22159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building AddreBa,suildiv Preen Identification PER.wrNO.
22159
ore arc: oc
CITY OF CUPERTIN0.BUILDING DIVISION -['� �� !y
C sName: �S GLkN. APPLICATION / PERMIT ser
1 � 1 BULL.DING-ELECTRICALPLUMBING- E NICA1. CATFLORY CONTROL#
Architect/Engtmer. Lk.No: '
QTY ELECTRICPERMIT ' FEE BUILDING PERMIT INFO
Add.
trERER1,mIssunNCE fd ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION L� .
I herebySccUtri 0B))ontlat LR,iM Softeadi nder eBuninwWamof Chairs od,annamc APPWANCESRF�ISIITAL JOB DESCRIPTION
i..Isrctlon force of DlvlNcm3ofthe ` andl4ofeatlanaCode,and �u
Ibemele Ins, tome and cf1 3. 1 PANELS
LicenseClan L1c# 1
Date Cmdracur
ARCHITECTS DECLARATION 301-10DOAMIS ^W
a Iundentardmy phruaWBbeused ll publieremrde OVERIODOAMIS SQ.FT.FLOOR AREA $/9Q.Ff.
Licensed Pmfcmbnal SIGNS ELECTRICAL
fn a bl OWNER-BUILDER DECLARATION SPTSIALCIRCUIT/1,4.9C
2(- � themebyefirmthelame,empt fmamlhe Cotractorh Llansetawfmthe
following reawn.L"�Ylo 7m15,&ulnen sed Pmfmlom Code:My sty m
O � TQ.fP.METIX OR[Y3LE INST.
F� mrntywhkhpe tolap a=m atrequ alttheapbvntfmibh.orrtpalr
anyatunun patens lbhuan,is abarequWsuant t the i achpumite POWER DEVICES
(Ile a signed wtement that he h IIcemM pursuant to the pmovhbm of the
Contmxt,r'.[,[cr eLaw(Chapler9(commancing with Section 7000)of Mo- SWIMMINGPOOLEIECTRIC
H�05 ecn3ofthe BusbemmdProfsabreC e)orthathebmmptther maM VALUATION
YI the bash for the alleged eeemptbn. My vldrtbn d Sailors 7m I5 by any
applicant for a permit subjects,the applicant to a dull penalty of not more than OUTLETSSWITCFIESFUCNR6
nv unfired dollars MW.
Gl g u I,as owner of the Property,or my employee with wages u their sole NEW RESIDENTIAL ELDCTR SQFr. STORIES TYPE CONSTRUCTION
rnmperuatlmi,will do the work and Ne structure hot Intended or offered for
O
as
le(Sec 70K Buencos ab Pmfembm Code:The Com mac ots Litems Law
[ Sg doe not a pply to a n-1 of property who bulbs,or Improve there,nand
a- whodoeeachwork hlmseffmthrwn
gh hlsawramploye ,provided thatuch OCC GROUP RES UMTS
ImprouemenU arc not Intended oro(fered for sale.It however,the W Ilding or TOTAL;
Impmwement hsold withlnomKyeardcanple.on,theownerkullderwW have
rdend peening that he did!not Wild or Improve for purpose of see.). QTY. PLUMBING PERMIT FEE
1,u owner of the property,am eachuWely contracting with Licensed FLOOD ZONE APN
contractor to mmatrun the pm)od(Sa 7046,Business ami Profeulom Code: PERMIT ISSUANCE
The Contractor's,Llcems Law don not apply to an owner of property who AL7IIt-DRAIN&VENT.WATER MA)WOds,or Imp.thereon, and who comram for such ptojem with a
ogIlpactom(s)llavned pursuant to the Cmtrana/s Lfoevse Law. FEE SUMMARY
Lf I en e.emps under Sec B&P C for this,reawn BACK FLOW PROTFST.DEVICE OUTSIDE FEES
Owner Date
DRAINSLO
FOR ROOF,AREA,CONTI. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑1 hereby affirm that 1 have a certificated consent to wlf-Nur,or a PER TRAP SCI-1001,TAX Y N
anile,ledworkm•Compem mlmmm ma amngkdropythemfOic RECEIPT
3900,Lab C.) GAS EA.SYSTEM.1 Bs'G6 OUTLETS PARK FEE Y_ N_
pun# RECEIPT�Co GAS EA.SYSTFAtOVFR#(EA)
ray BUILDING DIVISION FEES
lfted copy h hlreby(umWed. CREASE/INDIISIRL WASTE INTERCEPTOR PLANCHECK FEE
ennNad copy h filed with the mY inspection dlvWm.
CERTIFICATE OF EX] PFION FROM WORKERS GRFASETRwr PAID
COMPFNSATIONINBURANCE SEWER-SANITARY STORM E.A.2DaFr. Date Recti tIl
(This section need rat be completed!U the permith(move hundred do0an
(y100)m les) - ENERGY FEE Y N
Ianuywtmme peAomana of thewmk mm whlchwepem,tlhbuea, WATER HEATERw/vFxr/E3LCIR
I sha0 nM employ any pee in any canner n u b berme ambjea to the
Workcmi Compi mWbn Laws of C Womla.Dam WATER SYSTEN11TRE`i11°G PAID
PP NEW RESIDFMiAL PLN& SQFT.
Applicant Z OZ
NOTICE.TO e,sub APPLICANT: after mabng thh Certl(l,tedoExt s ptIhe you
bo Date TA tit
Hrn ahold berme object to the Warken'CommWewtlm pmvbbm,(the tabor TOTAL
Code,ym.9 forthwith comply with such puvhlonsorthb permit shall be BUILDING
LU ] dcen i revoked.
CONSTRUCTION LENDING AGENCY S I IC FEE
Z
d z I hembyefirmthe then h com
a umutim lending agency for the perform, ELECTRI
TOTAL CFEE
7 ,ns,afthe work!or whlcn thh perrtdtbbued(sec 3097,CW.C3
U O LcMar'sName PLUMBING FEE
LL F larder,Add,rs, QTY. MECHANICAL PERMIT FEE
O W lceAi hatihawmadthhappB tWnaMe tethathe abwelnfar on MECHANICAL FEE
1 6muma.I agree to comply with all cly and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>. N relating to building mmtunlon,and herby authorise representative ofthb
Z city to enter upon the abovcmrcnwmd property for inspection purpmea ALTERORADDTOMFLFL Date Recel tq
(We)agrn to ere, emrdfy an d keep ha ns,the City of Cupenw
V agalvt WWII it "smpensn ylnetywayacvue AIR HANDLING UNTr(17O 10,=CFM) SUBTOTAL:
against
old ace en permit.
niRIlnNDUNc UNIT(OVER to,(m cFM) CONSTRUCTION TAX
Sigmatumof AppB Contrs,ctm Date EmAUSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H fut)dUSMATERIALSDISCLOSURE
Wial.appB,m me, urt building oaipalCo , orhaMkharamdom HEATING UNIT(TO 100,000 BTU) i D ¢ 1
material a de/imad by the,Cupertino Municipal Code,Chapter 9.17,and the
Fie ITh and Sefety Code�+Section 2553I(a)t FffAT1NG UNIT(OVER 100,000 BTU) T
Rill
,+��--,II No
Rill the applicant mfuture Wilding ocupant ux equlpmet or de. VEIJTILATION FAN(SINGLE RISTD) r�H�SSUANCE DATELW
which emit hannious an conlambunte see deRrud by the Bay Area Air
Quality Management Diurin7 BOILER-COMP OHPOR 100,0M BTU) - ��`
YNo
haztead the h.Q materials requirements under Chapter 6.95 of BOILERLVMP(OVE IW,000 BTI!)
the Glifomhl-Iealth&Safety Code,Sectbm75505,25533and2 M.] 13D0INSPECTION DEP
uMnsM tathat ifthe Wve
ilding does not currently haat,reL that It bo ®
y NEW RDENIIALMECIL SQF .f ARi
respombiWy to notify the mupant of the requirements which met he met DC CUPERIINQ
prbrto Wuancedaartukaim.f O.arpancy. L YY{{1IffYY`"�,1111''
Owneror suthortud agent Date ISSUEDBY:_
TOTAL
OFFICE COPY