22367 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building P en IdentlfloUort PFBMITNO.
Ballding Adds: 22367
°I9
rcr• •me: / A
CITY OF CUPERTINO-BUILDING DIVISION
n maN.me: l�BAPPLICATION /PERMIT ql
BUTUMNGELECnUCALPLUMBINGMEC-IAMCAL CATEGORY CONTROL,./ Z
Arehkeet/Fngi.,.. Llc Nu (P
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. ^�
PERh9TI9UANt� ZaW /
LICENSED tlmhmnRduTeR'SDWC of ltap
IMmby•(flrm thutlam lksnaed under prwWon ofOupler9(mneme APPI]ANCLSRESIDENML OB DCSCRII'I'fON
lner.I Section 7f100)a Dlvblon 3ofthe Budrcaand PmfeallouCode,and my
BRnm b In full fo and°rad cited. � PANELS
Lken°c/ / - Lk.1
Date Cootrador
ARCHITECT UECLARATION 271-1000
WW, Iurden rJoypharashd]be ed upublieneem OVFR1=AMPSaa�� SQ.FT FLOOR AREA a S,//SSQ.aFT.
k L Lken�Prof®tonal SIGNSEI.ECTRICAL , 0 LP L—�71W
G<< OWNER-BUILDER DECLARATION
71.., Ihemby affirmthat l am exempt from the Contnnor's License IAw forthe �ECIALCIRCIIIT/M1SL
H following reason.Section 7015,Boelo.and Profeabn Code:Any city or TE '0.
OF muntywhlch rryulroapemdt tomrmtruct,iltec lmprvR,demoReh,or repair TEMP. ORPo
EI
anyetram,re prbrtolb bu•rce,•bo rtqulmtheappllanHawch pemdtta POWER DEVICES ^�
file•signed statement that he b Ikeneed punuant to the provblon of the (�
ATE
II,� Contractor'sLkeue Law(Chapter9(mmmenWg with SeMon 7000)of Dtvt- SWIMMING�7J •ian3of the Busineu•nd Prdmbm Code)ortha he b exempt therefrom andPOOL.ELECTRIC VALUATION
y3.•]] tk Wsd far the•Ileged eamptlmt. My WdaOon dSoRbn 703I5 by any /�
a� CD
eppllnntforapermk°ubje theappilc'•ntto°dvllpevhyofnat mth•n OITILE7'S1Y17CliE"'FLYfURFS '�e =Ja
f jiundred dollars(5500).
I,as owner of the property,or my employee with wages°a their soleNEW RE9DENTIAL ELECTR SQFI. STORIES TYPE CONSTRICTION
compenution,wBt do the wale and Neatmd Is rot Intended or offered for
p sale Sec 7044,Boslnes a rollPmfessbn Codnrue
e:The CoMdofa URLaw
$$ den wt apply to an owner d property wb helicis or Impmvn thertoR and OCG GROIII' RES.UMTS
whodonsu&hw hie if RthroughhbownemployR,pm Wd thatarch ^
Improvemedsarres t Intended oroffer<d!ores.Khowever,thebuiWingor TOTAL a0�J
Improvemerd bsold wkhinoneyearofcorrptdbn,the ownerhullderwW have
n of proving that he did not baaa or bnprove(«purpma,of sale.). QTy. PLUMBING PERMIT FEE FLOOD WNE APN
w•owner of the property,am exclusively one rwing with licensed PERMIT ISSUANCE
s to mmtmd the pro)ed(Sec 7014,Businem and Profession Code: Z.D
Codradofs Linens,Law don not apply to an owner d property who ALTER-DRAIN VEM-WATER(FA)
bullus or Improves thereon, and who mirtnM for such p4a)e.L with
c"At(ador(a)licensed ponuanttotheContndorl Llceraelrw. BACK FLOW PROTECT DEVICE FEE SUMMARY
LJ I am exempt order See B k P C for this recon
OUTSIDE FFES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner pile RECEIPT If
•t
WOR"AN COMPENSATION DECLARATION pp(TyREq pER TRAP ^I SCIRJOL TA)( Y_ N_
❑I hereby all that I love•cenl(Inte of consent to apyther od ora •La V RECpI'1'Y
RnlOcateofWorker'ComprmallmlmunnRascertified copythertaf l5ec.
3500,IID CJ GAS F.A.SYSTEM-1 RIKA OUIZIS PARKF-F8 Y N
REcE
Pdry a GAS FA.SYS EM-OVER 4(EA) DING'T
i---
C. nV BUILDING DIVISION FEES
certifi co b tedwth the
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
certlnea ropy b flied scion tit city wpedbn division.
CERTIRCATE OF F](EMPTION FROM WORKERS GREASE TRAP PAID-
net
COMPENSATION INSURANCE SEWERSANITARYSTORM EA.2OWT Date Recei # ` ,
(IMa aeNnn need race be cmnplded tithe permit b fR orc hundred doW n
($100)RI®J WATER FffATER WfVENT/ELECTR ENERGY FEE (Sr N
Illnoy thaththe person in of Nawork for which too ,sub)eItuM, �e�-1,
1 shall not employ any person b any maat u to bemme vbjcct to the WATER SYSTEM/TREATING
WRken'Compenutbn W w'a of California.Date PAI
O Z Appllunt NEW RESIDENTIAL PCMB. SQd.T. to R f t#
Z NC)TICEMO PLWANT:R,aaerm•Wngtbh Cenifceteof Exemptbgyou
should bemme subject to the Workeri Compenatbn provision ufthe Labor TO L:
CC N Code.you mrat(othwdh mmply with such provbbn orthb pemdtJWlbe U sCP
LL > deemed revoked. '
CL G CONSTRUCTION LENDING AGENCY S ISM IC FEE
Ihereby•f�rmthat them Is mrutruetton leodleg agency for the perform, ELECTRIC FEE rtss
7 Z once of the work(or whkh this permit b lassoed Sec.3097,CW.Q TOTAL _OD Za+QJ
V O Lander.Name PLUMBING FFA L -O
LL F Tanderb Addrtu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IRn-lagtlhave Radth aUdtbn•rdat•teUuttheabwedn teaaws f �a
It. bmrrttd.Iagne to complywhhaBdtyand muntyordDancv and state laws I'QiMTI'ISSUANCE �C,W FEES PAID:
} eftyloy terupcot est ron,aod he rtby•uNontrertpreontaave of lisle
F Z cityW)ar,,tosaeabove-rrcntlond propertyfnis the Cit of Cu . ALTER ORADD TO MECH. Date Recd t#
_
(We)sgme to ssve,WemNly and keep narMea the city of Cu penlro
OWHI
merw,m+s• pernwh,hmyln.yway.. AIR HANDLING UNIT CFO 10,000 CFM SUBTOTA .IdCNybaa ere oft • Ingdthb peAIR HANDLING UNII(OVFdt 10,000 CMM) CONSTRUCTIONTAX
dAppllcent/Contracor to FXHAUSTFIOCD(w/DLCO �--� CONSTRUCTION TAXP ID:
HAZARDOUSMA ERIALSDISCI SUREe appli.aorfuture building oavpart store or laM le hvardous HEATING UNIT(TO l M,0)0 BT" Date RLYCI t#
materbl as defined by the Cu penton Mu Ndpal Code,Chapter 9.17,and the
Health and Safety Code Section 755370)7 HEATING UNIT(OVER 100,000 BM
n Yn p No
Went the apphaNia tcodamiding aavpnedi by the Bay Ata drWRs VENTILATION FAN SINGLE RESID) ISSUA ATE
whichaMthaardot air omtaMnrd•a deRrcd by the Bay Area Alr
rQ..IftyyMavgement DLstrkd7 BOE.ER-COMP PI-D'OR 1f10,0(D Blln 1 ('6 1.0 10
4 Yn ❑No `'1 ''a
lit.° leeith SafdyCWt , ry.i 5nbunderehapter. I 0( BORER{O. P(OVO 1000(0 BTU
u Gal t Itifth hSafetyCode,Section25505,veatand75534. I
oodentaodyto rally the
N of not encp remen avi,k),ttat ltbmy NEW RESIDENTIAL MEt73. SQFT •w{ rl asa�IWik�
Pe to bBRyto edifytheocaparLL cthe«qulrtmanb whkh n.„be rent
prior to issuance da Cenlfimte olOavpanry.
Pvnar or authoroed agent Late ISSUED B .
TOTAL
OFFICE COPY