22484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Ion eat Identification PERMIT NO.
Banding wdart a: FQ ra 01 22484
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as$-708q CITY OF CUPERTINO-BUILDING DIVISION
C
on APPLICATION I PERMIT !
BUfI,D1NGfl.ECTRICAI PLUMBINGMFLHANICAL CATEGORY CONTROL♦
�L d d 2 7 LSI a
QTY ELECTRIC PERMIT FE,AAEBUILDING PERMIT INFO
Add. PE]UDTISSUANQ
LICENSED CONTRACTOR'S DECLARATION
I hemby affirm that l am licensed unser pmvWonadChapler 9(cmummc APPLIANCES-RESMENHAL
JOB
SVNInSbn7000)o/pvtheegmandPm/mmCodtnd
license
ihin full aifect. o PANELS pun
Lk
Deit�/ Contn¢or $ p0 I
ARCNITECI'9 DECLARATR3N -I OOO A-Mf5
�p+±�ZO Iunderwrdmmyaphnsslutl beu iupublic recvda OVERIODDAMPS SQ.FT.FLOOR ARE B/SQ.AREA
E Licensed Proflol
<� OWNER-BUILDI]i DECLARATION SIGNSFT TRICAL LE
• /
,t.., IhcrcbyafOrmtlot l sm exempt from the Contractor's License law fes the 4T_CIALCIRCUIT/MLSC
69..3p folbwing reason. 70315,Bualnm a od Prof,,abne Code:Any city or IFMP.MECIR OR POLE INSr. CYR
F9 cy muntywhkbrequ4 .pvW tomruwgalter, pm ,demolbh,orreFWr I
^J anystructum prim toltatwarice,abo rtqulrn the applicant for such permit mRDEV[ff5 II I R I 1
Ofile a signed statement that he h Housed pursuant to the provlabns of the POWE
u.� Cantnclors License Law(Clupler9(mmmentlng with Section 7000)of Divi- SWIMMING IDOL ELECTRIC t VALUATION
elan3o(the Budnmud PmfmbmCode)orthtl he bexermpttherefmmard
�5yp+ the hl./or the dkged exemption. Any Wdatlon of Section 70315 by any e7 r�i` 0-00
apPBaa
ntfor&Permit bJectatheapplkd m0�� .��, 5 ant toadvil puultynet anthan X4.01/ a�
Eve hundred dolWn({.r . ' NEW RESIDENTIAL ELFT IR }T, /
❑L u owner of the Property,or my empbyea wkh wages a tkk.ole `''Q STORIES TYPE CONSTRICTION
7
ted comperuatlm,wHido the work and theal,cturt h not blended or offered for
ale(See 7061,Busmen and Prdmbru Cade:The Codract«.License Taw
(�$g don no apply to anowKrdpropertywhob idsorlmproeatMrmRsnd
a- whodoessuchworkid xVorthrwgh hhown employees,pro ell thatuch OCC GROUT' RM IINTTS
Improvements are not Intended proffered fee ale.If,however,thebulMing ce TOTAL
Impmvemem h add whhln oneyearofcompictbn,the owner-bumerwlD hove
t raenarpmwirgthathedidnotwitsorImprovefawrPo•eorale.). QTY. PLUMBING PERMIT FEE H.GoozoNE APrT
U L as owner of the property,am ro,hedvely cur • ing with Ileensed
ontractas to construct the 7 PERMrrI ANCR
project(Sec 016, to i m and Pmfesbro Code:
i' the Ca.1 Imp's License Lw don net apply m an owner d Property who ALTER-DRAM k VENT-WA]ER(EA) .
Wilda or Imprwn ehaeon, and who mnaracts for such P(o}b whh a
artarW llonaed mane to the Contract«.Llove Law. BACK FW"PROTECT.DEVICE MM FEE SUMMARY
C U I am exempt under Sec B t P C for Nb reason
. OUTSIDE FEES
(
Owner Date
DRAINS-FlDOK ROOF,AREA,CONE). SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION R CErPT
01 hereby afn that 1 have o lossuate of consent to alf-kwna, a FSS PER TRAP $ 001,TAX Y_ N_
odiDote of Worken'CanpensaRon insurance ora ortrtRECEIPT aHled copy GAS FA.SYSTEM-1 INC6OUILEIS PARKFEE Y N
'
Polkyl�6MJr{7,C_ y/ 4"�7 g3 RECEIPT
Cum nv A.kI na GAS EA.SYSTEM-OVERA ITA)
❑wCertiBed ropy h hereby fuMahed. BUILDING DIVISION FEES
II [SIZe led copy h filed with the CRY inspection division. GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHE K�E
LFNERGYFEE.
�CERTIFlU E OF MPENS TION I FROM S"ANCEORKERS' CREA'� PCOMPENSATION INSURANCEnot becompleted lithe permit lafmonahundredd.11. - - RM EA L]L�rDR 1WATER IffATER W/VEVI'/EIECTR Y—
o,), enfWATERS,ST�/.�A.DNG
Wmken'Compenatlon[asva of Gll(onb. Date -
e Z APPDast NEWRESIDENTIALPLIAB. SQFT. Date R I tM
r Z D NOTICETOAPTO-ICANT:if,after making tw Cert0lata of Fiemptbn,ysu
ahold Rmme ubjM to the Warkus'eompeniaatin„p,ovl.mru orthe L.bar TO AL
~ N Code,you rruat(acthwbh mrnply withudprovbbv or ehb pemat shill be
deemed rew4ed. 5QIL]21NC;FEE
d p CONSTRUCTION LENDING AGENCY ISM
FEE a
I hereby tiff hottherehamnstructi.nl Ngagmcyfortheperfomf T�,� ELECTRIC FEE 11.00
t 7 Z asp of the workfor which thio permit h hued(5oc 3097,Civ.C.)
U O Ie"der•t`''n'e PLUMBING FEE
Ii LL Lenses AddQTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O Icertify that l haverendthleappucatbn and Antethat the above) for tiw
j 0 W hmrmY.lagreetocamplywnh.Ucty.M.m tyordwnm.nddatelaws PFRMITISSUANCE FEES PA ID.
U) efty toig enter
mrutuctlon,aM hereby property orir<pectioenpi posof thh
F Z cit(WO ser to save the indemnify and harmI the Cit pure peres. ALTER OR ADD TO MECFL
� (We)agree to ave,Indemnify.n d keep harMes the City of Cupertino Date Rm t#
V .gawtllabwits,jndgmew,mob and expetun which mryln snywayacwe AIRHANDUNGUNIT(IOl0,C00CFM) SUBT AU
d agawt Id Cltybmnsequenc fthegr.mt gdtwpm a.
AIR HwNDUNc 11N1T(OVER IO,WO CFM) CONSTRUCTION TAX
Slgruture Apptlant/Cent m ate EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDO SMATERIALSDISCLOSURE
Will the•ppDont or room buddingottvpant•t.mmbitnde hawdnus f1EATIN'GUNIT(TOI00,000BTU) Date RCCCi t#material a•definsd by tM CupeMI.Mu.idpel Cade,Chapter 9.17,and the
Ibalth.rd S./erycodreLr�_S1e�ctttoo 7S53]Wi - HEATING UNIT 100,000 BTU) `(� TO
W Yes u
wmit app0anta tulumboangoccufine um the Bay Are. vim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit airrict? a.,defined by the Bay Arta Air
Quality Management F914l BOILER-NMP QEB'GRlOQ000 BTI!)
Yet V.m
have rtadthe ha Nowrt odAab nqulrcmenbun3aChaple , 1 of BOfI.I:FCONP(OV[:R1W,000BTIn
the GlHomtaatifth[buildin Safety Cads Sheba 75509,vea tx nd7S536. I
respUd�nsiil that nthe tithe ongdoes not a requiyhaves whichL that it bony N'EW RESIDFNr1AL Iv¢CTi. SQFf n
nvponswOHym sat Oythcaccup fOrcupe requirements which crust be melt
prior to da Certificate of panty.
Qv,.rrm.uthbri.d agent —fir(-- ISSUED BY:
'IOTAh
OFFICE COPY