22194 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Baildl project Identification PERMIT NO.
Building Address:
22194
s
e N
Phone:
ZS3 Go 8 CITYOFCUPERTINO-BUILDING DIVISION 1A
. cLDAm
�Na 222N. APPLICATION I PERMIT
J3 1
U ` BUILDINGfl.ECIRICA IIMBINGMECIIAMCAL CATEGORY CONTROL
echftecx/Fsglreer. Lie No: ,
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
FFRI=ISS'UANCE _ ❑ ❑ ❑
LICENSED CONTRi under rDECLARATION I hercrctImn mthat l MWenaeduMerpmvWwuof Chapter9(mmmmc APPLIANCES-RESIDENTIAL JOB RIIRION
Ingwith I.fian form ofdejfl 3olthe BuNnesand ProfesslavCodr,and
Ranein CU full cora and dfed. PANES
Lkevr Clara Lie. (�•�sL+.�J'�j, �
Date Conbador —UP TO 2DOAMM
ARCHITECTS DECLARATION MI-1000 1
IuMennaM my playshaB be used a pub0c reeda OVE[RIOOD AMPS ALFaFA1
$/ Q.FT.
L U Gan"Pmfembvl SIGNSELECTRICAL lacw P TE R
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC 0 O
r hercbyaffl mthetlamemmpt I.the Contrarme,Lice.Law for the aft pp fallowing reason.45ed1on 70715,Bushes AM Profeeebv Codc My city or
TFbiP.METER OR POLE MIST.
FEP muntywhlch rcqulnaprmdlmmMrud,ilter,Improve,demoBehor repair
anyatrodurt prbrto iia Lsauance,abo rcqulesmeappBant roc ouch pertMb POWER DEVICES
O RIB a signed statement that he is Bayed pursuant to the pmvblov of the
�: Cont Aeota Lkevelaw(Chapler9(commendngwhh Sedbn 700D)of DM.lit SWIMMING IOOI,flFCIWC
O sbn3af the Business and Proresbv Code)mNat heb exempt merttromaM VALUATION
the basis for the Aleged exemption. Any eldatbn of Sedbn 70715 by any e
< applicant for a permit subjects theapplkaat toes eivll pevky of net more Hun OUTLEISSWITCHFS-FIXTURES
0Nw^dred dollars(t M. NEW RESIDFN LAI RLECTR
U 1,as owner of the property,or my employees wish wages as their sole �fT' STORIES TYPE CONSTRICTION
mmperuatlon,will dothe work and the structure b rut bdeMed or offered for
O sale(Sec 7014,Busloess aM Prefesbv Code The Contradors License law
door not apply to an owner of property who builds or improves thereat,and OCC GROUT' RES UNITS
does sus)work himself orthmagh his own employees,p.W .that such
Improvements arc not Intended oroHcred forsale.If,hmveeer,the building or TOTAL
( Improvemer wMwlthinomrarofcanplebRthewvner-buMermlil ve
v UT,*raenofpro.nngthatnedM wtbaddorimpmvetapurpoeeofsale.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am excWsleely contracting with Ibenxd FLOOD ZONE APN
PERMIT ISSUANCE
contractors to construct the projMee(S7014,Bushes and Prdulov Code:
Tbe Cmdraet e-Iles,Taw doer not apply to an owner of property who ALTER-DRAIN&VENT-WATER lFA)
bu0ds or Improves theme ,and who ommacta for such pRojm with a
0?ngAetcr(s)limrsed pursuant to the Contractor's Llave Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt under Ser. e k P C for this reason
•
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N_01 ITq I DE FEES
Owner Dale RECEIPT/
WORKMAN COMPENSATION DECLARATION FDCrLTRFS PER TRAP SCHOOL TAX Y_ N_
❑I hereby arlum that I love t aeufbte d consent to oopytnsrc,ora RECEIPT 0
mr,ifirste1.b of Workm'Canpewtlon Insurance a•anufed copy mertof(Sec.
3800,Tab CJ C7 GAS FA.SYSIE.1-11NC4OUTLETS PARK FEE Y_ N_
P'11gI _ (Q RBCFIl'f.
Com nv �I f'1d (L/� GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION ETES
with city I
hPilledcopyb�tm . GREASE/WDUSERL WASTE INTERCEPTOR PLANCHECK FEE
ertlfled copy b filed hthe cit.
division.
CERTIFICATE OF O(EMPIION FROM WORKERS' GREASE TRAP PAID s
COMPENSATION INSURANCE SEWER-SANITARYSIDRM FA 2D[)FT Date Recel tH
(fhb sedlon need nest Ix completed lithe permit le la one hundred dollars
(Sia J WATER HEATQRW/VENT/ELECTR ENERGYF-EE- Y N
I mnlfy mifytmatlothe pedorrtuna of the work forwMch thio pemdt bleved,
f ehau not employ any person In any manner sou to become subject to the WATER SYSITM/TREATING
Worker-Compensation Laws of GBfomla. Due PAID
-
zZ Appliont NEW RESIDENTIAL IeLMe. SQFT. Date Revel tH
Z Q NOTICE TO APPLICANT:]!,after ensuing this Certificate of Exemption,you
F N should become ssbytt to the Worken'Compevatbn provbbv of the labor TOTAL
Code,you must fun hwkh comply with such provlabv or this permit bull be
W > deemed revoked. BUILDING
W CONSTRUCTION].ENDING AGENCY SEISMIC FEE
M Ibeeof th work
thertbacovwdlonle 5,e roC) door. ELECTRIC FEE
8'8^^tY Pe
� Z arta of the work roc whichmb pemNtbLwed(Bee 3097,CW.C) TOTAL
02 Lender's Name PLUMBING FEE
IL H L<Mre.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IanlfythHlhave mad thbappllatbnaM etatethat theaboveln(omutiori
Lscorren.Igmrt tormoply with ail tyaM countyordivnmand date laws PERMIT ISSUANCE FEES PAID:
} N relating to building mroteudlm,and herby authodre representatives ofthis
F z '„y to enter upon the above-mentioned property for Wpectbn purposes. ALTERORADDMMECM. Date Recei ted
—
(We)agree to nee,i demNfy an d kap harmless the City of Cu penal
Against liabNties,jedgmem,moa AM eape.which may b any way aamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ages teal City in 04 /ens of the gnating d this Pe
1 Q, AIR IIANDUNc tJrrrr(OVER 1o,BoocFT.n CONSTRUCTION TAX
Sig taamo Appllant/Contractor Dale FXHALIST FK)OD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wilt the app0 ntorfuture Indicting occupant pare or handle hauaml us HEATING UNIT CFO IOD,000 BTU) Date RCCCI ted
material as defined by the Cupertino Mualdpal Code,Chapter 9.13,and the
Health AM Safety Coded =(m)?No
Code Sdon (a)7 MM MATING UNIT(OVER 1m,"BTOTAL:
as
Y
0lmeappEontor Wwrc ilding« pantuercqulpeneumdry VENTILATION FAN 6INCLE RESID) ISSUANCE DATE
which emit)unrdvua W eontaenlnama as deflvd bythe Bay Area Air
Qu Ifty Management DbtW i BOILER-COMP 0s) OR 100,0(0 BTU)
YPAID Y,, nn No
t have read the b.. maerlab requ laments under Cha parr 6.95 of BOILER-COMP(OVFRIOD,000BTU)
the California Fleilm&Safety Code,SMioru 35505,35M and 3.5531. 1 MAY
uMmtandthatifthebuilddngdceswt mntlyhaveatenanithatltbmMEIX FT
y NEWRESIDPN77ALSQ. .
eespovmRlty to ndlfy Ne occvpaM dthe requlrtmrrde which Hoot ler rrot
prim to Lsuana d a Cenlllate of Otapavy. W
Owner or amhodndagent w Date
TOTAL: ISSUED BY:
OFFICE COPY