22426APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm'ed ldentifkatimt
Building Address:
PFRNIT NO.
-
4.N�"Ale7L �T
22426
. ame. one:
�'j =j 2TjQ(/
CITY'OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
ContnctmaName:
�,Ix.NO:
11 (T
BUILDINGaRCTPICALPLUMBING lLAMCAL
CATEGORY
C
Archnccc/FngI.,.. Lle Na
QTYELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addre�'S� ezz_,4✓4�
PLRtATISSUANCE
❑ 1:1 1:1LICENSED
CONTRACTOR'S DECLARATIO
CONTRACTN
I hereby affirm that l am lkensed under pruvisfore Chapter uper 9(commmc
ingwith Section 7000)of DMalon3 oflhe Busmessand Profe edon,Cade, and my
APPLIANCES -RESIDENTIAL
OB DESCRIPTION
Limmn.re Cn.a ufZ> dol:.
Dae Contndor
PANELS
.les/ T
1 f ` D vC r
;lin-IixIII Ahi
ARCHTTECPS DECLARATION
I understand my plane shag beused as public beth&
OVEIRI"AMPS
SQ. Fr. RADOR AREA $/SQ. FT.
SIGNSELE2THICA1,
Licensed Professional .
SPEY:IAL CIRCNT/MLSC
OVINER-BITILDER DECLARATION
[hereby affirmHhan I.ed.7 cemptfmmsaffie Co mfessibLlano Ly for the
f ntyng reason, (S a p 7015, Business and Pmfpm Code: Any city or
ntm=mpHortotap am ,a n re cu a th, apmve,de wcbprrepalr
any at ructuretatemotthed he is a requ4naccamt the ronuchpeoMtto
fib a signed dor's &stamen, tMt ha t uansed pursuant to the pudebv of Ne
iet-
(bntndoe use Law dlCamer9 e)orth&heb Section ptthem0 ant
sion3ofthe Bu.inmsandl'mfesloru Code)orthat hale sump, thenefmmaM
the baeb for the alleged esemptbn. Any dalstion of Section 7mlS by any
.ppu.t fora permit subjecta theapplicant to. dvll penalty d no more than
ALE D IN
M P U T E
ALUAIIO n -
L• �1
IEbtP. METER OR POLE [NBT.
p0}yFR DEVICES
SWIMMING POOL ELECTRIC
OUILETSSWIICH2S-F13CTURES
NEW RESIDENTIAL ELECTS SQ T'
tier hundred dollars %SM.
O1,.s owner of the property, or my empty. with wages ae thetr sole
STORIES
TYPECONSTRUCTION
mmperaatim, will do the work and the strue ure b not intended or offered for
sale (Sec 70K Buslmnns and Pmfmbb Cud,: The Contractors License Law
does not apply to an owner of property who builds or impr,es thereon,and
does such work hlmaelforthrough his own employees, provided Net arch
OCC.GROIIP
RFS. UNITS
impr memen s ere nm intendedproffered tarsale. If, however, the building or
improvement b sold whhln arae yearolcompldbn, tk owner-builderwi0 have
TOTAL
tljg nrden of imeing that In, did not build or improve for Nrpne ofsale.).
LJ L as owner of the Property, am ex lualvely =,,,,Beg wkh Iben,ad
contractor, to mratmet the project(See. 70K Business and Professions Code:
QTY. ' PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
AI'N
The Cantndora Llan Law does not apply to an owner d Imperty who
or improves thereon, and who contracts for such p,,os with
o7fttPctoKs) Ileeened pursuant In the Contractd. Lose. Law.
LJ I am eaemp under Sec B k P C for this reason
� ppR-DRAIN & VENT- WAIIIt (FA)builds
FEE SUMMARY
BAOC FLOW PROTECT. DEVICE
DRAIN& FLOOR RODE, AREA, COND.
FIXITIRES PER TRA
SANITARY Y_ N_
- RECEIPT Y
Owner Date
WOfirm that COMPFNSAiION DECLARATION
❑I hereby, affirm I love a m rosail-Inure,
SCHOOL TAX Y_N_
moot m a
C lmumne
3M, Lab ofWorkers'CanperexlonlnsunnamaartBl,d ropy thereofC .
3800, Lb CJ '
�T.9
GAS EA. SItSTENI-1 INC-4OUTLEIS
PARKFEE ..Y N
0
R9CEE'T N
ComP.ftcy
GAS FA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
Certified ropy is herebytumbhed.
Vy
Certified copybfBed with the city inspection dlWalon.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE/INDUSTRL WASTE INTERCEPTOR
PLA CHECKFEE
-1
PAI
CREASE TRAP
COMPENSATION INSURACE
N
(Thor orad mat be completed lithe pend, b(more hundred dollars
Date Reoei tit
sETVEe SANITARY STORMEw 2�T
($1IX)vnI..)")
so as tobelWpermRl. Tailed,
]artily thatoy,eny erann In
1 shall nor employ, any person In any manner at v to become subject to the
manner
Workers Comperaatbn Lwvm Gllfomla.Date
WATERHFATERW/VENT/M137TR
ENERGY FEE Y N
PAID
WATER SYSCEM/DRPA"RNG
Applicant
NOTICE TO APPLICANT:[, ager making this Certificate of Fxemptbe, you
should beeom a ubFat to the Workers• Comperoatbn pbovbiaba of the Labor
Cada you bona, forthwith comply with such pm ist.. rthis permit stall be
deemed re. Ian].
Dale Recel [p
NEW IRFSDENIIAL PCMB, SQFI.
TOTAL
BUILDING FEE3
OD
SEISMIC FEE
a S-
. CONSTRUCTION LENDING AGENCYin
1hembya/flmnthat there is a coieaurtlon lending agency for the perform
ana piths work for which this pemJc is b>ved t5ee 30Y1, CN. C.I
AL:
ELECTRIC FEE
lenders Name
PLUMBING FEE
lender. Addeo®
I o mify thatl have read thfeappuatbn and pov
atethattheabelnformation
b eorrect.I agree to complywith all city ant rountymdirau. and state lawn
M tobulWing construction, coneuction, and hereby authreprerem ntatNes this
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES a D
yl 6 z7�F
dty to enter upon the a rbarntbred property for inspection purposes.
(W,) agree to save, t demmity an d keep harmless the City m Cupertino
ALTDH.
ERORADTOMDC
Date R7 R�
SUBTOTAL:
ago bNtles, P dgment; eaperaes which maylnanywayacvue
2 dC yin con the tingathe permit.
It z
AIRHANDLINGUNR(TO10,000 CFAs)
AIRHANDLINGUNTI(OVFRl0,B0OCFM)
CONSTRUCTION TAX
gnatvre a/Appliant/Contra« to
m LI;THOOD(W/DUCT)
CONSTRUCTION TAX PAID:
EIAZARDOUS MATERIALS DISCLOSUR
HEATING UNIT (TO lOg000 BM
Will the applicant or future building ompmtatoreor handle harardous
material ae defined by the Cupertleb Mubucipal Code, Chapter 9.IZ and the
Date Recei fed
F)FATING UNIT (OVER 100,000 BM
TOTAL:
S
Fbahhand Sday Code Sedim2S532(A)7
❑ Yes No
VENTILATION FAN (SINGLE RESM)
ISSUANCE DATE
���
Will the applicant or lure building omnpabt.. equipment or devlas
which emit hares rdoue air ebntaMrans.a defined by the Bay Area Air
Quality Management D M ?
Yrs ❑❑No
Y.read the hazvdou. materials rtqulremenb under Chapter 6.95 of
the Caluomis Health & Safety Code, Sedbv 25505,25M and 21i534. 1
BORER -COMP 13HPOR 100,000 BM
BOILER -COMP
NEW RESIDENTIAL MEC1ISQFT.
uMu aMthatifthe WDd gdonw, ntlyhaveatenan4thatitbmy
responsibility tonally the oavpar t of the mciuimmenb which must be met
prbrtobsuanaeaa CeruucateofO parry.
aye
ISSUED BY:
Owner a authori,ed agent Date
TOTAL.
OFFICE COPY