<ndcr'a Address QTY MECHANICAL PERMIT FEE MECHANICALFEE
O W 1¢dify lhxlhave rtadtw.ppBcatbnaM ratethabh<above ln(omutimr
bee ed.lagret to comply whhaU dtyard muntyordbunm and late law. PERMIT ISSUANCE FEES PAID:
>. N relating to butwing mutudlan,and hereby authorir<repres,mattvn d thio
H Z e city to enter upon the abuvt-mentloned Property for bepectbn prorpo�� ALTERORADD70MECH
V _ (We)agub save,fad emkelp fy an d p h.rmleaa the City of Cupert Uo Date R¢Cei t#
ag.hmt WbBRln,wdgmenq col.and ex,.which may in any way.mue AIR HAN]DLI NG UNIT(170 10,000 CFM) SUBTOTAL-
ago iutsaid City incmnequeri¢ f the gra ming dtwpemdt.
y AIR HANDLING UNITroVER 10,000CFM) CONSTRUCTION TAX
gnatun
fSlof Appllant/ des Date` D(HAUST HOOD(W/DUC"D CONSTRUCTION TAX PAID:
tra
HA2AR US MATERIALS DISCLOSURE
Will the applicant orfuture building otaNet lore or Fantle haeard.us HEATING UNIT(TO IM,000 BTU) Date Recti tM
nwerial.e defined by the Cupe,11 .Murddpe Code,Chapter 9.12,and the
Health and Safety Cede Section 2'x532(.)2 HEATING UNIT(OVER lOg000 BTU) TOTAL: V
❑ Ye ,L+, ,No ,
Will the applicant urfutu¢buildingary pant use cxflpmem or devices VENTILATION FA (SINGLE RESID) - 1-cDATE
which emit hnnrdous alr contamWNa as defined by the Bay Area Ale
Ihy MuugeorentWtrkt7 BOUS3,COMP OFM OR 100,OW BTU)
Ye �
.» puN. rtJUN 2 s 15yU
lay
ve mad the s materials qulrtmenb under Chapter 695 of BOILERLQt
OMP(OV1W,W0 BTIJ)
theGtandt bath ASafety Code,Se m25505,25533and2:531. 1'
reapntandthao lfthebule oeeaocs of therequirmnts tenant that ltNmy NEW RF57DLNTUAL MECIi. SQFf C4 Dertira
rnporwmULLyto cn aCereoavpantdthe rcquimmemewhich nut be mel YI 4V al 11
Aria to Issuance da Certlflcab of party. '
�
. 6:z5-9 a
Owner auth.rfeed agent Date ISSUED BI
TOTAL
OFFICE COPY