22408 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingProject Identlficatlnn PERWT NO.
B"adbgAddrta.:q545Fa ►lenhec n. 22408
�1'e4orsl - j CITY OF CUPERTINO-BUILDING DIVISION
Gr^�' APPLICATION / PERMIT
ArGkea g/mern NB11INFCTRICA 'LUMI - ECHNICL CATEGORY CONTROL
Y
[Jc No:
[[ r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— . /J ;S \ PERMITISSUANCE ❑ I PLUMS❑ ElM
LICENSED CONTRACTORS DECLARATION'
I hereby dftrm that l an,likened under provision.of Chapter 9(mmmenc APPLIANCESRESIDFNIAL JOBDESCRITION
Ing with Section'7")of Dtvlden 3 ofthe Buaireaaand PmfeadmuCode,and my
Ilconm la Inf dfeC. PANELS
C
L kete� Ip�Lk.1 �a
Date-�� Cnt
ARCHITEln CTS DECLARA N 2DI-1000 AMPS
q�q�uul�µyl7O I understand my plaro JuB be ead n pubbe remrda OVERIOXAMPS SQ.Fr.FLOOR AREA f/SQ.FT,
he y okuf Licensed Profesbnal SIGNSELECTRICAL '
<<O Q fd OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
F' a Iherebyafflrmwemw
t l enexpt fronCordractorb Llee.Lawforthe
7� Oq�y fcllrwtng r<aon.$eetlm Y(AIS,Buermand Profeaebns Code:Any dtyor
--tywhiekrequW-pemdtmmew eter,improve,de=o h,ormpdr TEMP.METTRORPOLEINST.
atmcted ateortolb he lu,6 Reereu ulpe.t to the provisions
of t e
O V floe.stgned statement that he b II¢rurn puna.;it w provistom of the IVIVER DEVICES
GOnlrtdOr.Lkcme law(Chapter 9(mmnendng with Sectbn,WO)of aVf-
3� slno3 of the business and Prof.bra Code).rust he b exempt therefrom and SW'B,DANGIOO C VALUATION
the baea for the alleged a emptlon. Any violation of Section 70715 by any
SpA apphantfora permk aub}M.theappRent to a civil penalty d not none than OITIT-E]'SWI
IN
�c lw,iih,undred dollars(SM.
�n LJ 1,as owner of the property,or my employees with wage as their an NEW RF9D L PIES TYPECONSIRUCTON
mmpensaurn,wlll do the work and the structure b not wended or offered for
p salo(Sm 70K Buslnm and Profmlom Code:The Contractor.Liet.Taw
(�f� don rot apply to an owner of property who build.or Improve thereon,and C
r, who dceamchwork himself orthrough wownemployee,provided that such OCG ROUP RES UNITS
Improvemew are net Intended proffered forsab.It however,thebuildhgov - TOTAL:
II11FIrvrment bsdd wbhin orcyearofcornplNoR the ownerbullderw111 have -
tIIL*rdeo of proving that he did not wild orlmpmve for purpose riser.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ApN
LJ Las owner of the Property,am exclusively mntracting with Ilcenxd
cauracton to mmwct the projeel(9-e,OG,BualnmandProfmbu Code: PERMIT ISSUANCE
The Cmuractor'.Lkenae Law don nor apply on an owner of property who
wOds or Improve thereon, and who contracts for seek pTItnes with a ALAI-DRAW k VENT-WATER(EA)
cgp(pdW,)licensed pursuant to the Contractor'.Lint.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U 1 en a empt under Sec B k P C for Nb reawn
DRAINS,FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT WORKMAN ICOMPENSATION DECLA RA TION FDMIRES PER TRAP 5CI100L FAX Y_ N_
I�]QJI hereby affirm that I haw a l rtcone of consent to rl(-Inert,or• REcE T Y
rci0Labrate ofWrrke(n�'Com'per1uaFU�mslnaunn¢ma¢rtlfkd ropy thereatL"ec. OAS EA.SYSTEM-1 NCC OUTLET PARK FFF:E Y N
3800,Isis C.t I)p I 4 I RECEIl #
1'dtty a GAS FA.SYSTEM-OVER♦(FA)
BUILDING DIVISION FMCS
I lcertified ropy is henebybed. GREASE/INDUSIRLWASIEENTEWESTOR PLANCHECK FEE
� soloed ropybrued with
tn thetie coy Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE S0WM,SAND'ARYSMRM E. mCFT Date Rceef HI
)or I.bn need not be cornp4ied I(tle penrat bloc ora hundred doBu-
a1Inrifyth WATMHFATERw/VFNr/ELECTR ENERGYFEE Y N
I¢rti(y wtin the Fedoman¢orw work forwMchtw pemdtb blued,
I-hall Ra empby any Peron In any manrcn an u to become subject to the WATER SYSTEM/TREATING
Worker'Cornpua
etion Lam.[Ca H.U.Date PAID
C! = Applicant
Z Q NOTICE TO APPLICANT:If,after making tw CertBlatte of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recei tq
N should become subyct to the Workers'Comet
perabn prob
viav of the Labor TOTAL:
_ C ,,,yue neat hmhwhh mnnply with seek pnevbbraorthb permit shall be
CC ] deemed revoked. — BUILDING FEE
aG CONSTRUCTIONLENDINGAGENCY SEISMIC FEE
I hertbyafRrm wtthereh.mmtruetonlending.ge for the perform
D Z arm althe work(car which this pemdt LS Laaued).Sec 3097c1v.c.) TOTAL: ELECTRIC FEE
02 Lender'.Name PLUMBING FEE
LL I— 1<nder.Addmv QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1¢ nify A l have read thisappllatbn and etatethat theabovelnfomatim
a bmrmct.l:gree to comply with all city and county ordloanm and state laws 1'IXMIT ISSUANCE FEES PAID:
r N rv],nug to wllding mratmct]m,and hereby authotee., rn.W.oftw
F z
city to enter upon the above-mentioned property for iapertbn purpose. ALTER OR ADD TO MOCK Date Revel t#
_ (We)agree to save,lodemntty an d keep baron.the City of Cu ped Iran
agaeut Wbilitles,y dgments,"a a nd expenses which my In any way areae AIR HANDLING UNIT(To 10,000 CFM)
waeuy In rr the gram rrtnl.pemdL SUBTOTAL:
AIR HANDLING UNIT(OVER 10000CFM) CONSTRUCTIONTAX
51 rtaf AppB¢nt/cm,trador D, ExE3wusr Hoop(W/DUCT) CONSTRUCTION TAX PAID:
HAlARDOUS MAT IS DISC U
Will theapplloM af�ture wading amvpnt sort or ndle havrdou- HEATING UMTUO IW,WO BTU) Date Recef t#
fkaftal.a Safety bythe Cupenlno2(a)? lCode Chapter9.1,,and thn
Ikallh andTardy Cade Section 2853,fa)7 HEATING UNIT(OVER 1110,000 BTU) TOTAL:
ELINo
Ro the appleahard nt or l cont wading ocvapedi by the Bay
a Aildevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which ends1lavnrarn all osntaonrawudefined by the Bay Arta Ail
17 YMavgement DWr4[7 BOILER-COMP OFR'OR 100,000 BTII)
( I-1 tw Fl No d
`Thayer titch cu- Coale,
tions 25505,25S33 and
Chapter&95 1 of BOII.EA-COMP(OV[A t00,ON BRIT ` �O
the Californiab Heahh k Safety Cada Sect bra ntly have
a u and,that. I i 0&r
under.tandwtlithe theocrdanofthenentlyenert. enantt.0 be
NEW RF37DFIJ-TIALMEQi. $Q.Fr. 'P 87
nspoto he,ua b nor Ry the k etc of t co the neyulnerrcnt.which oast be met /� �\
prior to lswance ofd CeruBcate ofOmnpan,cy. C �' �'F\/`Mia—i.i/J�
own"or authortred agent Date ISSUED BY,—
OFFICE COPY