20702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building project Wentlfkader PERbfIT NO.
B
uilding ru,: / " v/ 20702
CI OFCU RT[NUILDNG iV1'S91 Q
mtatla's Nam: Idc.No: APPLICATION / PERMIT
Lie.Na BUILINNGELFCTRICALPLUMBINC- Ff NTCAL CATEGORY CONTROL
ArehBm/Fsglreer.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcar
PERMIT1 ANCE El E] 11LICENSED CO.NTRARORS DECLARATION
I hereby affirm that l on kerned under pmvbima aChapter 9(eommnc API'L[ANCESREMENT1AL
IngwlthSmbn7000)af Dlvislm3olthe Busiroaa^d Pmfessiomt ,and my
Ilrensstin fait fore andLie. P
Llaroe Cha Lk.# ANFTS
Det. C.mbotor UP TO 2DOAMPS
ARCHITECT'S DECLARATION 1-1000AWS
Wrc0Z 1 uMenlatd my plan 811011 be used u public mounds. OVFR1000AMPS SQ.FT.FLOOR AREA S/Fir.FT.
V E Ul;-ed Prafmbvl SIGNSELFL7RICAL
/a OWNER-BUILDER DECLARATION $pI�,IAL Q2CUf.1./M79C
Ihercbyaffinnthat l ameaenepa fromthe CoMradorb Lleeu,law for the
0-9-p lollowing rcesm.Emlm 7m15,Buelnea and l'mfmbw Codr.Any tlty or
U� muntywhkhm)ubasaperm mrut Oter,Impm ,demolbh,ormpalr 7FMP.Mh"TFROR VLEINS.
SES anyetru¢urt prlartolb Wuana,aborequlmtheappuant(orauchpmNtto
O Ole a signed ateteent than he b provisions pursuant to the of the POWER DEVICES
m
;w� Contactor's Lkeme Law(Chapter 9(mmnrneing with SeRbn 700D)of Div{- gy�hgNG POOL ELECTRIC
O sbn3ofthe Businessand Prdmlov Code)orthat het thercfmmard VALUATION
? the basis for the alleged exemptkan. Any violation of Se nb 70115 by any
applicant fora permit subjects the applicant to a tivil penalty N not more than OUTLESSSWITCFESFIXT11RES
hundred dollea MOQ/.
�j owner of the property,or my employees with wages as their auk NEW RE51DENfLAL E.ECIR SQFI. SfOWES TYPE NN'STRUCI1pN
rerepNesafflon,willdotbe workandlhestmenerebrot Wended or offered for
Osat bee 71161,Buainea and I'rafmbv Cade:Tia Contntlols LIaroe Taw ,
s� does not apply to so owner of property who builds or impmvee thercer,and OCGGROUP RL9.UNR5
whomacsouchwork himaeAded orough Msown employees,provided that such
Impmwe mare rotIntended rarofcroffeforeab.ILh ser-r,t11eerMUngve TU"IAI.:
Improvement baold withlnoneyoarofcampletbn,theowner-buuderwl0 have
Ujg¢Wenofprovingtho hedldnotbuudorlmprvefaparposeofsoe.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U I,as owner of the property,sen esch hrety oantmeting with Vacant pp�g1.ISSUANCE
to construct the proje:t(Sm 70K Business and Pma
febro Code:
The Contractor's Liave Law don net apply to an owner of property who ALTER-DRAIN 4 VENTWATER LFA)
Wilds or imp.thereon, mm
and who races for such Mpem with• - GIS
91111setrW amend pursuant to the Contactor'.Liawe law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am eourpt under Sec. B A P C for this recon
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA COND. SANITARY Y— N—
Owrur Dane RFOEI7s
WORkMAN COMPENSATION DECORATION
01 hereby M.that I hove a mrBOate of crosem to self-Insure,or a FIXNRFS PER TRAP 1 t�a SCII TAX Y_ N_
artl0ote of Workrn'C«nperoaHm lrourana oraartillM ropy thereof lsee. l RECEIPT
3900,Lab GAS F.A.SYS12A-1 INCA OUTLETS PARK FEE Y_ N—
IT GAS EA.SYSTEM.OVER/(EA) RECEIPT
Coom nY BUILDING DI VISION FEES
I I CeNBM Copy b hereby furnished.afty
pL�J Ge"Wed mpybrind with the sty ln.pealnn dwwan. cREnsE/INous[xl wnsre wl'ExclrroR PLANCHECK PEE
CERTIFICATE OF EX sMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWMSANI]'ARY-STORM EA 700FT Date RC i 1#
CI'Meembn neea era be<mnpletea uthe perms b reraro hanared aallars
a1a)ele:) wATFx1TFR w/vl�vr/n,[crR ENERGYFEE Y— N
I mrtify that In the perfomuneeaf the work forwMch"pemdt t issued,
I shallnot employ any person le any manner sen to become mb}m to the WATER SYSIFbI/1RFAT[NC
Wetle, Campemrtbn LawsofCallfmn0. Date PAID
Z Appllant
ZO NDTICRTOAI'MICANT:If,aRern MMtM Certlflotof Eaemptb^,you NEW RESMENTIAL PLMB. SQFr. Date Recei t#
pshould bee sub)"to the Workers'ComperuLLlon proNro TOTAL
of the Labor TOTAbecome
Code,you mart fcohwnh comply with such pravbbro orthb pemJt Nall be
Q `� decnvd revoked. QUILDING FEE
W
—p coNthem S ane LEtv'DI en AGENCY SEISMIC PEE
I hereby•orkfor w there i•Corotmcllm dl(5, agency for the per(orm-
� Z anm of the work for which this pemdt bLwned(Sec.3097,CW.CJ � TOTAL: � a� ELECTRIC FEE
02 Lembn'.Name PLUMBING FEE 1 cas
LLI- Lender'sMdress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lartifyUAtllav bar thbappB tbnaMe telhantheabwe formetlm
b Corrm.Iagrcetocanply B auckyawm ntyondinanm"deatelawn PERMIT IaunNCE FEES PAID:
>. N refiling to building CorutnrGlm,and hereby autherLm repe,enttivn aftlels
H Z tlty to enter upon the above-mentbrcd property for inspection purposes. ALTERORADDTOMECFL Date Retei 1#
— (We)agree to save,I demMfy an d keep harrNea the Cry of Cupertino
agaiw WbW y gmeMs,mgaaM penia evh yin any way aceue AIR HANDLING UNIT(TO 10,000 CFM)
agai •mruaqu of 'gr.min ofmM. a SUBTOTAL:
.� AIR HANDLING UNTT(OVER 10,000CFM) CONSTRUCT10N TAX
Ignaturt of Appleo,t/ oeanar Nf€ E IAUST HOOD(W/D)CD CONSTRUCTION TAX PAID:
HAZARDOUS MAT RIALS DISCLOSURE
Wllltheeppba M or future building oaupent Morton handle haranloue HEATING UMT(IO 100,000 BTI)) Date ReCel [#
maletl0l rue defired by the Cupertino MuMdpal Code,Chapter 9.17,and the
I Lcallh and Safety Cade Smlan 255370)7 HEATING UNIT(OVER 10D,000 BM TOTAL:
qYee r]No
111 the eppilont or town,building ceeupant use equipment arch VENTILATION FAN(5WGLE RFSID) Sltiy(`jpb;
which emit havrdous an Conn mbunts as defined by the Bay Area Air IS1 "DATE
Qua lity Management Dun rit7 BOILER-NMP(3i OR 100,000 BTW
4 Ya No
havemsa the ho'ai"wa materiab requirement under Chapter 6.95 of BOflxROOMP(OVER 100,000 BTU) JUL p 9 1990
the CalBomh Health 6 Safety Code,Seclbm 75505,75533 and 25536. I 1
uMealandthatlfthebulldingdoamtarrentlyhaveatenantthtitbmy NEW RFSIDFNFIAL MECH. SQFT.
rnpomibillly to notlfy the occupard d the requirement which at be met �,...��{j�
prior to bsuana a.Cenlfiate of Oauperuy. NDN--
Owner or autharlsd agent Date � F
TOTAL ISSUED BY:
OFFICE COPY