20050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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CITY OF CUPERTTNO-BUILDING DIVISION
. Cmtndo .Na ne: Lix Na 'APPLICATION /PERMIT
BUfLDINGELEC7RICALPLUMBINGMFGHAMCAL CATEGORY CONIIZOL
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addn CJ '� `—
6
PERMITISSUANCE '❑ ❑
ICE ED CONTRACTORS DECLARATION
L
I Fereby affirm that l am kmaed under provlalonu dOupter 9(exermane. APPLIANCFSRESIDEMTAL - B ESC N
Ingwith5Mlon 7000)of DiV =3dthe Bu>ircaaand Prof�l CodC and � t /� ('
lice.is In full force and effM. PANELS DV� L4ztEJ
Lksnse Chao L.m ZZ756Z Pw e l v I
Date Comndor�dClaI11Ca1
ARCHITECTS DECLARATION OVER
000
q�q�Va rc0 7 I urdantaM my plana.hail be axed n public records OVER 1000 AMPS SQ.FI.FLOOR AREA $/�.FT.
Fi [j Licensed Prdesalorul SIGNS ELECTRICAL
«<< OWNER-BUILDER DECLARATION
7� IherebyaHlrm that l am exempt from the Contranor'.Licaue Law fee the ��uLCIXCLIIT/ht)SL
following rearm.L`acUon 70715,Bualneaa and Pmfenbna Code:Any city or TIME METER ORI'OLEINST.
cry countywhkhrequbnapem towcoon,alten, pmve,de lbh,ormpalr
�L any Mruaure prbrro ib lnvarc<,aborequknthe appBantfor ouch pem4t to POWER DEVICES
rt e,5 file a Mgned.htement that he is llcorued purauart to the'psvtdoru of the
Ojw Contr oe3Gcewelaw(Chapter9(comnendegwhh SMlon7DOO)&DIW- SWpggNG POOL ELECTRIC
O Mona ofthe Budnmand Pro(esbm Cade)or"he is exempt therefromand VALUATION
Q the b.ab for the alleged ehempthm. Any vldanon I Sailor 71815 by any
appBantfor a permit xubjem the appBaet to a civil penalty of net rtort than OUTLET&SWITCHESFIXIVRES
116L.dred ddw,MITI.
T,a.owner of the property,or my employees with wages as their role NEW RESTDFMIAL ELFi'IR SQ.FT. STORIES TYPE CONSIRL'CDON
< comperuttim,wdl dothe werk and thestroaum brat banded or offered for
.p .ale LSoc 7016,Bunlrcax and Prud eloro Code:The Contraetoe.Ueerae Law
docanatappNtoano mrdpmpertywlo Wildsorlmpr rather mend OCC.GROUP RkS.UMfS
0.0. who don.uch work himiell mthwgh hbownemplgees,provided that arch
improvemew are not Intended oroffered far sale.If,however,thebuildlng or TOTAL:
improvementbaddwB omyear&completlon,theowner-buWerwillhave
thLIlunlerofprovingthathedid wtbuildorlmpmveforpurpoaeofule.). QTY. PLUMBING PERMIT FEE
C a.owner of the property,am exclu.i contracting ntracting with IleenaN FIAOD TONE APN
contractors to mstrvd the penject(Sm 7064,BualnessaM Pr f.in.Code PERMET ISSU N E apt
The Corridor.Lkerue Law don not apply to an owner d property who W
WIM. or Improve thereon,and who rdram for aueh p(o)ec4 with a ALTER-DRAW A VENT-WATER(EA) _
rylll�dor(OBan.edpurauant to the Cmtradoa'.Liam.Law, gpCK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec B 4 P C for this reason
QUISI DV FEES
DRAINS FLOOR,ROOF,AREA,CONT). SANITARY Y- N_
Owner Date RECEIPE a
WORIGIAN COMPENSATION D ECLARATION pFRTEAp SCHOOL TAX Y_ N
®I hereby affirm Co I have• I n,ate&consent b copy
t wrc,ora RECEQ�'a
anular.ofWorker Comperaatlmlmunnaoraariflcd mpythenrof bee. GAS EA.SYSTEMA INCL OUTLM PARR FEE Y N
3800 ab CJ
I'dkya n* / GAS EA.SYSTEM-OVER6(EA) DINGRWElD IV
Co ausau ns O BUILDING DIVISION FEES
certified copy b hereby funtl0ed. CREASE/WWSIRL WASE EJTFRCFProR PLANCHECKII
Certified ropy b flkd Mth the eily wpectlon divwm. ,
CERTIFICATE OF EX[NIPTION FROM WORKERS GREISETRAP PAID
COMPENSATION INSURANCE SEWER.SAMfpRY SIT3RM EA.XIQ•T Date RCCCI IM '
(This aedlon need not b.completed B the permit b faom hundred down
LYI W)orle.leta.)J WATERHEATERW/VENT/ELECTR ENERGYFEE Y— N
Ianrte perramuna of mewakrarwNah this xr++dtisisuee, —
I than not employ any P.In any manner n as to become subject to the WATER SYSTIM/TREATING
W«keri Compensation Tawe&Cawmnh.Date PAID
O Z NOTIAppliCE
NEW RESIDENTIAL PIMB. SQ.FT. Date Re i to
.Z O NOITCETO APPLICANT.If,after making tMa CertBfate&Enemppttlon,you
H N should become subject to the Workee'Cmepertatmn provision afthe Labor BUILDING FEE TOTAL:
Code,you rout feithwnh comply with tueh prowlorta or this permit shall be
� > deemed revoked.
W CONSTRICTION LENDING AGENCY SEISMIC EEE
d Iherebyaffirmthatthmre amrahudlmleMd gagenryfortlaperfort - ELECTRIC FEE
Z ante of the. for which this u
permit b isedSee( 3097,Civ.C.) O
O nder'.Mnnx PLUMBING FEE
WTOTAL
U l
LL ~ Iander;Addresa &Y. MECHANICAL PERMIT FEE MECHANICAL FEE
O U
UI d lty Nat i have read rhbaod state are that the above informatlm la comet.l agree to comply with a city and county ondinanm and elate law. PFRMRISSUANCE FEES PAID:
(L relating to building coratrodlon,a M hereby autherlae rcprettentatives of this
F. V) city to enter u Pon the aho mentioned property for Wpedlon purpoen. ALTERORADDTOMECH. Date Recel f#
_ (We)agree to save.Ind cmrdfy an d keep hareeles the City of Cu ped B,o P
against nt7e,ydgmew,mM.a rd expenan which may In any way... AIR HANDLING UNIT(TO 10X00 CFA4) SUBTOTAL:
agaWt Wd City In consequence of the gra r"of this mm.
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
\gmnrreof Appuont/^Co I KDate 9 EXTIAUST HOOD EW/DUCT) CONSTRUCTION TAX RA ID:
HALAR dIDUS MATER IALS DISCLOSURE
Wllltheappilad cefutum building oceupant.tore or hand k harardoux BEATING UNIT(TO 10Q0D0 eTU) Date RCCCI tit
matcrlal as defied by the Cupertino Municipal Code,Chapter 9.17,and the
flea 0h and Safety Code Stolon 25532(a)7 HEATWG UNIT(OVER 100,000 BTU) TOTAL: Q
Y. No
Will the appliant w lure building orcvpart use equipment or device. VENTILATION PAN(SINGLE RESID) 1$$ ATE
which enut h.vrd°ua ale renuen tanto a defined by the Bay Area Air
•
Quality Marugemcrt District? N
i BOILER- MP(31MOR IOO,000 BTU)
IMveva
re.dthehamou°material.requirennendurderChaper&95of BODERCOMp(OVER im,OWIII JUN 2 G 1990'
the Glnornia Health 4 SafetyCode Svottem 25505,SS33 and 75534.I
undentard that lithe building doea not au eptly have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. n• �raaa.saa{{.�
re,prroibfilty to notify the ocrupant d the requirement.which rru.t be mel City of CUyuullo
Prior to Lsuan daCediflale of Panty.
k '�
Ownerorawhcdu .gent I Date' TOTAL:. ISSUEDB�v'�I,' II
OFFICE COPY