20057 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ewldl Pro m Iden kerion O PFRWT NO.
Building Address: /"I O O
23 00 UWI 23 -2 {C G
57
one:
CITY OF CUPERTINO-BUILDING DNISION pp
C tx YNa APPLICATION / PERMIT U �g
Arch 1 64e a No, BUMNNGA U
ELBCTRIC )MBINGMECHAMCAL CATEGORY CONTROLN
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. Qq ti "ss If ol ) ST ,S
PERMITISSUANCE ❑ ❑
LICENSED CONTAAROR'S DECLARATION
Thereby dllrm
mlicmaedunder
donsdChAllflANC6RESmEMIAL
ingwlthSbn�(p0).fDlWdoJafNeitugim 'ImleWdonsCode,and
Iloerue 61n/uB pqqyx d cited. L_
PANELS
Lloensc Gt Lina ,I
Dale -Tv-p—CoMraGor LO H ,ryl
ARCHITECTS DECLARATION HII-1000 " ' �L /
�ZR IuadenlardrnypUnss) UbeumdapubUcremrda OVERl000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
0 FA LlaruN Proferbrul SIGNS ELECTRICAL L ED IN
�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT
7F, Ihertby afOrm thatlame.emp(rm,the Comranora Lloe, LAwforthe /MLat _P UTE R
p rolbwing rem.(Sea :Pion 9015,Bualnea dry sM Pro(slons Code:Any dor
6 Z TFldla.METER OR POLE INST.
FSI anyamo�tywhlch rcqubea pemmtomruhuuirestheaprovgdemolbh,ornplr
�[ anyawctue prkxblbfuunce,aborequbethesppUant for each pamdt to [ON'Eg DEVICES
4/ 3/4
r4 Bis•dgned statement that h<t Ue(M pursuant b the pn,i,00mTOO) of the
9.o�n Contndor's Lkeroe Lw(Chaptn9(mmmendng with Sedbn 70o0)of qd- SWIMMING POOL ELECTRIC
donJdthe thealle and Prdesbn. Any orthatheb eumpt therefrom and VALUATIDN-
<E the bab for the alleged exemption. My Wdatb,i of SttYbn 9mt5 by any OUTLETSSWTICHESFIX URES •.
O� appUandredapermR abjcdatheappllunt toe ds'il penaltydnrs room than
B tl61,R.ndddWaheprMM. NEWRESmENIIALFL,F)CIR SQ-FC. STORIES TYPECONSIRUCTION
�n
pe ion,
ion,owno/theewor wormy empkre is with wages atkRdoor
componsatlm,will do the work and thescrociurc b not 6aerded ur offered for
Dsak bee 901{,Bwlnm aM Prof®loro Code:the Comraciora LInnu Uw
s� don rut apply to m owner dpropeny who Wilds or improve thereon,and
whodoessuchworkhlmeeBorthrough hhown employees,provided that.ach OCC.CROUP RES UNDs
Improvemems an,out Intended oroffered fesale.If,however,the bulWingar TOTAL:
Improvenaem bald wflhNomyearofcamplelbn,theavner-bullde have
t"rdenaf proving that he did not build or improve for purpose of sale.). QTY,' PLUMBING PERMIT ' FEE
"S a.owner of the property,am exchasively contracting with I�ruM FLOOD ZONE APN
contrarian to coromont the profq(Sm 70K Bushes aM professions Code: PERMIT ISSUANCE
The Contnnor'a Liceroe Law dm not apply to m owner d property who ALTER DRAW 6 VENT-WATER(EA)builds or improve thereon, and who donna a for sod. pm tojewith a
o�njEa,tm(s)Uanned pursuant to the Ccntneda Llnrm law. IFEE SUMMARY
1_J T am exempt under Sec B! P C for this reason
DRAINS FLOOR RODF,AREA,COND.' SANITARY Y N_
_QIITql"P 191
Owner Date R[CFJI•'r p
WOR KMAN COMP aNSATION f MRATION EUTRRtES PER TRAP $p-7Op1,TAX Y_ N
hereby affbm that I have•arti(lab d consort to self-insure,ora RECEIPT'
co oleo!Workers ComperoHlmirauranamaartl!led copythereof(Stt.
3800, abC GAS FA.sysrilM-i INCIOUTLM PARK FEB Y N_
Pdlg1caI m ICJS � I„y /fly GA EA.SYSTEMOVER 4(pA) BUILDING DIVISION FEES
O
!nv py 1wIRECEIVE4
Mahe . / GREASE/WDusrttLwASIEINTFACErroR- PLANCHECK FEL•
I7J�Certified ropy 6 filed with the city Inspection dMslon.
CERTIFICA TE OF EXEMPTION FROM WORK EBS GREASE TRAP PAID
COMPENSATION INSURANCE gL}ypR SAMI'ARY STORM FA l0�r. DBIC RM i IN
(rhissenbn need out becornpleted Lithe wrout 6(monehundred dollars
(S1W)vrlea") WATER HEATER w/VFM/F].ECTR ENERGY FEE Y_ N
I mAilythM In the performance of Ne work brwhia thin pemdt 66aued,
I duB net employ any person b any manner n as to become who to the WATER SYSHM/TREATING
Workers'Compenatbn Um of Glifom6.Date PAID
O Z AppllNOTICE[ ion,yout NEWRESDENTIALPLMB. SQFr. Date Reoeio tH
Z O should ETO esubC to
coixfter makingthis
pro lsa. ftof teLal,o
should become subject to the Waders'Compematlon prov6bro of the Labor TOTAL:
Ir - dmoadu ,must
forthwith comply with soch pmvb ro or this permit shdl he WILDING
CL ESCONSTRUCTION LEND AGENCY SEISMIC •E
I hereby aNrrn that tMrt 6• b mrutmdlm lending agenry for tlx pedom�
,7 Z ance of the workfor which this permit loved 309/
Eke. ,CN.C.) TOT L, ELECTRIC FEE
U O lerder'.Name PLUMBING FEE
LL 1- Lender.near... Qn. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1¢nlfythat I have read th6appllatbn and statethettheabovelnformetim
b oamou.Iagree to comply with all city and county ordtrunces and mate laws - PERMIT ISSUANCE 12.00 FEESPAID:
Nrelating to Wilding mnsnacti -ndlhereby autherlu representatNn o(thb
F Z city to enter upon the vcmentbned mpertyforimpeetbnpurpmes. ALTERORADDTOMECFL Date RCCCI t#
M'd agree to M
harmles thP-8=i6bWt ciPenich ylnanyway.. NR HANDLING UNIT(TO 10,000 CFWSUBTOTAL'
aglvt paid ign nt of permit.
tel/_ pv AIR HANDLING UNIT OVER IO,WOCFM) CONSTRUCI70NTAX
signstu IAppllont mtracter Date EXHAUST HOOD(w/DUCT CONSTRUCTION TAX PAID:
HAlAR IMUS MATERIALS DISCLOSURE
Will the applicant m f tum WUdingomrpant more orhandle harardaus HFATINGUMT00iffl, 0BM Date RCCCI tN
material a de0ned by the Cupertino Murldpal Cade,Chapter 917,and the
Healthardsafcry Cade Im75 (A)? HEATING UNIT(OVER 100,000 BTU)
qTOTAL: O
yesIwArN
YUltheappBnmorfikum Wlldingacapmtuseequipmentmde _ VINHIATION PAN(SINGLE READ) ISSUANCE DATE
whkh emit hanrdous air ountammarts as defined by the Bay Area Ab
. W 1 Y.avgemem No BOQ -0
FRDMP(311P OR 100,0(q BTU)
have red the hav erruleria6 Iremenb under Chapter 6.95 of BOILER-COMP(OVFLi 100,000 BTL1) JUL
the California Flea ety Code. 25505,755]3 md7553/. 1 J 31 199p
uMe,Wodthatl eW dingc a ntly!uvea ant,that It 6 my NEW RESIDENTIAL MECH. SQFr
rnporo1601ty nrilty a oca nt d th Ireme Mich rrwu be met �� r�
oriorin d nB f Ery. CTp lath/ cep nr �^
9--9 -ago �•-�.�� ,r���raF�H.,r�,,
ne authociad agent Rate
TOTAL ^i7r ISSUEDBY: VUl�--11'TV/.I KJ M,
: �I.�J
OFFICE COPY