22201 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingAddmelldin Project ldevdPflea 1. MIT NO.
josa F�Nwoo9 tr 22201
rrl. kpkAu%-ro me. CITY OF CUPERTINO-BUILDING DIVISION af�sll APPLA
cen'n u3.Nn: APPLICATION I PERMIT,qr
<Ue WArV0,;sv-q gs70 S BUfLDINGELECTRICALPLUMBINGMFG11AMCAL CATEGORY coNTROLI
ArchBeG/Engineer. Lr,No
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PFRMH SSUANCE
LICENSED CONTRACTORS DECLARATION
_ I hereby aHlrmthe l amliansed urderprnvieleruiof Chaplcr9(ommen APPLIANCESRESIDEM7AL � u
Ingwith Setlb 7000).1Dty .3ofthe Budrasand Pmfestlou ,.d
]Meru iit 11. PANELS
LI¢ue(ZLa. OvL1 �5c,9S
A L&Y- s
Date S��Cortncmr
ARCHITECTS DECLARATION 1'1000 AMPS
I understand my plans s)uBbe used m public neread& JOVER IOOO AMPS V1 1,3110TE
$/SQ.Fr.
�j LlreruM professional SIGNSELBCTRICAL
6FWh OWNER-BUILDER DECLARATION SpECIALCp2CUfr/hiLSC �(-Y
Fp' � I hereby afflnntlut l am exemptmn ¢
frthe Contnor'•License Law Law f¢the
Og ❑ f-0-wing realm.6edim70315,Budnmand Pmfe•aloru Codr.Any city or
F��� cmntywhkh requbaaa pereaB tomW
rruM alter,Improve,demolsh,or repair DMP.MEIFR ORPOLE KIST.
7anyw mmpr tolbL anee.abonyulm eapph=tf¢mchperml[to
9�6IY]Syp.R DEVICES
il Ole a signed statement stateent the he is[Io neprovisions;put to the provoof Iha
r� Centraetols Lkeave law(Chap¢r 9(mnurcncing wkh Se o7000)dDM-
3 slen3 ofthe Buenee•and PofubesCode)orthe he h exempt therefemard SWIMMING POOL ELECTRIC VALUATION
y.' the beta,for the alleged eaemptbn. Any violation of Seetbn 7MIS by any
<� applicantmB M u
for a persubjethe applicant to a civil peh ¢m
y d nore than OUTLETS-SWITCHESR
FCURFS
w ' fiv bundred dollars(5500).
I,ae owner d the property,or my empbym with wages u their vole NEW RESIDENTIAL ErE= SQFr. STORIES TYPEODNSIRLCTION
compeoartlm,wWdo thew¢kand Nestmceunbnot Wendedoro((em for
7,{ p sak6cr.7011,BuelnevaM lardewbm Code:The Contndoys Ll¢me Uw
Ey$ doesndapplytoanownerdpopertywh Wtldaorlmprovnthermreand OCC.GROUP RES.UNITS
work himself«through hlaownempin/ets,provided that such
impmvcrnewarenot Intendedprofferedforwa .If,however,thebuildingor TOTAL 11 T,10
Impmvemerd i•mld wXhlnoreyearafcomplelbMlhewvner-Wllderwlilluvc '
llyrk cndpmvingthnhedW=Wb fldorl yp afmpurµsedule.). QTy. PLUMBING PERMIT FEE FLOOD ZONE AIN
LJ L ae avner of the property,am e.hievely mot og wkh IkxruM
mntracroa to rormtmtt the 7 PERMIT ISSUANCE '� (ur
Project not 011,Bush o and IMembne Code
The Coon loop a Lkan�Law does not apply to an owner d property who ALTER-DRAIN 6 VENT WATER MM
cT)4- 0 Improves Ihceon, and ALM mrdnrn (or mch p-ojec. With
L.Tactor earrouedpunuanlrotheCmtntlesLKxrue Law. BACK FLOW PROTCCr.DEVICE FEESUMMARYFFI
LJ f ins exempt order Sec B A P C (or IIW rtuon
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
ow. Due R NG
t WOR"M'I COMPENSATION DECLARATION 1
r ❑I hereby affirm the 1 have a¢d10¢te of consent to•eI-beure,¢a \ =TR"
PERTRAP �s[,rj SCITOOL TAX Y_ N
¢dlBrrte d Werken'Compeunlm Imuran¢¢a¢trifled ropy Ihemof(Sec. RECEIPT
35(IO,Lab CJ G -1 INCA OUTLETS PARK FEE Y_ N_
Policy s RECEIPT s
Com ny GId-0OVER BUILDING DIVISION FEES
I ICenlBed ropy b hereby fumishN.
L~Ji CeNfcd ropy b filed with the Wy lupetlon division. GSIRL WASTE 1NTERCQ'IOR PLANCHECK FEE
CERTIHUTE OF INDA TION FROM WORKERS GPAID
COMPENSATION INSURANCE SRY STORM EA 2iiaFT Date Recd [#
(Tlda rection n3ed n¢he c¢vplemd If the permit is f¢ane hundred down
ENERGY FEE Y N
mW)orle
1¢dilyth hat Ir,the perfom2n¢o(IM1e work forwhichthiv penNtbhuM, WATFRF6�ATER NT _
I s12B not employ any perm in any r an a • p the WATER SYSTEM/TREATING Workeri utbn via fOWoml.,Dam { PAID
O z ApplicanNOnCE uL a �,.mr l NEW 7(mDFxML PLMB. .FT. Date Recel t#
Z O should ETOAPPLICANt:e, ori,ma Comp CedlU no Eaemtine La o
F y ebmldouoresecorne mbjhwith heoply with
Campouallm p. is neortha Gbor TOTAL
� _ Cadman n naul forthwith mmpy with mch pmvLsbm or Told shall he BUILDING
� deemed reroked.
W O CONSTRUCTION LENDING AGENCY S I MIC FEE
CL Iherebyafflrmthat there feammtrunlm krdingageruy(orthe pedomv TOTAL ay ELECTRIC FEE
M Z on of the wo4kfor which thin pe,ret66auM iSec 3097,CW.CJ L
00 lender.No. PLUMBING FEE CK7
LL ~ Under•enddClma• QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
Ow 1endlfythae l have read this appBnlbn am seelhatthe above lofamatluo � C(j FEES PAID
oser.l agreeto comply with all d manPFRR
eityaruntyordfiuio d aae.lawe MLSSUANCE
Nrelating to building mrutmnlm,area herebyauthMaempresentalhce(thls
F Z ehy,to enter upon the above-mentlnned ptopertyfcrfimpearlonpurpu•n. ALTERORADD TOMECI-L
— Athn.
e,I en y an d keep har m the Cityof Cupedl Date Recei t#
grnm•,ons ab eapeun whkh xray in any way Rome AIR HANDLING UNYIT(TO 10,000 CFM)mesequen¢of the gnuing d this pemdt SUBTOTAL•AIR HANDLING UNIT(OVER 10,MCFM) CONSTRUCTION TAX
t/cmiractm Dale no-uusr Hoop(w/DLCnCONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
t or tune buBdto «cupant pore or hendk havrdoua HEATINGUMT(N100,000B'[V) Date Recei t#
y Cupertino MurddpalCodc Chapler9.IZ and the
I kahh and Safely Code SMion 7G59')(a)7 FdEATING UNIT(OVER 100,DOO BTU) TOTAL L
❑Yrs M No
Will the appllmnt or future building—pert..equipment a devices VENTILATION FAM RINGLE RFMD) ISSUANCE DATE
which yend t harerdous air mora Mt2nm a defined by the Bay Mea Ab
QuaINYn nage— 'r'
BOILERLOMP DILL OR 100,DM BM �A
Y ❑Nb
an"
theF rdws Ceele,brtle.255ncsunder.125534.1 of BOILFRCOMP(OVFR 100,DOOBM
�o the[ a sad that lith Sa Safety Code,SMbuntly have
a tend,that
NA J
urdentardthat notify the building &the requi hav3s hkhtrust It i,toy NEW RESIDENTIAL MEIN. SQ.F7 'I/ F
r¢povmllty,to notify the oemparu d the rtqulrernente whkh resat be,rrct �
f prior to tswanm of a Cediilote of Occuparuy. /Tea `
tl�� s
Owner.authorized agent DateISSUEDB .
TOTAL:
OFFICE COPY