21786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hudd Lig AddrBuuildin ERN
Project Identification PERMIT O,
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T ,tiL. ��� 21.786
K OK -Soo 7-53 '7e)tt�e� CITY OF CUPERTINO-BUILDING DIVISION
Contract¢j(amrt Lk.No APPLICATION I PERMIT L
VV.J BIR MW-E•ECTIHCAL-MU INGMDCHANICAL CATFOORY COMJIO �y
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PfRMITISSUANCE �C-V ❑
LICENSED CONTRACTORS DECLARATION
I hereby affbmtlutlam Bcevadhe BuM rovWavrof uweC(cor drr AI'I'WANCE&RE9DFMIAL BDFSL N
Ing with Section]!1W)of DlvLUm3 olthe Bualreeandl'rulevlonaCode,and �a„Yo n-k-00^
Llce la In fuB(ortoanddfra.
PANELS �.JyLL
LI¢nse CWs Licl
Date Contractor
ARCHITECTS DECLARATION AMPS
pOZ I understand my plaro.WbW used a a pubk rends OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FL.'+ 00al
Lkrrued Professb OWNER-BUILDER DECLARATION SIrECIALCB2CUIT MISC/
< SICNS ELECTRICAL
'Lw
I.,�2 conIn he¢bhylceh firenLtheata l ametmoropt vfmwn the IContractor's Lkeve law faW the
6SIFppQppQbwbg on.(SaUon]031Busuall Prof¢lbvCodr.Mydtyor
�P.METER OR POLE INST.
fo
F v�� ty•"r re9u Pew c4a p h,orre Ir
any alrudure statement
I,alvredi pursuant to the fasuch peofNt a POWER DEVICES
O fik•abed statement the he b r 9 nnea pursuant to the ti o 700M of the
µ Con 3 of
Lkevslaw(Clupter9(mmmendngwMSeRbn7000)ofpd-
30 Divi-
sion the Buafnena and Rofesslov Code) hebezempt thercfvmard SWIMMING POOL ELECTRIC VALUATION
y.' the Wes for the alkged ezemplant. My Wdatbn of Section 70315 by any
[�$�« nppB¢ndrtd ddlan aub}ecblheappBcanitoa Wllpevkydnat mo¢than OUTLEISSWI7CF16FUOT1RF5 6c� (�0)
tSR1+ O'er' NEWRESIDENTIALELECTR }7. L,
LLWJJ I,aownerof theevurk,aorhetmnum is rwRhwage astktrsok STORIES TYPE CONSTRUCTION
M on,wBllorsaawrkandlhea Code:
Welled or offeredLoo
❑ nak(See pply Busto..asall Profetsaicterpropecy, Co de The Contractors u,. I.w
whorldoes t pchy rkhw Umth pgh aw em ori provitedthatand OCC.GROUP RIS.LINIIS
0.0. bnpd ssuchwomintelda oro a hlsmule.I hmveprw•We Jhdhnrch
� LnprovemeNa arc tont Intended oroHered for nab.l4 M1mvever,thewiWlnB¢ TOTAL I SIM
Lriprwement bsdd whhlnorcyearofcompldlon,tM ownerbullderwW Wve
t"rdendpcovinglhehedd not wild orlmprove la purpeae ofsale.k QTY, PLUMBING PERMIT FEE FLOODZONE AEN
u L as owner of the preperty,am erehulvely contracting with 11eevd
mnl¢daa In roratvd the pm)ect(See,7014,Buinwand Pmfeanbro Cade: PERMIT ISSUANCE
The Contndore Lberue Uw dm not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
wilds a Improve theeon, and who contads fee auch PNFm wBh
eglBrydm(a7u¢nsed pursuant to the Contractor:Lice.. . gA«FlpWpRD,TBCT.DEVICE FEE SUMMARY
LJ I en ezempe order Sec— B t P C for this reasnn
QQTqIQF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dee RECEbrra
WORKMAN COMPENSATION DECLARATION FUOIJRF_S PER TRAP SCIiOOL TAX Y_ N_
❑1 hereby affirm the I have•¢rtlfi¢te d consent to uV-bort,a a
w'
aofWorknn'Comperuatlon Imuran¢as¢rtIfIM copy Ihered Loc. RFS:FFI
m
1800,Wbb G7 CAS E.A.SYSTEM-1 INGf OUT= PARI( N FEE Y N
PT
CoPolm, GAS FA.SYSTEM-OVPR 4 LEA) DING DIV
Y BUILDING DIVISION FEES
Cerd(led cepy b hereby tumbhed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CMI/ied copy b filed Mth the cry Inspection dfWnlon.
CCRTIFlG MFO S FTIPf10NMOMAN WORKERS' GREASE 772AP PAID
COMPENSATIONLNSURANCE SEWER-SANITARY-STORM-SANITARY-STORMSEWER-SANITARY-STORM FA 2OWT D C 4R.ipt#
Z4(f hb acRbn need nd be completed HtFe permL b/aorc hundmf dollar
ww)aleat.) WATER FIFATIF w/vFxr/E.ErrR ENE FEE Y N
I¢dlfythatlntheperfomun¢ofthewakforwNch Wsper i.6dN, —
I n W B net employ any person In any counter m as to become subject to the WATER SYSTEMfTRFATING
Workeri Canpematbn Lawn d California. Date AID
O Z Applicant �t m
Z O NOTICE TO APPLICANT:14aher making lhb CedHLate of Exemmpptt ion,You NEW RESIDENTIAL PLMB. 9QFT, LD tC Recel t#
nhmld become sub)ecl to the Workem'CompeveLm provblem ofthe labor TO AL: 4
~ N Code,you mile fathwhh comply with auch provisions or thin Fermat shall
y deemed revoked. l) a(:O jorfFSE
CL O CONSTRUCTION LENDING ACENCY S SMIC FE
IherebyafOrmtWtthertbnmrutrucUon krding agerry lar the perform - TOTAL: ELECTRdD
IC
M Z. ata o(the work forwhich thio Per^dthbved bee 3097,CW.C) PLUMBING
O Lends.Name
LL F Lenaer.Aaamaa QTY. MECI-IANICAL PERMIT FEE MECHA FEE a
O W Icertlfy the l havemadthbappBntbM nastatethe theabove Information a•-T
b corral.I agree to comply w all city and county ordleanm and nate lawn PERMIT ISSUANCE l/+CO FE P
} a relating to wlldbg mrotvctlon,ard harelty.uthoricat repremtattve of thio
r In city to enter upon the awve-mentbvd property for ivpedlon purpnia. ALTERORADDIOMECH. cra,�
V _
(We)agree to nave,Indemnify an d keep harmless the City of Cu pertlno be Cteipt#
aga Wt WbNtim,Ndgmerw,cvna."e.petsea"ich may inany,wayamue AIR HANDLING UNIT(TO 10,000 CFM) S OTAL•
spa Wised City egos¢d the granting d this From.
Z1�9� AIRHANDLING UNIT(OVER 1B,BaoclM) CONSTRUCTION X
SI wred7tppuant/Contracts Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TA AID:
HAZIRDOUS MATERIALS DISCLOSURE
Will theapphrant or future wilding occupant noreor Wrdlc harardov HEATING UNIT CM 100,000 BTU) Date R 1 t#
material as deflred by the Cupertino Mu Ndpal Cad,Chapter 9.1 j and the
FIeahheASafety Code Section25532W7 HEATING UNIT(OVER 1(X0,000 BTL)) TO AL:
qNaYn
filtheappbcants wumWOdbg« pantumequiprrcntsdeW. VENTILATION FAN 6INCLE RFSID) ISSUANCE
which enut hazardous ab mntaMvnts as defined by the Bay Area AL
Qualdy Mavgament DWrkt7 BOILER-ODMPOFW OR 100,0(U BTU) QAwe
Ye ❑ -6`n�slCwll
have mad the hazvd materlab rtyuiremena undcrCW pier G95 of BOILER-NNPIDVCRiW,000 BTU) r-a.,
th<Glafomla tleaLLh kSalety Coda Sectlov 25.505,75537+rad 255b.1 �� �
understanrmpoea(bBUy to notify the occupant d the reeubeenems which mre be men d that lithe buLldingdoes not woontly have a tenant,that It is my NEW RESIDENTIAL MECH. SQFr l4 SVf -• 1
-
Edon to Lauana d a CertIH¢tc of Oavparsy.
a�hl
Owner or authorIced agent Date .•r1j ':•��]a � G�
TOTAL: ISSUED BY/Vf Imo'
OFFICE COPY