20938 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro M IdeeO(iution 7 PERMIT NO.
B°Ibing 20938
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CAsslahe111 CITY OF CUPERTINO-BUILDING DIVISION
ca nc«nccN,�me: Lk.Nm APPLICATION I PERMIT
O BUILDINGFIECCIUCALI'LUMBINGMpClIANIGL CATEGORY CONTROL Y
reh /Englrucr. Lk.Nu
1 _ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adtlreas: 3Z ``�V�� 3 PERMITISSUANCE (�QI' ❑ ❑ El
CONTRACTOR'S DECLARATION Cy
I
thereby
afflrmthatlam Bcm,MurderpmvlalmsofCupter9(� APPLIANCESRE-RDEM7AL PBD
Ingwlth5ec 7000).(DNLdedm�3softhe Buelxu,ndrrofealonaCode,and
Ifocvels lnb oppgndLddY -1 03S PANELS /' ` ,` `("ep !
One G``1I CoMnnlor �R5 m,r LI l/ �•�.O-a9/7"
ARCHITECTS DECLARATION 201.1 WE AMPS
OZO IuM[rstand my plain shall be used u public records. OVER 1000 AMPS SQ.FE.FLOOR AREA $/SQ.FT.
Iy Licensed Profesebrol SIGN5 ELECTRICAL
G
Q hitIam emptfro DECLARATION
7T' 7 IherebyafOrm thatlam exempt from the Contrmmr',License Law fee the SI'ECLILCIRCUIT/MIS
6� '� (ollowln (Section 7m15,Bunines ami PmfedOiu Code:M d or
F� wnasmr. Y ty TEMP.METER OR POLE INST.
Ftp county hkhrequirtiap ar ,m requ,altheapbmntfm &ornpto
fqq any nmeturt ut,,meltnbuaxe,,benaud pursue ,tothetmfale ad t e
O l !Ile a ngnad statement that M b BmNed pursuant to the proal by d Ne LOVER DEVICES
uu. C. tncior',Idcerue law(Chapter 9(mmmeneing with SeNon 70M)of Dlvl-
F,�O el.n3ollhe Buslnw and Pro(esbroC.dr)orNn M1ebe,empt then(mmaM S1VpdA9NCIK]OL ELECTRIC VALUATION
SaT,� the basis for the alleged exemption. Any vlolatbn of Section 70315 by any
b � apphomt for a permit subjects the applleant to a civil peruhy of net mon than OUD.I:ISSWITCH6HXTURFS C7OO —(D($
Lwi foe hundred dollars($500). NEW RESIDENTIAL ELECTR .FT.
F1 1,as owner of the Property,or my employers with wages u their sole STORIES TYPECONSIRUC Kl)N
pernaUon,wildothe work andthe structure b rot Intended or offered for
O sek(Ser.7014,Bud.unci Pmfeaabv Code:The Conlrsciors Lt..Law
$ don real apply to—owner of property win builds or Improves thereon,and
�$^ whod«swchworkhbveB«Nwgh hisownemployem,prm,Wod theterch OCC.GROUP RES.UNITS
lmpmvemenbanw Intendedorofferedforule.I(M1mwe ,Nebuilding« TOTAL:
Improvement bsold wlNln Oxyearofcomplctbn,IM owner4vllderw111 have
t enof —F1provingthathedid rutbuddorimprove(«purposeofule.). QTY. PLUMBING PERMIT FEE p7ppDZONE Apt,[as owner of the property,•m ex lualvely mn
ntctined
g with lannu
rontradon to omlrua the projeci(Sec.7004,Business and Prdesebro Code: PERMIT ISSUANCE
The Contractor,1,1i IAw does not apply to,n owner of property who ALTER-DRAIN k VFM-WATETt(FA)
Wilds or Improves thereon,and who mntnns for such PI)eet,with
cgp(Eacterw Browsed punusnt to the Contrsda,Glave Law. BACK FLOW PROTEGE.DEVICE FEE SUMMARY
I_,I am exempt under Sec B k P C for this mmn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
OLTSIDE FEES
Owner Date
WORICNAN COMPENSATION DECLARATION RECEIPT Y
WL TA% Y N_
❑1 hereby affirm that I have•umflate of consent on,elf iruum,« pp^(Qgpg PER TRTRAP• RECETPE Y
3 ,IABCJ S
certmate Of W.rium v
Compeation lv « art
unnaa lfled ropy thereof Sec. GAEA.SYSTEM-1 W4
C. 0UTLE15 PARK FEE Y N
PolCom n GAS E4.SYSTEM-0VER4(FA) RFLEB'I'Y
Y BUILDING DIVISION FE FS
Certuled copy b hereby tthtit e city city CertGRFA.SR/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certifiedd ropy b flied with Inspection dlvWon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SE%V R-&AMTARYSTORM EA.2OWr. Date Remi t#
(TM1leanf ahs complded BtM permit bf«ox hundred dollen
(5100)Or len. WATER BEATER W/VENT/ELLUR ENERGY FEE Y N
IartByN tN epedomunaof thew«k/orw pe Islwred, —
I ehaB ore a any pe ray mato. at u t o the WATER SYSTIN/TREATING PAID
Wmken'C nL .1 b.Desk
O Z Appllnn
Z 0 NOTICE M ,a ser ng thbCMRlate o! <mpbn,you NEW RESIDENTIAL PLMB. SQFr. Date Remi t#
Mould become subpct to th n'cm pevatlon pmvbo.of the tabor TOTAL:
= N Code,you rust fan hwhh comp thwrh pr.vbbro or this permit stall be .�
> deemedv
reoked. BUILDING FEE
W C CONSTRUCTION LENDING AGENCY S I MIC FEE
CL Ihertbyafflren that then b•covtmoren kodingageory for the perform ELECTRIC FEE
M Z +nm.fthe work forwhkhthb permit b Issued(See 309'/,CIv.G) TOTAL:
U O Tender,Name PLUMBING FEE
LL ~ Iendre,Addrev QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I unify Nat l have nae lhb,ppllotbn and nate that thea bwewamwlon
bcornd.l.grteto complywM•B dtyaM county Ordlnanmsnd nate law, PERMIT NUANCE FEES PAID
} S X.izubfflt
ng rovtNthe above-mentbred property for Wpecibn purposes. ALTERORADDTOMFGIL2 save,Irrdrmrdfy an a keep hamdess the City d Cupertino Date Rttci t#
Judgmenpsud ezpen wblchmaylnany.y.coue AIR HANDLING UNIT(TO 10,000CFT0 SUBTOTAL:
in con ria the gram dth1, 2AIR HANDLINe cINTr(OVER La,aaocehD CONSTRUCTIONTAX
vont not
Date F�alwusr l-IooD(w/DUCD CONSTRUCTION TAX PAID:
FIAZA DOU M TERIALS DISCLO URE
WOltheapplkantortuture ingeompantnmeorhardkh rdous IfEATING UNIT 100,W0 BM Date Rttel 1#
mmerlal as deBxd by tit Cupert ro M.,JdpaI Code,Chapter 9.12 and Ne
1-leahh and Safcty Cade 5eciion 75533(a)? HEATING UNIT(OVER 103=BTU) TOTAL:
❑Yes N No
Willtheappliom or futum building oaupant usrequlpment«devkes VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit Mr�rdous air connmlxnts a,deflvd by the Bay Arte Air nw,R^�
• Quality Maxgemem District? BOILER-COMPQ POR 100,001 BTV) C{">D
4 Yn 4 No r��-
Atitatifthebuildingdoesnotmmentlyhav
ad the M1avr out mtenab rtqulremrnn under Chaplet 695af BOILER-OOMP(OVFR 1fA,000 BTU)
elleeWScSafety Codr,Smtbv25SO5,5533 and]5534.1 Q CJWV
eatenanLtluIItbmyNEWRF57DFMIALMECH. 9]FT y to rally the occupant dthe requbeerems which ovist be met
senada trof Oevtpaxy.th
TOTAL: I%UED BY: IfTaA%1 LA �
OFFICE COPY