22931 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building AddrtBuildin Project IdentificationPERMIT NO.
. l oo rw",l 92 22931
ante: me:
Y SLAA!Gam( /'j —�JSIQ CIiY OF CUPERTIN0.BUILDING DIVISION
amt nor. ante:n f, Ix.Na: APPLICATION / PERMIT '
I ✓"��r —C BUNZiNGELECMCALPLIIMBINGMECHANICAL CATEGORY CONTROL 0
Architect/Englruer. Lie No: '
�` QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO _
Address,Pp. &y So 5, //!ih � 9WyV PERMITISSUANCE ❑ ❑ ❑
LICENSED C�R'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(aommec APPLIANCES-RESIDENTIAL JOB DESCRIPTIONingwith ScVbn 700%of gvislon3 ofNe Butlrree.mdlha(etloneCede,and
Ony lienee b In fail for¢ d dfM. '/ PANELS
Liet.C���lappp�3t�iLr. �`7
Date—i Contranor - I sr.,/�i^ UP TO 2WAMPS
// ARCx1TECTS DEc1ARwnoN 20 W0
AMPS c7.
turner mi my p6ro B b
ahae u�aspublic records. OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
01.., Lken.MPnefesslonal _ SIGNS ELECTRICAL LED � N
«<< OWNER-BUILDER DECLARATION
7 ? 1 hereby afflrmthat l am e.empt fromthe Contraetorb Lim.law for the +'raLCIRCNT/MLSC � E ^
pp following nue,on.(Seetlun 7MIS,Business and Profvbru Cade:My my or ■R
TEMP.METER OR POLE MST.
Ftp .�ye. hkhn t.iaimr m aLsoren,altheapb=tf wch,orrepalr
y anyetrunurt tatrn olta that
he U Bee seal pus tamp t the porwchpermt a POWER OEvias /3
c4 fib a mune. ter.nt thn he b r 9(. pars g to the pro7=) f the _
Qµ Cnntnctors Llcevelaw(Chapter9(mmmsnMg with Senbn 7000)of qv4
SWIM
Mon3afthe Bu•Inestand PmfembroCode)arthat he es exempt therefmmaM
MING POOL ELECTRIC VALUATION
Y.' the hands for the alleged exernptbn. My vlolatlon of Senbn 7MIS by any
<� •ppH.t fora pemdt subjects theappBant to a elvll pesky dna rnone than OUTLETS-SWTTCFIESFIXTURES
flN,,ndmd dollim WM.
u 1,
as owner of the property,or my empbycm with wage u thMr cola I NEW R®FNTIAL ELECTR 9Q'FI' STORIES TYPE ODNSIRLY'1'ION
mmpevatlon,will doth wak,and the Mmetum bort Intended or offered for
O sale(Sec.7044,BualmeaM Ptdessbro Cede:The Contractor,U.law
S$ dm not apply to an owner of property who bullets or lmprvue t hereon,and
^ who dee such work hlmnelfoethrough Id...emplryee,pmeklM that such OCC.GROUP RFS UNITS
Impror"nies net btended OrofferM fatale.If,however,thebuWinger TOTAL. _
Improvement baoldwkhln arcyarafcornplelbRthowner-bullderwlll have '
I idendpmvingthathdwmWfldorknpmveforpurpo•eofw .). QTY, PLUMBING PERMIT FEE
leas owner d the property,am a
a lWely contracting with Ibensed FLOOD ZDNT' APN
mntnnon to mmuh
urt the project(Sec.70K Ruches and Prdessio.Code: PERMIT ISSUMCE
The Co'dnct.e.Llama law doe not apply In an owner d property who ALTER-DRAIN&VEM-RIOTER(FA)
builds or Improve thereon,and who contracts fee such ptojects with a
ry0ioctor(al Banssd pursuant to the Contnctor'a Liam Law. BACK FLOW PItdIT]CT.DEVICE FEE SUMMARY
lJI int exempt under Sec B k P C for this re�eonOUTSI DF FEES
Owner p� DRAINS FTaOR ROOF,AREA,CONTI. SANITARY Y_ N_
WORWANCOMPENSATIONDECLARATION RFLEIIN
❑I hereby afflrtn that I have•artlflote d ewiaent to eelf-iresum,or PICTURES PER TRAP �� SCIiOOL TAX Y N_
arti =rof Woreenm
'Cornpeation Insurance or a ceitlfieci copy thereof Sec. BE)=g
moo,lab C.) GAS EA.SYSTEM-1 INC4OUTLEIS PARICFFE Y_ N_
Poiky Com • RDCEIPT GAS FA.SYSTEM-OVER 4(EA) DING DIVISION
cry BUILDING DI VISION FEES
CertlOM copy b hereiy le,lwtumecity GRFASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
trifled copy is filed with the city Inspection division.
CERTIFICATE MPENS TION O.N`FROM WORKERS' GItFiL�TRAIa PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA 2)(IFT Date Recd t#
(TMs section need rat h completed Bth pemdt is forom hundred dollar
alm)alessd
WAT _ ENERGYFEE Y N
1¢rtUythat tithe penfamunaofthc work(orwhlch this pemdt lebsued, Ht FIFATDt W/VENT/RIECTR _
1 eha6 nae empty any penvon in any manner m as to become subject to the WATER SYSTFAf/TREATING
warkets'comwpertbnlaw,of C.Ilfornis.Date PAID -
rP
A llant
Z O NOTICETO AI'1'LICAM:If,after nng ukithis Certlfiute of FaamNEW RE4DENTIAL H.MB.
ptbn,you SQFI. Dale Rceei t#
Mould become sub).t to the Workeri m
Compeatbm n pnovlsloof the labor TOTAL:
F N Code,you mM forthwith comply with such provisions or this pemdt shall be
LU > deemed revoked. .
CONSTRUCTION LENDING AGENCY 5EISMIC FE
CIL ]hereby afflenthlthrtisamrutmnlon lading agetay for the perfomv ELECTRIC FEE
= era o(the work(Ass whkhihb permit lelwed(Sec.3097,CN.C.)' TOT Q
02 iroder.Name PLUMBING FEE
LL ~ I<Me'n Manes QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW AmAlfy thatl luee read thbappllatbnend statethae the above lnfonvMm
1 iemMnee
rr .lagtocomaean
plywkhaBntyaMmntyordWndmtelaws PERMR ISSUANCE FEES PAID:
N relating to building romtmMon,Aral hsrebyautho npreentative d this
I F U) mytoeneerupon the abavcmentbrN property for kupenbn purposes. ALTEEORADDTOMFLH.
U _ I (We)agree to save;indemnify an d keep harmless the City of Cupertino Date Receipt#
P&��
Webaju Ms,mtl,and e.penees which may In anyway..e AIR HANDLING UNIT(TO 10,ODO CFO SUBTOTAL:
C xquercedt ntingdtM.permit. AIRFiANDLINGUNIT(OVERIO,(AOCFM) CONSTRUCI70N TAX
f Appli /CoAtractor Dae [ EX11nU5T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
I=ARDC) ERIALSDISCLOSURE -
WBltheepphantorfuwm- dingoaupant store orhandb havndous HFATINGUMT(I0100,000BTU) Date Recei t#
d
rruterlal as defined by the Cupetlw Munpal Code,Chapter 9.17,and the
health and Safety Cade Section 25532(a)? HEATING UNIT(OVER]m,0m BM TOTAL:
F1 yes No
WWtheappheart turebuddingoaupantumequipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which ends by the Bay Mei Air
Qualitynanagement Dimriet7 BOILER-CYIMP OHP OR Lm,Om BM PAID
YY [—]No
have read the ha re.,materlab rcqulrcmenb under Chapter 69S of BOILER-CO.Y.P(OVER 1m,000 BTU)
nth California Health k Safety Code,Senbro 75505,75533 and 75534.1
uMerwM tifthebu BdNgdoenwtmv ntlyhaveatenan4thatitNmy NEW RESIDENTIAL MECH. SQFr - �O,/
tl
reporedbilky to notify the oaupanl d the requirements quireents whicrwM m
h tbe et
prior eo lauanee d a C<rtNatc of o.pancy.
t f-ITY OF :I 1ptHir 'au
Owner or authortoed agent Date ISSUED BY-.
TOTAL —�
OFFICE COPY