20863 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '
-BuildlM Project identification PF3N0TN0.
B�uIdmg naare�e 20863
'ane7Z.��7�i CITY OF CUPERTINO-BUILDING DIVISION
( ontrarm .Natne: Lk.No APPLICATION / PERMIT
BUILDINGELEC RICALPLUMBINGM NICAI, CATEGORY CONTROL
Archhm/Fsgineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
❑
LICENSED CONTRACTOR'S
❑ ElOR'S DECLARATION -
Iherebyd(Irm that lam llcm.ed under provmweof Cfupter9(r$tunm AI'['flANC6RE5mENf1AL JOB DESCRUFf TON
hee.a1.fian7000)d DYWtlon3 ofthe BuNneuand ProfinelouCode,cent
Lictue b in(uB fora and dim. PANELS
Lbemc Clave Llea
Date Ca,,,,ar UP TO 200ANU�\ I KIT
ARCHITECTS DECLARATION 201-1000 ion 1 `
00z�j I understand my pbreahaB be ued u pubflc retard. OVER 1000 AMPS SQ. .FLOG AREA 5/SQ.Fr
Licensed Professional SIGNS
6LttAA�� OWNER-BOLDER DECLARATION 'L
Ihereby.fflrm that am exempt from the Cordraceori Liceeee Law for the AV
�... following rea.bn.(Seelon 70315,Budnuard Profeabrs Code:Anydtyor OR IN
r� county whldirequlrnapermktomruhuat,altcr,lmpmw,demolbh,orrcpair '
�[ any atncturc prtermat that
he i,aboreq purnatat to the fm iutiom of t e CES
3Kµ Ble•signed ice.La that he b llmnxd pursuant k the i oNsbm of the
µF. Contr.nor'.I.fcerse lAw(Chapter9(aomnendngwM Smbn 7000)of DIN- SIVINIMII VALIJJ'I�N
ebn3os fa the
Pro(ubn. Any orNaon of exempt 70315 by a y
thebob forthe dbged *tsth .p Anyt to.ciiofSection nombymy
OA appllontlora permit eubJectatheapplbnttoa civil pealtydnot rtnrcthan O FIXTIllt6 J V
ndred dolbn fi.+DO).
e 1,aowneroft=perty,or my empbye,a wit h wages u their sob NEW RESIDELECTR SQF. SIDW6 TYPECONSTRUCTION
antoe"w"I intended m offered for
p p ale(Sec.7D14,Business and Pm(mbm Code:The Contractor.Llceme Lw
�S$ don me,apply to an ned
owr property who bnlldaor improves the., it OCC.GROUP RES UNITS
m
who doauch workhimse forthmugh hbownemployem,provided that etch
improvemcns am nM Intended oroftcred fineelc.If,however,Ne bulMing or TOTAL:
Impunlenofbeoldgthb bneyearofcuddor n,theownpurpderf lua
t11r�n I.
--of owner of the p oe dtty,am e d sh,ely cant urpoaeofaale.). QTY, PLUMBING PERMIT FEE
LJ S aeoassn m the property,am 7044, usi contra ting with If Code: FLOOD IONS APN
T.aaaCoat actor'.
mnnvuct the projet(See apply to an owner
a prop rt Code: PERMITISSUANCE
The Cont impr'.Limnx Lw doe not com e if owner d property who ALTER-DRAIN k VENT-WATER�
W fids or Impmvee Naaort and who mntrsm for e,L pAo)cm with a
a(actorWlnrtsMpurswne toNeemtnctor.Llc&PCfa BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am<:emq uMer Sec B k P C for Nla mason
DRAINS FIAOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Dale
WORKMAN COMPENSATION DECLARATION RFLFIPT F
1 ❑1 hertby dorm thx I have a certilhrc of cusem to.ell-loom,m a FIXNIffS PER TRAP SCHOOL TAX RECEQ'T P
rnrt bC-L ) S EWorkers'CampmationlisunnceoricertBled roPYNenbfRee. GAA.SYSITM-11NC41OTLE15 PARK FEE Y N_ d
Folie eb G
GIC. +aaray GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION
Ceed copy b hereby furNNed.���ertfed
copy b filed with the city Impmicm divWon. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCI IECK FEE
CMTIRCATE OF EXEMPTION FROM WORKERS' CREA'¢TRAP PAID
COMPENSATION INSURANCE SEWER-SANTEARYSIORM E.A.ZOLFf Da[C Reoei [#
(fhb ration need not be completed If the permit Is for ore hundred dollar,
R100rrWythin) WATER FIFATER W/VFNr/EECTR ENERGYFEE Y N
Isnot employ
arfperaothe m aof manhe ner so
obeco e, b)it abooed, -
1 01la not employ my penin b any manner as a to become wbJect to the WATER SYSTEM/TRFATINC
Worlicant npewtbn less.al GlHotnb. Date PAID
O Z Applicant NEN,RESIDENTIAL PLNB. SQFT. Date - Recei t#
Z O wneeroAlmLICANT:u,.germ.ld�twcertulatedExemption,you
FU3 Noumbemmefortlatoomplyni co eh promnprowlnadtheiaabbe TOTAL
Code,you cont(orthwth comply wit],each provbbro or thio permit eEW I be
� > deemed revoked. ULJILDING FEE IVZ 0;P
W 0 CONSTRUCTION LENDING AGENCY SEISMIC PEE.
1 IhercbyaHirm that there b a comtructloa brdingegerry for the perform TOTAL: Iry
ELECTRIC FEE
OZ ace of the workfor which Nb perms b Lased IS,3097,CW.C.) PLUMBING FEE
O ]ender.Name
LL — Ienaer.Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O L) l mrtllythat l haw readehbapplleatbnand state thatthe above information FEES PAID
a bmrtm.Iagreeto comply wth aB dtyaM county ordlnmmand state lawn PERMIT HNANCE
r N cry toe ter upont mmtrotimt,and Mrcby Property
p,tesentativn dthb
F Z
cry ,boa.ify.nedptoperty(or irmpeu it purpose.. ALTIIt OR ADD70 MFT:H. Date Re eipt#
— (We).gra to axe,W errtnlfy an d keep harMm the City of CupertW
�
.gatBabiBtb,Ndgtnermmatenpen.eawhldch maybaywayacaue AIR HANIXING UNTf(N 10,000 CFM) SUBTOTAL:
agal mt emof of Ing dthle mdt.�` fi e 7.9a AIR HANDLING17NT (OVERldODOCFW CONSTRUCTION TAX
Sl,rarrfof Apjrfftantjcontratm Date E)GIAUST HOOD(W/D1JCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappgant mfuture building wivpant store or hardb harardous HFATINGIINIT(10100,"13TO)
Date RCCCI t#
tvterial ae defined by the Cupertlm MuNcipal Code,Chapter 9.IZ,and the
flealthamiSafetyCode Setlon25531W7 HEATING UNIT(OVER 100,000 BM TOTAL:
❑Ym r]Nb
Will theappBrant or future building occupant sae equipment or deWcn VENTILATION FAN ISINGLE REID) I O DATE
which caret h,vrdbue air eonbmW mea defined by the Bay Arca Ab
• Qaalit Management Dbtrict7 BOILER�ODMP.PHP OR 100,0(0 BTU)
71990
4haam,aNeha�oua ed,, npb< nrsnnamewpm�9sor Bo rRooMProvFxlrooaoBly AUG
the CaB(amia Health k Safety Code,Setlbns 25505,15533 and 25SM.I
` urdmt,nd thatlithebu0dlngdommt,,amnt)yhave atenant,that ltbmy NEW RESIDENTIAL M.ECH. SQ.FT
respouibOdy to notify the coeupant of the requirements which nme t be met �s�
. Prior to eauanm da Certificate ofOavpancy. City of CuQ4 fln
Owner or aathcm ed agent Date ISSUED BY:
TOTAL:
OFFICE COPY