22140 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen ldentlfkatlm PIBLMIT NO.
Building Address:
22140
-7509 --bJPAtES 2-
e: APPLI�TIONSIJBM11TAL DATE
waaa Lc. �/knRlsT 253�l b9 CITY OF CUPERTINO,BUILDING DIVISION
G°^tr•"Z •Iq� —� GAO APPLICATION /PERMIT
r 111111.DINGELECIRICALPLUMBINC-MECHANICAL CATEGORY CONTROL/
A:rhBeR/Fnglneen Lic No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihertby affbmthatlam llcn.aduMer powlrasuof Chapter9(rsxnmm< AFPLIANC6RESIDENTIAL )DB DESCRIPMN
Ingwith Se .700Mof Ovldon3ofthefltud Band ProfeeMonaCcdgand try
license is in full for¢and effect. PANELS
Lbe.Clam Lk..
Date ContaRor �V�'E/•
ARCHITECTS DECLARATION AMPS
m Iuvd.nta red awry pWushaB be usedmpubllc rooad.. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
�619[j LtmruN Professional SIGNSELECTRICAL
G Lbu
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MI'SC
aO � Iherebya(Orm tlutlamevemptfromthe Conte or's Lkense Lwf«the l
I (ollawing reaaon.(Sealon70315,Bualnemard Pmfeubru Code:Mydtyor p.MEhR OR POLE ANSI'.
FSC muntmw mInqulma peramt,alwequiea capmvgdessudh prroh to
any.xlgGertuterto Its Comes•boamed p. hettothntfaauions of te — DEVICES
O fib a algoed statement that he b Ibenaed pursuant it the don 7000) of the
CnmranOt's Llcenne Law(Chapter9(mmoendng with Seabn 7000)of Dlvl-
S�OS afon3o(the Business and ProfmbmCode)orthx�elsexempteherolmmand SWDdMING POOL.ELECTRIC 4 VA
S^ the baela for the alleged La
exemption. Any violation of Sbn 7MLS by any (> OUD.ETSSW/7C}fESFIXTURF3
I
QO apphantforaps mbje theappllewttoadvilper hydnmm mthan CXJ
& hu ndreddallaa(E.500).
.. n I,as owner of the property,or my employm wdh wage an their wle hlEW RFSIDENTIM ELECTR SQ.Ff. SIO TYPE CONSTRUCTEON
C76 compewdon,wBldothe work,and thestruMm is not uuerdd or offered for
PjD d (Sec 7011,Bu.u�.and pn pu y Code:The Cowano.th. Law
S$ dmndapplytoanoweer dpropexywhobernpleies,preideneon,and OCC 'ITS
E whodoowchwarkMmaeRmthnvngh Naownemplgers,pmvded that such
Improvemew are wt Ntended�oof(ened f«sale.ILhowever,thebullciingor TOTA[
Improvementlaaold wLLhinomrarofcamplelbn,theownerb Werwlllhave
rdLn of proving wt tie didm build or Improve forpurposeor.ak.). QTY. PLUMBING PERMIT FEE
as wvno,of the property,am eswNely contracting with Iben.ed FLOODZONE APN
tractors to mnutrun the project(See 70K Busbns and Pnaf® N
lom Code: PERMIT NUANCE
CE
License law don not appy to an owner of Property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Irnprove thereon, and who m^tmtl for writ projects wbh
ry➢�ae'tar(s)licensed pursuant to th.Cmmdor'•Line.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt-oder Sec B k P C for this neawn
DRAINS FLOOR ROOF,AREA,CONE,. SANITARY Y_ N_
Owner Dab R)C=Y
WOR KMAN COMPENSATION DECLARATION
E'El hereby affirm that I have a aertll{ate of consent to 11118-bort,m FIXNRFS PER TRAP SCI10pL TAX Y N_
390 of WarFen'Compenxlm Imurwn m•¢mifkd maa
pythef Sec. RECEIPT a
SEW,.Lab
b C-1 GAS PA.SYSPEM-I 1Nc10UTLEIS PARK FEE Y_ N -
I olky 1 GAC EA.SYSTEM-0VFR 4(EA) RECEIPT a
C° ^Y BUILDING DIVISION FF.0
Certfled copy is fled
the eyedi. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CenNed ropy Is(fled with the city WpMbn dlvWm.
CERTIRCATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATIONINSURANCE SEINER-SANTTARYSTORM FA.xIWT Date Remi tN
(ITJaaenbn bead bat be compined Bthe permit 6 f«cru hundred doBue
(E100)«fyth WATER HEATER W/VENT/ELEcrR ENERGYFEE Y N
Imnot rnplaat in the persowmnyraw«k anrwMohtwe,mbten ito the
I shall not ennplwy any person In any runner at m to hemnrc ub(et to the WATER 5YSIEM/TRP ATING
w«ken;c«npewtlnn lawaar alB«nla. ore PAID
O = NOTICE NEW RERDENTIM,PLM B. SQFr. Date Recel O
Z O NOTTCETOne subC to the orl,maWngtwjaulon pm of EaempteLabo
.hml, becometforth it the Wly with
eampenaxim,provabmofthe Labor TOTAL
LU N Coornodumtst/athwdh®,py Mth such proWbru or this permN shall be
� > dLLmLa ne.�aked. UUILDTNC FEE
lL p CONSTRUCTION LENDING AGENCY S MIC FE
CL Z alhembyafRrmthatt me amnutrucimlendingagencyfortheperfor EOTAi. ELECTRIC FEE A
anoftheworkforwNhthb permla it Issued Sec.3 ,Clv.C.)
Lf O l<Mer's N.ere PLUMBING FEE
LL ~ Iender'.Addrom - QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I«nlfythxlluve madtw appLLotbnaM ratethx theab>ve LJomWlon
iemrtea.Isgnee to complywLLhaB dtyard many oodlnanm and ices laws PERMIT ISSUANCE FEES PAID:
} N relating to Wlkling mb nstrudlon,and hereby authorrepresentatNn of this
I.— V) my to enter upon the abovennentboed property for inspection purposes. ALTFRORA3TOMEC11.
-(We)agree to save,krdemnity an d kelp hanrdem the City of Cupeniro Date Recelptit
V agalast WbWtin,tudg.rus,noses and eapemn whkh rosy N any way..e AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL•
agaWt said CLLy In mnsryuenm of the�a 1�/o1(thl"a.soma-
\ I/ y .aTg/y/ AIR EIANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX
B1kNt-rt ofAppllant/Cmtanm JC6 M Date I E�IAIJSTHOOD(w/DLrD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplla odafutumbullding« pantstomorhaMb hazardous HFATINGUMT(LOI0O,0D0BT1)) Date Recei tN
nuterlal v defliud by the Cupenlw Municipal Coda Chapter 9.IZ,and the
N<anh aM Safety Code Setlim 75532(a)7 HEATING UNIT(OVER 1W M BTL!)
14 yTOTAL:
yesE No
l the applhnt« ,Wilding oeevN.t uxeequlprrew or devices VFNTI IATION FAN SINGLE RESID) ISSUANCE DATE
which emit hav rdo is air mntandrants as deBvd by the Bay Area Mr
Qu alny Managerrcrd DlstrW 7 BOfI.ER-COMP PIR'OR 100,OOD BTU)
YyesI�No
t azy oils a n�
have read the hmlLriaH requlrennents under Chapter G95 of BOILER-COMP 100,000 BEV)
the Ca Ofomla Heahh&SafetyCode,Seabv75505,75M"d2SS3C. I Y *�s
understand Hut ifthe Wlldingdoe.not mnentlyhave,tenant,that ltismy NEW RESIDENTIAL M.ECH. SQ.FT
resporoBdiity to natty,the occupant of the requbenmnts whkh roost be con ,C
prior to Ltsuanuu ofa Certif ate of Oavpancy.
Rn
Owner or autharlad agent Date ISSUED 11Y:
TOTAL:
OFFICE COPY