21614 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Id.etlfaton pT NO.
Bu"Ego 2
1614 .
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7 —07 CITY OF CUPERTINO-BUILDINGDIVISION �2�2C---ct6
cmOm�s' I Lk:Na APPLICATION I PERMIT L
BUILDINGELECTRI PLUMBING-MECHANICAL CAIILORY CONTROL Y
Architect/Englven Lk.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Aadtea PERMTISUANCE ❑ 1:1 ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am Umsed under pde,Wors of Chapter 9(comment, APPLIANCESRESIDEMTAL
JOB DESCRIPTION
IngwlthSMbn 7000)uf DlVldm3 oftheeudve»and ProfeAdmeCode,snd
ince.la In hill force and effect. PANELS /` 0p
Lleenac CV. Lk.a � ' b
Date Contractor ' UP TO 2DOANgtS
ARCHTTECI`S DECLARATION 1-100DAMPS
r, 7 luMeetand ..yplansshallbeusedapubberends OVER 1000 AMI'$ SQ.FI.FLOOR AREA S/SQ.FL
Licensed Pmfessbrul SIGNSFT
Q OWNER-BUILDER DECLARATION SPECIALCD(C
I hereby afirmthat l am exempt from the Contractor's License[rtw for the
p folk w g msane.(Sed oo 7m15,Bwlnee and Pmfesabv Code:My tlty m
OZt- TEMP.M O EW
muntywhldtrt toluper me,alwrequ iter,bnphv tfmoWh,or t.
ak.mg ed st.temmta Bud
he I l�s e d lrnsuant t the provisions
oflt a pON'FR D
Co a dgnea statement the he b llmved punuant b 1r proWloro,f the
COQ don3o thee Bunte.and Pm(e bro Cede)ortha6hebeu pt thete(tvd cont N C VALUATION
•s� the W sic(or Ne alleged exempUs. Any Wolatbn of Sectbs 70315 by any »
0'3 app0ant fora pemdtsubject.the appBcant toe dull pevltydna more tion FIXTURES
qDvyndrtddollars
as owner oftheproperty,or my empbyea wkh wage as
O pavanon,wBldothe wcekand the etromert b rot Wended or th
NE �'�' StGTPE CONSTRUCTON
off
salesee 706Buabmsed Pd®bvCod,..TheContra m`.1JaLofew
Sg dcenotapply town o o(propertywho WlWaorlmprvvntherem,and - OCC,GROUP RkS.I/fv775
who domeuchwohhbraeBmthswgh hbownempirryee,pcovbM that udt
improvements are not Intended oroff red fmaale.If,heswver,thebulbing or TOTAL
bnprovenent badd wRFN orcyearolcvmpletbM1thewvner-WllderwBl have
LIr,�rdanofpmvingtAd he aid rwtwudorlmptm-efmpurpeseofaala.). QTy. PLUM#IN(;tPERMIT FEE
LJ 1 as owner d the property,am er<hulvely contracting h licensed FLOOD 77000E "N
conMd.to construct the project(So.7014,Buslnessand Prdeubns Code PERMIT ISUAN'CF
The Contractor:License Law does not apply to an ownm of properly who MTS-DRAIN A VENT-WATER(EA)
Wilda or Imprmca flu ene, and who contracts foe ad pto)ects wgh a
-7111ractw(s)Boenaed pursuant to the Contractor'.License l.w. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this reason01 ITS!DF HE q
•
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_Owner Date ereRECEIPT If
W(llrm ve ORIONAN COMPENSATION DECLARATION
❑(hby athat I lo •certl0avnFDCTURES PER TRA
te of consent to ae8-Ia
,or a P S ]C)Ct.TAX Y NRECElPI.s
380(),Lab
Workers CmnpewtlonlnaunnceceacedBled eopythereo(fSec. I GAS FA.SYSI-EW1 EJC4OUIIETS PARK FEE Y N
If
Coms CAS EA.SYSTEM-OVER 4(EA) RECEIPT
y BUILDING DIVISION FEES
CerUfled copy b hereby fundhei. GREASE/INDUS[RL WASTE INI}3tCEPTOR PLANCHECK FEE
CcrtNed ropy b filed with the dty Ivpe tbn dlvW w.
CERTIFICATE OF IXETIPTION FROM WORKERS GREASE TRAP PAID
SATIONINSURANCE
(lTbaection need natua bee co completed tithe permit b for care hundml dollars SEIVFRSANITARY-STORM E.A.XFT. Date Ref:eI t#
(S100)m1ea')hatrmit WATER HEATER W/VENT/EIJ'fTR ENERGY FEE Y N—
I rrdly
employ
an pe,s r,In an the manner
for to bthbp subjedLwM, —
1 ort, not empty any perem In any rtunner n u to become object to the
WAT02 BY$IEM/TREATING
wmkr�c npen>atbn La.of uluamla. Dae PAID
PP NEW RESIDENTIAL PLMB. SQFr.
Applicant
Z NOTICE TO APPLICANT:If,seer makingtMs Certificate o(Exere ' you Date Recel t#
should hec mxr subject to the WmIusti Comperuatlon provbbv of the Labor TOTAL
CC _LO Code,you nand fcrthwhh comply with such ptovbbroor this permit dull be BUILDING`> deemed rooked. .
lL o CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Ince of
that there b a mtutructlm lending agency for the perform xC� ELL•CTRIC FEE
Z Inof the workfor which this permit blued ued bee.3097,C1v.C.) TOTAL:
00 Iender:Name - PLUMBING FEE rfltlob
LL F 1,ender:Add re,a - QTY. MECHANICAL PER FEE MECHANICAL FEE
O W Icertl(ythatl love read thha1,,,h�eEy
rat rttheaboveln(ormrtint
C bcornV.Iagreetocomply witodhenrcesandstatelawn PERMIT ISSUANCE' FEES PAID:
} relating tobullding mvtnuctlmthaN<rcpreeenbtiveoftM1feF Ncity to enterupon tFeabovrmetry for inspection purpose. ALTER OR ADD TO MFLEL
? (We).greetosave1MemNharmlesetheCityofCpertino Date Recei t#, , .eswhkhmsylnanywayarn,re AIRHANDLINGUM'TGO10,000CFM) SUBTOTAL•agabat sad ertceng dthl.permit- AIR HANDLING UNIT(OVER 10,00(CF ) CONSTRUCTION TAX
2_2
Igv ofA 1 t/ to0or Date D(HAUSTHOOD(W/DLGT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
W01t a mfuturt bu0aing omvpant.ton or taMkharardoua HFATINGUMT(TO100,000111"U)
Date Rccei t#
materialaedeB by the Cupertino MunicINICode,Chapter91Z and the 1
Healthand sty CodeeSSodiooe75532(a)I HEATING UMT(OVER 100,000 BTU) AL:
n Yea . LKb'^`''
Will the applicant orfuturebullding occupant use equipment orde VENTILATION PAN(SINGLE RFSID) 1$SUANCE DATE
which cMt haaardous air mnumlvnts as deflrcd by the Bay Arca Air
S Quality M nagemcrd DM BORER-CAMP OFT OR 100,000 BTU)
Ye
4have
read the haaa cause matelals nrenb under Chapter 69S of BOILER-OO.W(OVER 100,M BTU)
the California Health k Safety Cade, by 75505,ESI3 and 75534.] SSL aYS
utddsLa,dthstifthebulidingd notoudentlyhaw.tenant,thatltbmy NEW RESIDENTIAL NECK SQFF �n4Ica
ropovlbi nnifythrtuv cont henequiremenbwhkN
hvwbeend
P
rior da C< l panty.
L o •
Qv rm agent to ('-�
TOTAL' ISSUEDBY: D
OFFICE COPY