22091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro' ldemlf"fien PERMIT NO.
Building Addrms. 206j 22091
re ante:
CITY OF CUPERTINO-BUILDING DIVISION
ee^Mo-a`o`eNam: E Q )
APPLICATION / PERMIT
Q�L SMS 1 L' v I Bf111.DINGF],F]CTRIUI.PLUMBINGMCCHAN1uL CATEGORY CONTROL,/
J Archllatt/Engiab.er LNo:
QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PFRhITI.AUANCE �(� ❑
,LICENSED CONiRACFOR'g ECIAR ,TION
Iherebyafflrm tlutlam l:censeduMn talwsof CTapter9(mmmaic APPLIANCESRISIDENTIAL JOB DE9CRIPTION
ingwlth ScJ.. (10)a(DhMlon Soft B and fasel.Cde,andny
license cent<nse is In fun(aoften, PANELS 1-T.-tt-T.
License Clase Lk.1
Date Cn mador UP TO 200AMPS
ARCHITECPS DECLARATION 201-ILIO
02 ]undemerd my plan ehaBbe used.public remnla OVERIWOAMPS I AULMO I5/SQ.ET.
Lilmosedi Professional 9GNS ELECIR CAL -% P T E
6 OWNER-BUILDER DECLARATION WEMLCIRCUIT/M6C
7F,��, 1herebyafflrm that l am exempt from the Contractor's License Law for the /. ITER
pp following m..t5ectlon 7MI_S,Busters and Pmf®Ioa Code:Any city orcounty (� v
6 Z TIMP.ME ERORPOLEINST. ME
..
..Ygm which ao trud,alter,UnpmvgdennlbM1.orrt to
q anyatrvdurtptementahauarcgalwrnrylrusuettothel(«aulem,of to POWER DEVICES
file a signed imoseLa that he mr9looM pursuant b the don 7 0T) of the
3OG Contractors IAcemeTaw(Chaptu9Cod0ordng with Seabn7000)n and- SWIMMING POOL.ELECTRIC
��5 the Ist, tfo Budnmaed!a or easloi.0 Any
victld n,of esmp 70313 by and _ VALUATION
the Web for the alleged oeemthe apt My t tolatbn of Section not room
by any `� �'7� a.`0
65 aPPncantferapmdt eabJMsNeappncan(toadvll penalty of not moretlun OUT[RISSWITCFIFSFIX'['URFS 'L L...�l J00�` W
Oye�undmd delta.(LW.
I,as owner of the property,or my employees with wagos as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
]�
compensation,wBldothe work,and thestrudurt is,not Wended or offeredfor
.1c(See.70K Buslrcv and Pnefeaslons Code:The Contractors License law
5$ doesnotapplyb ae owner of property who builds or improvtheon,and CK:C.GROIIP .Rk5.IJN775
who domaues re
chwmkM1lms elf«through hbownemployees,provided that each
improvemewmmn tendedorofferedf«rde.ILhowever,the Wilding« TOTAL: L
' Improverrcntbeod wlthinorcyurolc«npletbRth<owner-bullduwW Wve
trygila rden of proving that he did not wild or lmpmve for purpose of salaJ. QTY. PLUMBING PERMIT FEE
LJ L as u ownof the property,am e=l ufvely contracting with Bemused FLOOD ZONE APN
mnt.d«s tomMatllhe pmjM(Sec 7014,&.Ines and Prufesba Code: PERMIT ANCE
The Contractor's License Law dm net apply to an owner of property who ALTER-DRAIN&VENT-WATER p3A)
Wilds or imp.thereon,and wW contracts f«such pRoJects wild, • FEE SUMMARY
�ry2�+dor(.)licensed pursuant m the Ccedncter'.License Law. BACK EDWPRQfF�!'.DEVICE
LJ I am sac until Sec B 6 P C for this rtiwn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner - Dale RBCEEf
WORKMAN COMPENSATION DECLARATION FI)CrURES PER TRAP SCHOOL TAX Y_ N_
r-11 hereby affirm That I have•certificate of consent to self-Iwrt,ora RECEIPT s
certificate of Worker.'C«npraadw Insurance«a mrtifL copy tbemef(See. GAS EA.SYSTEM-1 nJC4 OUTLETS PARK FFR Y N
,W,Lab Q
Polley a GAS EA.SYSTEM-OVER (EA) RECEIPT 0
Ce ny BUILDING DIVISION FF.
C[
I CedlRed copy b bed with cityed. GREASE/I SDtL WASTE INTERCEPTOR PLANCHECK FEE
7L9J Cued copy bfliedy h the city inspection division.
CERTIFICATE OF OD]11PI'ION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SFVELSAIJRARYSORM FA.200FT Date Rtt i t#
(lhbaedbn need nb be<omplded Bthepmdt bf«care hundred doflan ENERGY FEE Y_ N
(51IX)orfy that
WATER HEATER W/VENT/ET.F>=1n,
I cent cop o theperson performance of the work for n towhichb co permit c leaned,
I Shan net employ any person le any manner at m to become mhbJM to the WATER SYSTEM/TREATING
W«ken'Cempensdbn laws of Gllfemia. Date PAID
-
zZ Applicant NEW RF�FID1ALPL.MB. SQFT, Date ReeeJ tq
2 O NDnceTOAPPLrANT:lf,anerm MngtwCertilnteofEeempbn,you
F N ehwld bemmeabfect to the worker;eempen,etbn povbba orthe L.bnr TOTAL
CC _ Code,you rtwstforthwith comply with such provbbnsorlhis permit shill be BUILDING A
W ] deemed revoked.
d corvsrRlxT1DN LETDwc Acwcr FEE
SEISMIC FEE L
Ihemby•fflrmthat there b amatructlon lodlegagency,forthe perform ELECTRIC FEE (�
D Z ance of the workfor which this permit b Loved Qec 31197,CN.C.) TOTAL ELECTRIC EEE
0 O Lendee.Name � -
LL 1- Lendee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W
UI cedify lhdl have mad thisappllolbnsrd itatethat the abovelnfomutim,
ta mrnd.I.gme to comply whhan dry and muntyordwnm and slate law. PERMIT ISSUANCE FEES PAID:
} a matingtowlNlegmestruetto aro herebyauthorlumprosentaWaofthb
N dty to enter upon UBe above-menrbrcd property for bupeerbn purpose. ALTERORADDIUMECK
Z (We),gree to save,Indemnify an d keep harmless the City of Cupertino Date Recel tlf
V ag.1nort lBtica,ydgmente,mob and e.penr•whicle may In anyway... AIRHANDUNG UNIT(TO 10,000CFM) SUBTOTAL:
'18Z,
g .°a YCky ir{cgn.egper�ce° ntbg of this permit AIR HANDLING UNIT(OVER 10,000 CFMI CONSTRUCTION TAX
fa V�0ortracL yl`3°l%� CONSTRUCTION TAX PAID:
gvturt of Appnont/Cwtr.d« Dace EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSU E -
WWtheappncaru«future building oaup.t stertor handle h.,dous HEATING UNIT(T0100,000 BTU) Date ReCol tq
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
lienallh.rd Safety Code Section 25S32(.)7 HEATING UNIT(OVER 100,000 BIT. AL:
TV
Ythees N.
- VENTUATION FAN RESID)
nlmt applicant« tortminants a.:efindby equipment or it ISS ATE
whichemithanrdou.abrict?contaminants a.defined by the Bay Arta Air -
IcyM�vgcrrcntDbtrkd7 BOILER-COMPOFB'OR100,000B11A rR 3 "'MI
Ym FF��No 111- [F
ehaveread ealth&he �ous mode,Se tionirtmenbundeaC 25534. 95 of BOILER-COMP(OVER 100,0008]ll) n.."
unU.Glifomta Health ASafdy Code,Sectbnsntly hve atand,that. I iwv as,v
u pmaogtonmifytlldln Pao dnot mmntl .t.whn Lthatdbmy NEW RE9DFNIIAL MECH. SQFI yy • `
laponsbBlty to.tarty the omvpant o(tM1r requl.menb which eruct W met —
prfar ro Lauanoe of a Certificate ofOavpancy.
Owner or authodvcd agent Date ISSUED 61�`�
TOTAL:
OFFICE COPY