22385 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project IdemlfkaUon 7 PERMIT NO.
e.Baing Aaa.: yI. p 190Q, i P� 22385
I O
rs ams: . one:
CITY OF CUPERTINO,BUILDING DIVISION
Contmdor.Name: Lk.N. APPLICATION I PERMIT
BUIIDINGELBaTRWA MP BINGMF] NKAL CATEGORY CONTROL
Archfted/Engineer. Lb.No:
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERhff['ISSUAN'CE El ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby Ikensed provisions aper9(mmrren APPLIANCES-RESIDENTIAL if F RR'IION
Ike.I.ert1on InOp)of Dlvialon3ofthe Buslnmsand ProlestlonsCode,and Tol'p/ey .
Have ie In lull(o d died. PANELS
Lia Cla Lice -� !r�
Date Cordrad. , NNs./rd[ 1 �Umb
ARCHITECI•S DECLARATION 2QI.10DQ AMPS
@aO ZpZ❑ Iundervand my plans.lull be used u public recards. OVER1000AMPS ^Q.FT.FLOOR AREA S/9Q.FT.
k u Lkimsd Profexbvl SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION 4'ECIALCIRCULI,/MLSr I'�CIrJ lA.11. r
I.., I hm
erebyafirmthutl....emptfrothe Comd
raor:Liarue Law(athe f
Fp ❑ folbwing rtasm.tSccHon 70315,Bu W er and I'rv(ubv Codi.Any tlty or !
ZiG"'� county which requlresaprmd[to mmtrucy alta,4npmrve,demolbh,orrcpair TFl./P.METEt ORIOLE INST. 1 P e��
anyW =mprbrtoWbar alaorequir eappfantfwmapemdtto POWER DEVICES
E file a signed statement that k 6llaruedpursuant to the provisionsof the v' Z
QQc Contradols)}cense Lw(CFapter9(mmrmruingwfthSectbn7000)o(DiW-
>O�' don3afthe Bust .dProfe .Cmde)ort hehere theldromand '`MING IXJOI.fl.ECIRIC. VALUATION v
<5 the bash for the alleged r.rmptbn. Any vlalatlun of Sed) 7(FIS by any _SWITCHES-FIXI.URFS
appUontrorape tmbkabtheappl nttoaddlpevhynf am.re than
E � tiNhundred ddbs(S. mpertyor my empNEWRESIDEN'IALEI.EM SQ TYPECONSTRUCTION
�n I,as owner or the ppro , byen with wage u there sole R �J T E
compensation,willBotheware,andtheatrode: hrotomadedor offered u..Lfor
O doe does not.p ly to atrow.d
ci( dexbro Code:The Corded e.in,tJanse law
whorl pplytoak i.lfdt .ghrt In Wlbaorlmi,p.Wt ertoR and / R�UN�
wprones ucL work himvelf athrwgh hlevwnemployen,PrwidM thatarch
Inrprovenerda am rot Intended orotlered(a aai.14 however,the W tiding or TOTAL: J
MTE
improvementhwWw hinomyearo(compleUoy ownerbullderwWFave
ttiS nlroot provoiftba he aid int wed or lmpmve fa purpose ofote.). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am emIusively mnlradNg with llanaed FLOOD"LANE APN
�tndmeto mvtrud the projM(Sec.70Y4,Bvinm and Prdmbn Cock PFRMTrlSSUANCE
The Contractor'.Lberue Law does nU apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
Willa or Improves Nercon, and who mrdrads for such plokda with a
ogp7pcmrW licensed pursuant to the Contrador:License taw. FEE SUMMARY
LJ I am e.empt under Sec B k P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
. Owner Dale RFLER'I'Y
Waft O tAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCIiO0L TAX Y_ N
rI!hereby ar/4m that I have o art .. d cwrnt to apy6r rc,ora REc�.Y
to of WorFer�i^Compensatimlraunna as�ja-rt�ltled mpythem f(Sec. OAS FA.SYSI.E]N-I INC4OUTLEIS PARK FEE Y_ N_
laic o CJ 1 CZ OIiJ RBCF]PI'Y
IY>fky GAS EA.SYSCFAIOVER 4(EA)
Co v��a�.io�ma Nid ' � �. BUILDING DIVISION FT.CS
(�CortBhd espy la fakdlwth thehed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHE•CK FEE
�7CcrtNed espy Is filed with the dly Wpedbn dMaion.
SIC CERTIFICATE OF EXEMPTION FROM WORKERS CREASETRAP PAID
COMPENSATION INSURANCECrhlaSEWER-SANITARY-STORM EA 70m-T Date Rani HI
)u,I ctbn errs na br compldea atlas permit lataorehnnartd aon,ra C•NERGY FEE Y N
(SII oiler.) WATER HEATER W/VFM/FlECTR
Iartilythat to the pedomrwany warefor whichthis prmbjbhared, '-
1 sHp nest imp itr any pensee b any manner w a m become cobjed ru the WATER SYSTEM/TREATING
Workers'Compavatbn laws of Ub(arnh.Date PAID
-
z Appbant NEN,RF9OFNTIAI.PLMB 90.Ff Date Recei tis
Z O NOTICE TO AFMICANT:lf,after nuldng this Certificate of Exemption,you y
shmld bemme subject to the Workers'Compevatbn provisions of the Labor TOTAL:
1_ FO Cade,you must forthwith comply with such provbbv orthh permit shall be
K j dremea revoked. BUILDING FE
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE• �„ t
CL I hereby afOmnthat them ba matrudion lending agency torthe perform, ELECTRIC FEE I�-q' �_r}
M Z anaofthe workrorwhich this permit hiarrd(Sec.3097,CW.C.) TOTAL Drer l
U O seder's Name PLUMBING FEE
�nder:Add. QTY. MECRANICAL PERMIT FEE
LL MECHANICAL FBE
O W Imn,t I. Tee,have read this with all itlonand dinounethdthe abovedstatertws
Mal"t.lagreeto complywlth ail dtyandmunty repnmanaesofthis I'FRh11T ISSUANCE FT:ES PAID: l i / )a
i
} city to enter
nt rupongmvove_me,a nedi property odupe do representatives olthh rl�C`/'1 '1 e 1
F Z cityW)aree to see,Indemnify an d Imepenyfais theyC purposes. ALTEROR ADD TO MFAH.
V — (We,.bier to rove,Indemnify an d knp h the city of Cupertino Date ReO L
aif
gaWtllabWb,lydgmen4 ooasard eaperum wh nayb any wayamve AIR HANDLING UNR RO 10,000 CFTU SUBTOTAL:'
agalvteal ftpb a or gr.mbg or this mw. AIR HANDLING UNTI'(OVER I0,000CFM) CONSTRUCTION TAX
sig rtar ppua cat a - EX11AUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS ERIALSDISCLOSURE
Will the apppantnefuture WBding occupant stare or handle hared HFATlNGIINIT(TOt00,(=RI1) Date Recd tic
material as defined by the Cupertino Muddpal Code,Clupt 9 Z rulthe
Fleahhard Safety Code Sedion255U(a)7 Y HEATING UNIT(OVEt 100,000 BTI) TOTAL:
Y. ,p+(-J,No
Willtheappll . m'(uta ,buddJngoceupantuaeequIpmeovadevkes VENTILATION FAN(SINGLE RESID) ISSUANCE DATE -
which emlt havrdms alrll��oonntamLuntsas deBrcd by the Bay Arra Ab
® Qualityhlunsgemeot Dbtrkt7 BOILER-CAMPOHPOR100,0(DBTU)
Yes ®®No
I have'ad the hardrdous matcr)alamgtl.n .t%..dr,Ch&pt,r 6.95 of BOILFRLbh(P(OVER 100,000 BTU)
the 011fmnh I leafth h Safety Code,Section,75505,75533 and 25534.I
understand that](the Wilding does our mrrently haveatrnaot,that It h my NEW RESIDENTIAL h¢a. SQFT
repo mty(.o Iffy hraceupant afthrrrqulnmmtawhk muabrmet
P o la la teofooupancy.
Owner or au eda ent l5afe TOTAL: ISSUELRYA&�
OFFICE COPY