24439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identlfleatlun PERMIT ND_
B°Bding Addmv: 24439
e. arm. one. A
CITY OF CUPERTINO-BUILDING DIVISION
certtne exams: Lk.No, APPLICATION PPERMIT Y"
s BUILDING-ILECfRICALPLUMBINGMECH LAICAL CATEGORY CONTROL I
AKM1IIM gimer. 4c No;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
FLUMIS
Add r I'EIU9TISSUANCEEl ❑ $ ElLICENSED CONTRR
AORS DECLARATION
Iherebyaffkmthatlam lkru-d underp Wmeo(Chaptcr9(commm APPLIANCESRE9IxMlAl BDESCRIPHON
Ingwllh Seebn7000)ot Div I 3otthe BuJ and Prof oruCe'd,,and my
Iimme b in lull and dfee. PANES ,.S
asaa
L)oense Clam LleeL {1 GJs
Dae Lie.# or
UP T02DOAMPS
ARCHITECTS 10 201.1000 AMPS
p�p�uu¢O Zp I understa nd my phm sha0 be used u public record& OVER TWO AMPS SQ.Fr.RMR AREA $/SQ.ITE
Fe Fj LI¢med Professional SIGNSELECIWCAL
<G
�< OWNEReBUILDER the ComATLON
t.., � Thereby affirm that latm eaemptfmmthe Contneor's Ll¢melAw for the SPECIAL CIRCUIT/M1SO
folbwing¢aeon.Eedim 70315,Business and Pmfrabns Code:My dty or
6� TEMP.METER OR POLE INST.
P�fl mnntywhkh rcqubnapemdt tommtruct,alto.bnpnrne,demaLLsh•orrtpalr
1 anyetmcture prbrto la ieeuame,abo nequlrasthe appBantf¢auch pem0t to POWER DEVICES
c Ilk a signed statement that he b Ilmnaed Pursuant to the pmvlslom of the
G w c,mmacarb Wceme Taw(chapter 9(commencing with Seelon 7000)of Dlvl-
f-�OS slon3ofthe BM ustrumaProfmlom Cedn)ortiat hebemmpttherefromand SWE.4.UNG POOL ELECTRIC VALUATION
Sat the baals for the alleged ezemptkut. Ary ei laHon of Seebn 7015 by any
OQ5 5 TC}US-F1hT()RE5
appB¢rttforaper eea
bjtheappllcanttoad 1pevhyofnam mtl n
ffMhu.drM ue!5
doll50[1. NEWRESIDENTIALFtF TR SQ.PT. SIORI6 =CONSTRUCTION
1 s owner of the property,or rty employees with wages as their sole
C 7]]6 compensation,wllldothe work andthesbumare boot Wended or offered for
sak Ear.7014,Bushru,and Poo(essbm Code The Contractors Llmnse Law
�r$ don net apply to an owner of property who build,or Improves thereon•and OCC.GROIIP R6 UNTI5
who does..work himself orthrough his own employees,Provided that such
Improvements art rot Ntended oroffered(m ask.If,however,the W Ilding a TOTAL:
Improvement bwld withinomyearofcompietbR lheowner4wllderwW lave
t relena/poeingthahedld net Wild orimpreve for purpose ofule.). QTY. PLUMBING PERMIT FEE FlODDZONE APN
1,as owner of the property,am evchuWely trMing with lioe sed
contnctmn to ormtruct the projeci(Sm 7014,Business and Professions Cade: PERMIT ISSUANCE �
The Contneers License Law does not apply to an owner of property,who
Wilds or Improves[Freon,and who contracts for such M"with
a ALIIIt-DRAIN4 VENT-WATER(EA)
ogait+ctor(s)Beene•d pursuant to the Cuntraeors Ll¢ese law. FEE SUMMARY
l_I I am emeno under Sec B 6 P C for this reason BACK FLOW PROTECF.DEVICE OUTSIDE FEES
DRAINS
Dae FTDOR ROOP,AAPA,GOND. SANTTARY Y— N—
Owner _
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirme thus I have a aertl0aconsentte o!consent to self-Insure, 5CHOOLTAX self-Insure, FD�gFS PER TRARECEIPT#
,ora RECEIPT
mrtlflab afWarken'Compemalmimuran¢era¢reified copythemofOer. GAS EA.SYSTEM-1 INC-4 OLUL 5 PARK FEE Y_ N—
pute38W, f cJ
Gone ny GAS -0VER4(FA) BUILDING FEES
I CeNlied copy b M1led with
the ed.
/fap'Sn Certified copy b hereby ththe sty lmpMlon division. GREVSE/wDll51AI,WASTE INTERCEPTOR PLANCHECK FEE
CERTIFI ATEOFIXEMPTIONFROMWORKERS CREASEIRAP IpplD
COMPENSATIONwSURANCE SEWEIygANITARYSTORM F 20(FT Date Reaei tic
(Thbseabn need rat he c—¢nPlatplated lithe pend[b!mom hundred dollen
3100)or lyth WATER HEATER W/VENT/M TR ENERGY=- Y N
1¢not emploat in y
anyhe person
m an [mann kan an to
mepemdc bbl theed, —
1 eni, not employ any Lara f any rtannrr at as to become vbjee to the WATER SYSTEM/TREATING .
A pllanCompensation lawsof California.Date PAID
PP NEW RESIDENTIAL PLMB. SQFI'. Date Reeei t#
Z p NOTICE TO saubICAM:R, of m,'Com erartionoteol Eaemptbn,you
cc N Coded.must ub)Mith to co Worker'Compewtbnprovhb permit Ilse,bor TOTAL:
Code,Y. .and.forthwith comply with such provisions orthb permit"I be,
� > deemed rewked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY 5EISMIC FEE
0. I hereby affirm that the¢b a mntrtruelan kMing agent'br the perfomm
7 Z anof the workfor whkh this permit is Issued(See.30 V/,CIv.C.) T ELECTRIC FEE
V O Lender.Name PLUMBING FEE
LL1— le"&s Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W. 1 oertlfy that l have read thbapp0 tbnard stale that the above information
bcorme.lagrte to comply withal]etyand muntyardlnanon and state laws PERMIT ISSUANCE FEES PAID:
} N mlatIM to building mmtmctim,and hereby autho mpresrnmtivea olth:e
(— Z city to enter upon theaWve-mentbred property for lespeabn put ALTFRORADDTOMECH. Date Recei t91
_ (We)agree to save,btdemNty and keep harmlu the City of Cupertme, -
agaOmtBabWtln,ydgmew,mstnand eapensn which mayN anywayamue AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL:
age Wt old City N mnsequerim of the gnnting of tole pemtit.
AIR I-IANDUNc cJNTr(OvFR loaoo cFM) CONSTRUCTION TAX
Slgmtureof Appilant/Contractor Date D(HAIIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WRltheapplk mw atom Wddingoovpantstomorhardleh.vvdds HEATINGUMT(TOIWA0Bnn Date RCCfI tN
material as defined by the Cupert m Mu Mctpal Code,Chapter 9.17,and the
EWhh and Safety Ce Ian 255374)7 HEATING UNIT(OVER 100,000 BTU) TOTA �
[ WYe odo
the applfnM A.re ildirg occu pant use re.Avrm VENTILATION PAN(SINGLE RE4D) ISSUANCE DATE
Q.."y rtlom-b;-onteminaMeas defined bythe Bay Oma AU
Qu INy nagcrrcnt Dis7 BDR.ER-COMP OHP OR 10,00 BIT)
IlY o
lav ad the ha sue materials nequft nenb under Chapter 695 of BOILER-OOMP(OVER I00,(gO BTU)
the Califc mut Health & fey Cade, ism 2550.5,25533 and 25534.I p�k
undenta dthatitth building dm currently have a tenant,that It is my NEW RESIDENTIAL MEIN. SQ.FT r A ' D
rat saity to al the. pant the mqulrementswhkh mrJberret
P to a e a Arte of parry. & NO
V A In
Own aulho end Da ISSUEDBY: a
TOTAL s•rr—
-. .... ..... sv
OFFICE COPY