24079 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
HuRdIn,Projed Idemtlfleatlen PER-WT NO.
Baflcl"gAddre"
LL 24079
104(p0 I
rcre �// one. ADATE
�I A V300DALL. CITY OF CUPERTINO-BUILDING DIVISIONrj ��
Connttnader'.Name LR.N APPLICATION/ PERMIT ``'C�Jj —'l
IL-'a
— st �ul Ie '� BUIIDINGFLECIWCALPLIRABINGMLCHAMCAL lIg CATEGORY CONTROL.
Architect/Err.
LU,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
LPERMITISSUANCE ❑ ❑ ❑
K:ENS ED CO.NTRAROR'S DECLARATION
Thereby affirm,that lam licensed oftheunder provision,dChapter 9(mvnmc AI'PIlANCESRESRJENTUL BDFSC N
Ing with Jooin
000)of anddieon3o/theBuslree.and PmfeeelovCode,and my /I
license bin(uaf�and dieser. PANELS
Dale_`(!��ARCHITEctor RATION �- 201'1
UP TO 2DOAMIPS
OVER 1000 AMPS FT.FLOOR AREA
qq+��+++ Turd<rYard my phv ehaBbeu pu=me.rds SQ. $/SQ.FT.
Fi Licensed Pofembvl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Ihembyaffl.thelamexempt frau the Contractor'.License Law fatha
2o following reason.healon 7(BIS,BualnmsaM Pmferbv Code:Mydty or
OLE' awn hkh tress tomvVuct,alter,bre TEMP.METER OR POLE INST.
Fg tyaw ped pru^it Improve, repair
.c any Ymcture nuor-b her he In domed
petL° t to the
roach s,of t e POWER DEVICES
��sp file a Ygried statement that k k,llrensed pumnnt to the provblov of the
P31„E. Contnctora Lkenae Lao(Chapter 9(mmmendng with Seetbn 70M d DM- SWIMMING POOL ELECTRIC � VALUA77QV�
f- OJ Yon3 ofthe Buidnesa and Pro(embvCode)orthm he b eaemWt therdromand CiG7
f5 Q R the hank,for the+ledged exm oum. My vlolatlon of Smion 70115 by anyOUTL-�gWITCHE&FD(T URES O O/�
apparent fora pe mIt subjeae the applicant to a civil penalty d not more than V
a 0ve�undred dollars 0500.
2 f1,u owner of the Property,or my"loyeea with wages as their sole NEW RESIDENTIAL ELECTR SQFr. STORIES =CONSTRUCTION
compensation,waldothe work and theYrutlure is rot intended or offered for
�p .1.C.704y Busircasand Pv(essbv Cade The Cmdractor.lJmve Law
$$ does retapply to an owner of property,who builds or Improves thereon,and OCC.GROIR' RIS.I1M15
who dm such work himself a through his own employees,provided that such
Improcem am=lntendedorofferedfa.ab.Iflurvever,thebulldingm TOTAL:
improvement bold within orcyearofco mpldb,the owner-builder will have
d"ben ofprovlog that he did rot build or improve for purwae of sale.). .QTY. PLUMBING PERMIT FEE FLCOD7nNE APN
LJ L as owner of the property,am eefuYvely mntru Ing with licensed
mntracton to mnal,ect the ponied(Sm 7044,Busies®and Prdessbru Code: PERMIT ISSUANCE
The Contnaoh Llnrue law don sot apply to an owner d propertywho AI.IER-DRAIN 4 VENT-WATER(EA)beads or Improve thereen,and who contracts for such pt,ofecia with a
cta(M11 purwant tot a Contradoe.Ll¢ve Law. FEE SUMMARY BACK FLOW PROTECT.DEVICE
OUISI OF FEES
• B 4 P C (or<hb reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner_ Date RFCEIeT
• ORh I Pa ermfi ON DECLARATION FR,NRFS PER TRAP SCHOOL TAX Y N_
❑1 k affirm that 1 have o artitrano d-.vent to o y thrmof ek• RF�E2PT a
3S(V,rent[Rateo/Workers'CwnpwuonlruunnamaarYfkd mpythereof hese. GAS G.SYSTEM-11NC,4 OUTLET PARK FEE , Y_ N
lvk Iib CJ
C.I'Y a GAS EA.SYSTEM-0VER 4(G) BUILRDCElDING
Y
Y EUILDINC DI V ISION FT.ES
Certified ropy is hembyth the ed. GREASE/INDUSIRI.WASTE INTERCEPTOR PLANCHECK FEE
C<rlBied ropy k,(sed with the city Ivpmbn diviYon.
CERTIFICATE OF EXEMPTION FROM WORKERS CREASE TRAP PAID
CmM con% l&I fft NSDRfE SEWER SANTLARYSIORM EA200FT Date Reecl t#
(D)orI bre need na hecompleted Btk prmlt isToone hundred doaan
ig100lm1eseJ WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
Inifynot sup in the perso perof formance, he mwork for which ttd.pmdtislowed,
I shad not employ any pawn in any canner,o n to become subject to the WATER SYSTEM/TRFATING
Worken'Campensstbn law.of GlBmnb. Date PAID
C) Z NOTICE
NEW RESIDENTIAL PLM B. Date Recei t#
_Z 0 NOTICE TO AIrPLIGNT:if,after rnakBig this Certificate of Exemption,you
should become sub}ct to the Workers'CompevYon proNabv of the Labor TOTAL
~ _y Cade,you neet/orthwdh comply with such provlsbv or this pemdt"I be
Q > deeed revoked. BUILDING FEE
W
mO CONSTRUCTION LENDING AGENCY ISMIC FEE
IherebyafRrm that titre k,a mvWcims lendingageocy for the perfam, ELECTRICFEE
Z a nmoftheworkforwMhthk,p..rmXbb (See309/,CIv.C.I TOTAL'
O I!neer.N.
PLUMBING FEE
IL E- Lender'sAddiess QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtilythatl have read this appliotbnard statetibe the abwelnfonretlm
k,CnIom I agreetocomplywtth all cityand muntyoNlnanmand state laws PERMIT ISSUANCE FEES PAID:
>_ N relying to buliding mvtmWon,and hereby authmb<mpmaentatNn of this
F Z cLLy to enter upon the abowennentbned property for teepectbn pupors. ALTQ(ORADDTOME(ZH.
_ Mr).gree to save.Indemnify an d keep harmiless the City of Cupertino Date Reeci t#
agaWt .judgments,mtla and rapemes which may N anywayamue AIX HANDLING IIMT(TO 10,000 CFM)
SUBTOTAL•
ago Ids gnnUrig of this point AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SI ,, m/ n a Dare WIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
WdltkappllaMafuwn beading acvpant store orhaMle huallous HFATINGUNIT(10100,"STU)
Date RCCeI t#
material.s defined by the Cupertino MuNcipal Cade,Chapter 9.17,and the
I k.hh and SYety Code Sealer 25532W2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑
Y. No
WW the epplia of N re building—pant use equipment or d evim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hast 1.Mr motamW est.u defined by the Bay Arca At,
Quality Me aglmeta DWrlct2 BOILER-ROMP OHI'OR IMOM BTU)
.`
Y. No p
4TTr�''II
have va�ouenetcbis q rtmn pp�� PSI under Chapter BORER-COMP(OVER P
the GlBonb Hahh 4 Safety Cod,Sectbv 25505,75573 and 25534.T
understand that lithe building does mt amrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFF AUG O
responsibilitytotheampantdtherequlrerrcnU which mustherant 19
relortoissuance ncay,the to of ftheracy.
CITV (]
Owner a authorised agent Date C
TOTAL ISSUED BY:
OFFICE COPY