21319 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Yrv' Idemlfiestl® PIXMITNO.
Building ABdreas. 21319
J,AMONAA�lL 1?E.vI n n �e
wQ.1'. CITY OF CUPERTINO-DUILDING DIVISION
c«,t • N,n<: Lk.No: APPLICATION I PERMIT
1 l,0 LS a' E3 Z BU LDINGdECIR CA4 LIMB NGMFGHAN CAI. CATEGORY covix�L t ��
Archlten/En�neer: No:_ .C,
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PER7ATISSUANCE 4�
LICENSED CONTRACTOR'S DECLARATION
Ikh dtlrrnth,tl (m m3e theBrprovblwrof F mar9(mmmm APPLIANCESRESIDENTIAL B N
Ingwt,Is In
null 7o00)of d eff m3dlhe Bu.InmandProlesdan.Cade,and my
r c,m D rr 4 3a�ren. 'L2 D 3 F3 Z PANELSLica
Date ontr,ctor
—UP TO 2DO AWS
_(a ��. AItCH1TECP5 DECLARATION mi-I�AMPS
M? Iundu rd my pl,m,hall k used as publle remade v OVER1003"PS SQ.FT.FLOOR AREA S/SQ.FT.
WO
LyL�j LberuM Pmtembnal S)GNSE.ECIRICAL
6{I�B O R-BUILDER DECLARATION
z��G Ihenrm « n
by,fBm that l aexempt from the CrtnLicense or LicenLaw f«the SPECIAL CB2CUIT/MISC
folbwbgm+ .Section7015,B s,l and Profnsioro Code:Mymyor
O s. ir TEMP.NM7ER OR POLE INST.
FW muntywhkh prq toil perWte,.Iso ruui.the.prove,demol6h soch permit
to
any a signed
statement hat ha as erased lmsuant t the pr ,isum,of e POWER DEVICES
file,signed statement that he 6lkxneM pursuant to the prov6by of the
y^���p5ss Contractor'¢Litems Law(Chapter 9(mmmencing with Section 7000)of Divi-� SWQ.tABNC POOL ELECTRIC
VALUATION�5 sbn 3 afthe Business and PrdObv Code)orthat he 6 exempt therefrom+nd
S"•• the hes6 for the alleged nemptbn. Any Wolatbn of Sectbn 7015 by any
0�
applicant fora pet sobjectni
.the.ppheant to a l penalty d not mon than
than GUH.EISSWITCFQSH%IUItFS
five hundred dollars(S50f).
F1I, o,owner ottkproperty,or my empbyees with wage.,their sole NEW RESIDENTIAL ELECiR SQFT. STORIES =CONSTRUCTION
t o mmpaua0m,wllldotk wok mdthestmentre 6mt Werdedor offend for
5 ❑ sale(Sec.7DN,Business and Pmf.W.Code:The Corannoe,Uceme Law
dm wt apply to m owner of propertywho Wildsor improves therms,and �y OCC.GROfN RLS UNTI5
C whod« mchworkhm lforth ughh6 nemiployeee,pro WMtlutudi l 1 S
Impru•emewuem tendMorofke foraele.If hcss ver,thebummg« TOTAL. O
improvemem6soldw hNomyearafcompletbn,tkownerbullderwWlave
t dent&pmvingthat he did.wad or Improve r«purposeofeak.). QTY. PLUMBINGPERMIT FEE
L.,owner of the property,.m exchahely centracUng with hemmed - FLOOD TONE APN
mntran«e to mruwR the project(Sm 7DS/,Rusinew and Prdemlora Cade: PERMIT L%UANCE �Z�b
The Contractor',License Law don not apply to an wnm of property whooeALTER-DRAIN k VENT ffN
woes or Imrove pthereon, and who con trans for..eh ptojecv -
with , I y FEE SUMMARY
yIltvecto(a)Banned pursuant to the Contractor's Ll¢nse Law. 2 BACK FLOW PROTECT.DEVICE —(aCL1
U I,m exempt under Sec B k P C for this rearm
DRAINS FLOOR ROOF,ARPI,GOND. SANRARY Y_ N_Owner Dae RECFLef I
WORKMAN COMPENSATION DECLARATION FDC A PER TRAP SCHOOL TAX Y_ N_
MI
hereby orMn that I have o losolate of consent to upy the r o (Se. RWETPI'
e ,La a of Work<n'Comperual«ilwnne«a certified mpythereo((Sec- GAS Fa.SYSEh4.1 INCA OUTLETS PARK FEE Y N
Pull N CJ
1'dlry l
Cny' y F— I •d RECEIPT CAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION
ISION FEESocert copy
6 ford with
thehM. GREASE/INDUSrn WASTE INTERCEPTOR PLANCHECK FEE
(q CertlnM ropy 6 tiled wim the city wpotlon dlvlelm.
"Y CERTIFICATE OF IXEf,1MON FROM WORKERS GCSE TRAP PAID ^^'�T
COMPENSATION INSURANCE BEIVER-SANRAAY-STORM EA.HAFT. DRIC RCCCI IN ` J3a�O
(CN..enbn need sat he<onpided Bthe pemdt 6f«orc hundreddollve
(SI(A)«les..) WATER ITEATFRW/VENT/ELECTR ENERGY FEE Y N
1 ll not that in employ he perfomana of the work for which W.permit 6 fto the
1 shag not employ any phos f any manner so as to become object to the WATER SYSIFM/TREATING Z4b PAID
W«heri Comperwtbn laws of G Womb.Date
Pp NEW RF9DENT(AL PLMB. SQFT. it
A Ilant
Z Q N'OTICETOot,subCAtothe after osums,Hrylhix eroati npro,ificate ens oftExempthe
Date TA [b
.hmld bemmewbFct to the Wohen'Conperuatbn pmMebnu oftk Lwr TOTAL-
U)
OTAL
fA Code,you moan forthwith comply with such provlalon,orth6 pemdt shank
W > deemed revokM. 13UILDING FEE
CL o CONSTRUCFION LENDING AGENCY SEISMIC FEE O
Iherebyaf0rmthettherc6amnutronlon lendingagenry for the perform- t ELECTRIC FEE
7 Z anmoftheworkforwhkhth pemJt ed(5ee30YJ,CIv,C.) TOTAL
U O. lender's Name PLUMBING FEE m
LL F Lender.Addre., QTY. MECHANICAL PERMIT FEE MECHANICAL FEE QCD
WO Inrtlfythai have readth6 appRatbnand a+tetha theabave lnforrrwl® �t
(Semmes I.gnat.c.mplywlthWdtya"d ntyordln andmtelaw. PERMIT ISSUANCE ` yCV FEES PAID:
>. N relaing towildbnd g mvtanlon,, hereby antheriu rtpresentatives otth6
f. ntyto enterupon the abovcmentbred property for 6upexlon purposes. ALTER OR ADD TO MECFL
Z
Z (We),gmn vIndemnify to sae,Indeify an d keep ..hamsthe City of Cu peW Date RecCi [Ifrt
ag+Wt NbDltle.,ydgmrnb,mesad expen<.whieh may in any way a¢roe AIR HANDLING UNIT(D010,000 CFM) SUBTOTAL
against a+ld City In consequence of the grant tag d this permit.
AIR HAN13uFrc ulvrr rovER 14DDDCFM) CONSTRUCTION TAX
D 34
SJ tare arAppbam mune«e Dam EKFUI>ST'HOOD(w/DECD CONSTRUCTION TAX PAID:
kImL1 w USMATERIALSDISCLOSURE
Blthe apPPlk by the
Ud�grtinoMomupantode, hhindle Z.ndthe HF.ITTNG UhTT(TO 100,000 BTU)
m+terlal as dcOrad by the Cupemiro Mu NnpalCode,Chap( 9.12+rad the Date Recei IIF
Ife,hhand Safety Code Seett.25531(a)7 L 2 IFEATINGUNT(OVER100,00DBTU) I � TOTAL:
qYe ri No
Illtheappliant orutumwOdingonapantuseequipmel0 ordeWm VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdeus air mntom,ants as deRnM by the Bay Area Air PAW yy.w
Quality hfarageme.t District? BOILER-OOMP PEE'OR IOUM BTU) AW
Ye Nb
have rtad the ha�material,requbemen6 under Chapter 6.95 of BDILER-COMP(OVER IW,000 BM ��� „V Vat
the Gllfeen6 Health k Safety Code,Sectiam 15505, 33 and 75534.1 -
understand that if the wilding dce.our eurrently h.vn,tenant,that It es my NEWRESIDENTIAL MECH. SQTT .
resor to issuancey,to
Of a certificate
arvpant of foreope nqulnrrcMs which rwa k con
Prior to L+Buarce notiy the cxoof Qxvpa ray.
Lnner or «I' agent Date ISS(IEDBY: `•� �
TOTAL: O.Pot
OFFICE COPY