22329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildleR Pm et Identification PERNWE NO.
BuildbgAddrear
22329
rcr. am/e.: one: APPLICATION sUB9ffTX1=
. .ttiW ] CITY OF CUPERTINO-BUILDING DIVISION
® Centra or'aNanrc: Uc.No APPLICATION /PERMIT _
fix' "'�� y� BUILDINGELk�17UGLl'LIJMBINGMFLFIAN'ICAL CATEGORY CO 0
Architect/Engineer. I.fe No:
QTY. ' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE' 1:1 El - F-1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm ehitIML'cenaeduMe paw of Chapter9(mmmmc APPLIANCES-RESIDENTIAL JOB ON
ingwith Batten 70Mof DIWNon 3ofthe Budneae,nd Paofe ndoro Code,and my
11¢aela In(sift famead tied. PANELS
`
Lkcruc Chn ' Lb./ .�
Dxe ('.mrdntnr
ARCHITECTS DECLARATION 201-10WAMI5
q�q�uu x I understand my plamshall be uaxl is publicrecord.. OVFR100AMPS - SQ.Fr.FLOOR AREA $1SO.FT.
k Licensed Professional S'GNSELECTRICAL
t;6 OWNER-BUILDER DECLARATION HTGIALCQICIJIT/MLSC
I., I hereby affirm that l amexempt I.the ContnRor',Llceme Law f¢the
O�'o following reason.(Section 70315,Bwlnea and Pro(esbv Code:My Aty or
Z � iE1MP.METFR OR POLE RJSf.
anymm khpe tolapea meal reqs lter,Impmve,demoWh,orrepalr
S Q any xmturtpatemn lbhe he It.IW rtqubnthext I.the
of Ute POWER DEVICES
foe a agnea.,cement tM1x he b u¢n,ee pursuant m the provblro of the
� a Concrwmrb Llce.L w(Chapler9(mmmendngwkhBeaten700)ofDIW-
�0� .ion3ofthe Wdneaad Professbro Code)orHst hebeaanptthertfrom+cad ''WGIMINC IX30L FlECIRIC VALUATION
•.-st the Gab for the alleged exemption. Any Violation of Se tion 7015 by any
p� ppeant fora permit subjects th..pptioat tots tWl perahy of not mon than OUII-EISSWIT'CEECFIXTURES
ff6--dredl dollars(i5M.
9' 1,a owner of the property,or my empbyna with wages u their ante NEW RE9DFNTIAL ETFGIR SQFr, STORIES TYPE CONSTRUCTION
comperoatio ,wW do Ile work,and the.tructure Is amt lxerded or offend for
nsite(see 70K Busionto and Padesslona Code:The CnMractor.LE¢na Law
�$$ don not applytoan ower d property who bull.orimprovntheren,and
whodas.uchworkhimselfmthmughhl.ownemplaye ,provledchatmch OCGGROUP RES.UNITS
Improvements are,M Intended mothered forsale.If,however,the bulling or TOTAL,-
Improvement
OTAL:Improvement b.olwhhln orcyearofcomplelbnthowner-bullmwill hive
tlrk¢uden of pawing the he dl not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE - FLOOD ZONE APN
U 1,a owner of the property,am exclusively reauneNng with licensed
mPERMIT ISSUANCE
ntrad.to rormtruct the project(Sec 70K Business and Pre(essba Code:
The Contnaar's Licenm Law don not apply to a owner of property.who
Gods or lmprwes thereon,and who contracts f¢.uch pPfxi, ith a ALTER -DRAIN (EA)
opi(artmaea>uan.ed paaa,,.ntrothe contntQ.liaraa Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I,m esempc under Sec B &P C for this renin
nvrqI DE ELF,
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y_ N_
. Owner RECEIVE
M 1
WORKAN COMPLNSATDECIECL ARATION FIXTURES�.�a SCHOOL TAX Y_ N
I hereby affbm have
that I a¢rti0cave mm
tof mnt to self-Insure,or,
¢ 10¢ce of Workm'Canperoatlen lrounn¢e•mnlfied copythereo(6ec. RECEIVE
380
,LbC GAS E.A.SYSIflft IlVC40[JII.ETS PARK FEE Y_ N_
Com v R � �6�y,�.., GAS-PA'BYSEFA/-0VERa(FA) BUILDING DIVISION FEES
c`dllled ropy gmml.hed. CREASE/INDUSIRL WASTE hNTERCEPTOR PLANCI IECK FEE
ce"Ined ropy b rued wdth the tty IropecHon aiwimmn.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRA PAID
COMPENSATION INSURANCE �SANITARY-STORM FA LIOFT Date Recd t#
Oldsmtbn need net be completed B the pemdt is for one hundred dollars
a100)orlea..) WATER HEATER w/vENr/Fd.EcrR ENERGYFEE Y N
1¢wy that b the pe"orsman¢mf the wvk mrwlch tnb 1= b waed,
1 hall not employ any peawn io any manner as as to been.subjett to the WATER SYSTEM/TREATING
Worker;enmpematmn[A.of C,ufamia.Date PAID
O = Applicant NEW RESIDIN'IIAL PLhfB. SQ}T. Date Recei t#
Z O NOTICE TO APPLICANT-.If,after rneklng this CMBlate of Exemption,you
should become subject to the Wor4en'Compen.xbn paovl.bm of the Labor TOTAL
F r70 Code,y..efathw hmmply MthsuchpmvlabvorNbpemJtehallbe
LU > deemed revoked. BUILDING FEE
d 0 CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I h.rcby s(Orm ICAC there b•mrotrutlon herding agerry(or ck perform ELECTRIC FEE
D Z ,nao(lie work(orwhlch thio permit bieved 6ec 3097,CW.GJ _ TOTAL iE
C) O Lemdxb Name PLUMBING FEE
LL Undre.Addmea QTy-j MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1¢nify AlnavemMthbappB tbnaMd tethatthe,boveinfor on
bmrnt.l,greemc¢nply wdh a0cttyaM countymdute,.and natelaw. PERMIT ISSUANCE FEES PAID:
} y relating to Wiling mmwtion,and hereby authoriss repreaentativn of this
F Z city to enter upon the.boscmentbrcd property for heopetlon purpo.n. ALTERORADDTOMECH.
V _
(We)agree to ava.Imenwry,n d keep Farad.the city of Cupertlno _ Date Receipt#
against liabilities,pcigmenb,costs eal eapena which may in ayw.ya.e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
+ayrat aid City b fBrest,d We permit.
AIR HANDLING uNIT'(OVER IB,000 cFm) CONSTRUCTION TAX
re of Applicant/Contractor / rot. / EXHAUST HOOD(W/DUGD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applleant orfuWre Wading o¢upant stop or haM to hauuloua HEATING UNIT(TO 100,000 BTU) Date Recef t#
material as defib by Ile Cupertino M.Mdpal Code,Chapter 9.17,and the ,
Health and Safety Code Section 15531(a)1 HEATING UNIT(OVER 100,000 BTU) TOTA -R1111'the
0enet 1ppil Zru future WBaing o¢upantuu eine Bay Area
Air
VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which eMtnavNm,•air conbMronte as deflasd by led Bay Arca Air 'PAZ
.
Quality Management Dstaict7 BOILER -0'DR IW,IXD BTU])
4yesYNo
havemad the h materials requirements under Chapter 695of BOILERNMP(OVER 10,00BTU) r�c q
the California Health&Safety Code,SectionsSections75505,15533 and 75530.1 41 P 9 109
urd.rxaM that It tM1e Wilding don rotmnentiy haveatenant that itbmy NEW RE9 DFN TIAL MECFU SQFT Y
respoamddy to notify the occupant of the requbemedawhich must be mart
P rcobsue,eda ifi teofOcevpamy. ` n4 at
Owner or authorimJ agent Date RUED BY
TOTAL
OFFICE COPY