22208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build Ing ProM ldenti(lution PERWT NO.
Building Addre;s O (s,g a s �„ 8t, ' 22208
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O .Sr/V r S2 CITY OF CUPERTIN6BUILDBYGDIVISION .��q I
Centra¢ '.Name: I, APPLICATION / PERMIT l
0 Lki%J BU11,01 GELLCTRICALPLUMK:AI.BING-MECHANCATEGORY CONTAOLY
Arthded/F gircer. tar.Nu
QTY ELECTRICPERMIT - FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm Wtlam Bcmacd under prwblm.dChapter9(oonrunren APPLIANCES-RESIDENTIAL )08 DESC N
i.gwlth So Wn7000)of Didam3oflhe BuNrcssand PmleWmaCodeand
Bane b In(us Teen and dfeR PANFTS
LkxnseClaa 0_LICI �77_3,? —,�--7
Dae Contractor
ARCHITECTS DECLARATION -1 AMPS
N Zp I understand my play.bBbe used n pm
ubkrerds MPS OVER 1000 ASQ.FT.FLOOR AREA S/SQ.F7.
hsFj Lkerued l'raf®lovl SIGNS EI73CTpCAL L'�,. '7L4L qz
OWNER-BUILDER DECLARATION SPEC1ALCatCLBT/A715C
E'�� Iherebyalflmn that l am e.empt from the Comranor'a Lice.law fee the
7.p following ma.m.(Section 7m15,Buaimeu and Prefm.b^s Code:Any city or
07.1"' mum hldrrnNOna repair TURP.MEEK OR POLE INST.
F O n tany.tmP'mrdttomrahud,alter,lmPro`T,demoWh.orrudure prbrmib b.,vance,alw requlrnthe appeontfo such pemdt to ppy/Eg DEVICES
O fib a I
Conindo,E. statement that he b Ilansed pursuant to the provisions of the
r'a Llcenxlaw(Chaptn9(mmme^dng with Section 7000)M DM- S1yBd�NG I00I,ELECTRIC
BOJ .en3 of the Buanem and Pmimbv Code)orthat he ise rapt therefmmand VALUATION
...7777 the Wab for the alleged exemptlen. Any violation of SttYbn 7(315 by any OUTLETSSWTTCHFSFDn-URES I l�I I L S
appfla tforapenm mbjedatheappkanttoadvllpevitydna mthan L I L
$ nv Wnarednerofthepr. NEWRE�ENTIALELECTR SQFF. STORIES TYPENNB1xUCT1ON
1,a1 owner of the property,or my empkym with wage as their rob
C < ®npenaatlm,wllldothe work,and theatructurebrot Wended or offered for
��O ulc Dec 7WL Bu.lnn.and Pmfubv Code.7lr CoMradota Creme Lw
don not apply to an owner of property who builds or improve thereon,and OCC.GROUT' RES.UNITS
GG.• whodmach.moollraelfmthrwghdownemIfhown rthetdtluinger
improvementsarerotiLMeocdorrofcoipleoe.tf,howwer,theerIW ve TOTAL'
impmvemcnt bsdd wBMn orcyurofcomplNONtk ovner-0ulldcrwW hews
t rde.of proving that he did not build or improve for purpose of sale). QTY, PLUMBING PERMIT FEE F1�OD7ONE APN
Lj L as owner of the property,am entualmly mntraciing with Ilmued
mntndort to movtruet the project(Set.7000,Bu.lnm.nd Pmfea.lov Code: PERMITIR3UANC2
'Die Contractor:LLLeve Law dm not apply to ar,owner of property who ALTER-DRAIN k VENT-WATER(EM
builds or Improve thereon,and who mntram for auch pfo)ecb with a
-WifactorW llamad pnr, .t to the Contractor:Llm..e law. sAo:F[.owl�tnrECT.DE'vtcE FEE SUMMARY
IJ 1 am eaemp under Sec B 4 P C for thio mon
i.
•
DRAINS FLOOR ROOF,AREA,ODNO. SANITARY Y_ N_
Owner Dale RECEIPT1
WORIC.IAN COMPENSATION DECLARATION
01 hereby affirm that I have a¢miBeate of emu.t to self-tors,or s FV(7VRES PER TRAP Sa400L TA% R �s
38W,Lab ab CJ o/Workeri CompvvaOmloran¢aanrtifled mpythereof(Sec. GAS FA.SYSTEM-1 INCL OUTLETS PARK FEE Y N
polk Ldky I DING DI/
Co ^y GAS EA.SYSIEM1f-0VERd(FA) BUILDING DIVISION FT FS
Cert111ed ropy b hemby filed
city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�eedwnd copy b filed wdtb the sty w),e.tlm.dlwlam.
CERTLFICATEOFEJ(EMPTION FROM WORKERS GREASE TRAP PAID ��1yr���
Cut ben—ATIONINSURANCE SETYpFSANRAAY STORM EA marl. Date Recd t# .Lfc)
(this section need nor hecmnpletnd Bthe pemdt bfororc hundred dollu.
(S1m)al"a')
wArm l-ffATExw/vExr/p�erR ENERGYFEE Y N
f.ewythatmthe pennrmunndmewonk mrwNchtwpemUtbboned,
1.lull no omplmy any penin m any rtunner eo as to became enbject to the WATER SYSTEM/TRPATTNG
W.rkeea Compenutbn Law.of Glffornb
O Z NUCRt NEW RESIDENTIAL PLMB. SQJ.7. Date ReO'_I tit
2 O vApplh,mt LICANT:u,.Herm.kinglw�rtulate.fE.emptb.,yo,r
FAmid become aebyet to the Workera'Compevetlm provlslu ,of the Labor TOTAL:
CC N Code,you o.ut forthwith comply with.uc)r provbbv or this permit ahaI be
deemed! oked. IN s
W co
0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hereby afM^that there b a mn.tmdlm lending agency for the perform ELECTRIC FEE
7 Z an¢o/the work(or which thio permft6baned 6ec.309'/,CW.C.) TEAL
U O Iarder:hlame PLUMBING FEE
LL ~ Lander'.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I eertify,that l have read tw appecationand natetha the above inuu,nadm
bmm_t.Iugreomcomply wLLhaB dryand muntyordlnanmand storm laws PERMITIBSUANCE FEES PAID:
NMatingto Wlldingcovtrudlon,and krebyauthrrom nepretentatNnofthb
F z greo dry to enter upon the above-mentlorcd property for Wpedbn puryo.e� ALTERORADDTOMECH.
V _ (Wa)ato aawe,indemmy an d keep menden the City ed Capertiw Date Recei tit
agah„ts,bwt�,pdgmerpm .t. th e.pe..nwhkhmayln anywayadm,e mac HANl3uNc uNrr Tlo lo,000 cFM)
agabw uid CLLy mn. ner�¢oftk gnMingdthl.permlL SUBTOTAL:
3c AIRHANDWNG UNIT(OVER 10,000CFM) CONSTRUCTION TAX
sigvtu o pBnd/ mtrada Date E)(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
ILAZARDOUS MATERIALS DISCLOSURE
Wliltheapph Mo/WmbuddingamnpantstomorhaWlehaw s HEATING UMT(ID 108000 BTU) Date RCCCI tq
materbl a.deflned by the Cupertino Municipal Code,Chapter9.12,and the
Hnhhand Sacty Cade Sed1cn25532(.)? HEATINGUMT(OVER100,000 BTU) TOTAL' t
` ❑Y. �]No
^;t Will the appi"morfrtum building omupant use equipment or dov ea VFNTILATIONFAN(SINGLE RFSID) ISSUANCE DATE
which eMt kvrdmuU cvMaMvnb a,de0rcd by the Bay Area Air
Quality hLvgemeM Dbtrkti BOILER-NMP DHPOR 100,000 BTU)
Yo ❑No have readtheh.wrdws rvteriabrequime nbunder Chapter6,95of —7—
?h BTU) �u
the Glifomia I Tealth k Safety Code,Sedlov 25505,25533 and 75534. I ��'ylI(kW]j
u ndesatanl that if the Wildin g dean rot currently have a terunt that it b my NEW RMDENTIALMECH. SQFI.
respovmilry to nolfy the umupant d the requmnmr.whkhmu.t be mT[ r�/1� tt
primtolssuawedyCe lMn.� n...wmT,. I f'1 U
Owners auth ud agentpale— a
TOTAL
OFFICE COPY
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