20709 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldl Protect Idemlfkatlan PERMIT NO.
Building Address:
6Ob -,a6, / ZZ . 2
0709
nr. arrc one:
CITY OF CUPERTINO-BUILDING DIVISION
Cmtreaa'a N+me: Lie Na APPLICATION /PERMIT
a �•0 BUR.DINGELEX'fRICALPLUMBING-MECHANICAL CATEGORY CONRROL 0
ArdWea/Esgtrcer.` Lie.No:
6 QTY ELECPRIC PERMIT FEE BUILDING PERMIT INFO
Address I 7Eth4TISSUANCE �� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby.aHlrm that lam Bens i under pmvblonsof Chapler9(eamnm APPLIANCES-RESIDENTIAL JOB RIPTION
Ingwith Section 7DDO)of Division 3oftheBuelnenand ProfesYomCode,and ony
license is In foil fgR and effect. PANELS
Lice Class a— Lie_e A ' '�q jz
Data Comnaor ✓ '^�
ARCHITECT'S DECLARATION AMPS
rc0 7. I rete"my plans shall be used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
�E rod esbnsl SIGNS ELECTRICAL
AL
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/hU.SC
OQa� fo the reason.afRrmshat l+rnelenptfmmtbe Corurei.e.Lleenx Lswfmthe
ZC� 4a1m 70315,Buelnm a"Profession.Code:My city or 7pdp MEIFR ORI'OI.0 INST.
�� countywhkh rcquMapersktomratrua,alter,bnpmve,demoLLeh,orrtpalr
2P'^
anysimaure prlorto lbbu+rce,+bo rtquWtheappbontfauch permXto IA)WER DEVICES G. t
Ole+signed statement that he Is llcenned punwnt to the prov oom of the
3" Contreaor'sLicense lAw(Ch+pler9(mmmeneingwith Section N00)ofDivi-
SWIMMINGIGOL E.ECIRIC
Orn sion 3 ofthe Boehm a"Pro(emaeCode)or that he bls eNerc(romam VALUATION
a S^5 the basis/or the alkged exemption. Any dalatbn of Scabn 70315 by any OUTLETSSWITCHESSFE)MMES Oa iJ�
��55 OQ a ppllontforapermltab*n theapplkanttoativllpemkydnM=mtM1 n
E $Y five ],ase doofthellars pro NEW RESIDFNDAL E,FCIR SQXT. STORIES TYPECONSIRUCTION
PI +.owner of theproperty,orrrTyhe employees withwageatheirwoe
temp oe.70K will desk work,and shenruaerc b not trate""or offered for
D sale l5ec 7014 Buelrim a"ProfessionsCode:7Ie Camnaoh uceroe Law
don nor apply to an owner of property who builds or improve,t heron,and OCC.GROUIa RFS.UNITS
who doeswmed
ch work hiforthrough his own emplo/ea,provided that such
improvendms are not intended oroHcred forsale.If,however,the building or TOTAL:
improvemem bwld wlthinoneycarefcamplabntheowner-bullderwW have
t Nen of proving that he did not build or bnprove for purpose of sale.). QTY. PLUMB PERMIT FEE
Lj L u owner of the property,am e.!uevely mntraaing who Bcensed FLOOD ZONE APN
eentmetree to conatus she pm)m(See 7064,Business+"Profesbm PERMIT T ISSUANCE
The Cordr+aori Llarm law doe not apply tow owner of property who
Wilda or Improves themon,and who mrum. for ueh pR jem wIN a ALTM,DRAW 4 )
ryu¢aetee.)lisni purw+nt to Ne Cmtnnor.Llan.Law. FEE SUMMARY
U 1+m e.empt order Sec B k P C for thio maso.
D FLOOR.ROD SANITARY Y_ N_
Owner Due, RECEI T/
�.� WORNNIAN COMPENSATION'DECLARATION ppg 5Q{OOL TA% Y_ N_
U/1 hereby+/firm that I have+aertl/inte of consent to uB-Inure,a+ RECEIPT X
mrtifirate of Workers'Compersadon I nau�ranne,or/+certified copy UumeffSec. CAS EA. WGBQ PARK F'F£ Y N
3&p,IAb CJ alE+/G� 33 1'l"fU•/c� RECEEPT4
I'wkyl T�'+T/.JL.. CAS.EA. ' VER4(EA
Co y BUILDING DIVISION FEES
Ccrtlned copy b hereby ferrd.hed. eREABE/I w PLANCHECK FEE
Certified ropy b filed with the city,Inspection divulon.
CERTIFICATE OF EXEMPTION FROM WORKERS' PND
COMPENSATION INSURANCE SEWFRSANITARY- RM EA Dale Reoei t#
(Thbsnlbn need net be eanplesed tithe pR b ermfe,one hundred dollars
ma0)orfea) WATT'RHEATER w/vENT/ TR ENERGY FEE Y N
Iartlly inn bite perfornun¢o(the work farwNchtw pemdt blaueQ
I shall not employ,any person b any rrenner so u to become Wb)eet to the WATER SYSTEM/TREATING
Waken'CompcnsaHan laws.!CABfornla
O = Appllant NEW RESIDENTIAi PIMB. EQ�. Date Reeef t#
Z O NOTICE TO APPLICANT:U,after making this Certificate of Exemption,you
should become ub),ct to the Workers'Compensaslon provisions of the Labor - TOTAL:
F' V) Code,you mu at forthwith mrnply with such prowbna or this pemdt shall be
7 deemed revoked. BUILDING FEM
W O CONSTRUCTION LENDING AGENCY ISMIC FEE
d Ihereby+flirm that then b+construction Lending+gercy for the perform
Z anreowork for whlchshb M
pert bswd(Sec 3041,Civ.C.) TOTAL: ELECTRIC FEE
(� O le"e"r'.NaNme PLUMBING FEE
EL F- L odee.Add. QIY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cert By that i have road tw+ppliatbo a"state shat the abovslnfarmatim
a lemr Y.Iagra to complywlthalltltya my oNWnm+nd date bwe PERMIT L%UANCE FEES PAID:
} resting to building mmtrualm,am uHiW reprelenhHve of this
f.. N city toe er upon he abort-mem p rty la WpMbn purpme ALTER OR ADD TO MECFi
e) gate to awe m +n a bamda�me coy a Cupertlne Date Rxei t#
V +g+ bWtb,fud sande con which may In wy w+y+muc AIR I{ANOLING UNIT RO t0,0D0 CFM) SUBTOTAL:
.ga aC Inc ft Ing d this pe.L
AIR HANDLING UNTr(OVER I0,000CFT) CONSTRUCTION TAX
fAppu t/ ons Date E>a-IAUsr FLOOD(vi/DLC:D CONSTRUCTION TAX PND:
IU UB MATERIALS DISCLOSURE
Will sh .PF ea luta Wilding oavpans neat or hardk M1awdms IfrATWCIINTT(TO 100,000 BTU) Date Rttei t#
mat vol de0rcd byt C Nov MuNcipal Cade,Chapler 9.11,and she
Ikahha"Seety Code 15531(.)7 HEATING UNIT 100,000 BTU) -
Yn o
ill the applicant or future Wilding o pantuw qulprrem or device VENTILATION FAN 6WGLERFSID) ISSUANCED TF'
which eMt halaNm++b mnUtNmnss as deRi by tM Bay Are+A4
Quality Mansgemom DLst BOILER-COMPOhIFOR100,MBTU) JUL I
.I Ye U
.1 mad mtedabriou 255enb5S33.Cha-t534.95 of BOILER CVMP(OVER 100,000 B'1l1)
she Caldornla fkalth h Safety Coda Sealom b5Q5,ZxS33 and 75534.I (sem TY„
rainy In tM1e Wllding does nor evrtentiyhavcatenan4Hutbrnet
NEW Rm DENTINE MECH. SQFT
Twos dlty so nor Immama wM1kh rrvd be mel
priors orf+ N
Chvne r sharlad ens Date ISSUED BY: j�`-"�V•7•T"^�L+
TOTAL:
OFFICE COPY