23568 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildi"K Prv"ea Idemuwel® ' `r PERMIT 23568
Building Addms.: Co ('�
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/ eAg" CITY OF CUPERTTNO-BUILDINGDIVISION 1 �
cmtnao �lWame: LC.Nu APPLICATION /PERMIT .,�,"�`�02—
BUILDING-ELECIRICALPLUMBINGMECH NM.AL CATFfARY CONTROL.
ArchLLed/Engtnnr. - Lk.N¢
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naanea. pQuarlssuANcx ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
thereby affirm Uutlam lkmmftheB pmvWdllrofhomr9(mandm
APPLIANCES-RESIDENTIAL /� pgingwitr EIWC ,
lice.h5Mbe le,mear Divlelm3otthe Buelreaandl}o/msloaCodgmd - w'"'`�',Jl
Iinrm V In/ua Porn and dfeR PANELS ~•7• I 1
Lleeme Che Lk.I '
Date Contractor UP TO 2MAMPS
ARCHITECPS DECLARATION M'low
K7$� i uMentand ny plaru shall be used u public remede. OVERIM(]AMPS SQ.FT.FLOORARFA
�j Licensed Profi.lor l SIGNS ELECTRICAL 3 u
�<
oZ, OWNEREJt DECLARATION
Z ]herebyafRmtlutlamexempt mmthaLkealaw fn<ha
O
SPEICIAL CIRCUIT/MLSC R
'ppppl f.11mong reaeon.(ection 70315,Buea dnand M
Immislou Code: y dly cr TEMP.METERORPOLEIN
F�Q� countywhkhrequirnaper toconumMalter,Improve,de=Wh.ornpalr
Q anyatm=mpr toiub ame,ab requbntheappbmnifnwchpemdtto
°S o file a signed statement that he te Ikeneed pun o nt to the provbioru of the tV WER��� I MATr ,
Contnctorb Lkenee lrw(CEapter9(conu Ing with Seaton 70(0)of Divi- SWVALUATION
�o.] rbn3o/the Businns and Prduba Code)orthrt heberempt thertfromaSWIMMING POOL
�a
O•] thebasis for theallegedjee the ap Myt to.con of Section out7MIS bymon,
any OUfI%ISSWITCHES-SWITCHES /3 V' 1 L
ppEuntfor+pemJt.ubjecb the appacanttoa tldl psnahy of na mon than V 4
area dd Wa(SSfle).
� I ae ovva of the property,or my employer with wagn u their role NEW RESIDENTIAL ELECTRSQFf. STORIES TYPE CONSTRUCTION
Cpcww
tion,will the nru
ik and the stctub re W Intended or offered for
ale 5--7aµ Bu.Ireu.M Promo oro Code:The CoMa=e.Lines Iave
den rlotapply to ae owner of property who bulWov
s or imprthereon and OCC.GROUP RES.UNITS whodon euchworkhlmveUfn ghhisownemplay a provldedthatmch
Improvememe are not tmended oroffered fcrsale.If,however,thebulMing or
T, improvement b"Mthinomrarofcomplelbntheawner- MerwaI have
t"irden or provingthat he dM one bulla or Improve fnpurposeofule.). QTY. PLUMBING PERMIT FEE'
Ll I,a owner of the Property,.m eaehutvely contracting with IberuM FLOOD ZONE APN
onome,ton b
to mored the project(Sec 70µBueteess and Profealoa Code: PERMIT ISSUANCE ..
The Contnaof.Lim.1aw den not apply to an ower of property who ALTER-DRAIN k VENT WATER(EA)brad. or toy.thereon,and who ommatla for aurh Imijsas with
ryRlEartm(O llnosed punuant to the C tracme.Lkeae Law. BACK FLOW PRl7TECi.DEVICE FEE SUMMARY
L.J I am exempt under Sec B k P C for thio reason
OUT51 DE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
Oww Dale RECEIPT I
WORKMAN COMPENSATION DECLARATION FI%il1RFS PER TRAP Bpi001,TAX Y_ N_
r-11 hereby af(Irm m
that I have a tie m of cme
eenl to.114 um,
attests of worken'Campevatlm Inerrann ma ratified evpythertor 6ec. RTCEPT I
.Vb� GAS FA.SYSTEM-1 WC{OUTIEfS PARK FEE Y_ N_
RECEGAS FA.SYSTEM-OVER4(EAI DING l
Com ny BUILDING DI VIBION FEES
I-"�Certuled copy b hereby b"aen`d' GRE, /IrrousDu,WASTE wTFnCEPTOR PLANCHECKFEE
Certified copy es(Bed with the dtY linpeabn division.
CERTIFICATE OF IJ(FMPTION FROM WORKERS GRFASETRAP PAID
' COMPENSATION INSURANCE SEINER-SANITARY-STORM EA x10,7 Date Recel t#
(Thio xctlon need not be completed B the la/more n
hundred dollars
(SIM)on lm.) WATER HEATER W/VENT/Fr.ECTR ENERGY FEE Y N
I artffythat In the pedornvnn of the wnk rorwhich this permit b b®ned,
1 shall not employ,any penin In any manner an as to become subject to the WATER SYSTEM/TRFiATING
Workenwtb
'Compen law.of California. Due PAID
Appilaint
NEW RESIDENTIAL(LMB. SOFT.
Z z NOnCETOAPPLICAM:B,aftermakingthbCertifwteofEaemptbn,yw Date Remi t#
.Wald bcmme aubkct to the women:cnmpeneatMn provbba reins Lbor -- TOTAL:
WCCN Cede,you maat(w<hwtlh comply wilh.uch pnvdsba orthh prmdt Wil be WILDING
,j deemed revoked. .
CL G CONSTRUCTION LENDING AGENCY 5EISMIC FE
I hereby afit thatthenbamntrudlon lendingagency fortheperform ELECTRIC FEE
� Z arm.fthew.rkrorwho,hLKb Permit blsued L5ec 3097,CIv.C.) TOTAL:
Iry
0O I<idees Name - - PLUMBING FEE
LL h- I,oder',Address QrY.1 MECHANICAL PERMIT FEE
O w toe"�'thatlha.ereaathe.ppBallon.ed r.tethetheamvewomwion MECHANICAL FEE
Lsmrma.lagreeto complywhh aadry.rd countyordborme and rote law. PERMIT DANCE FEES PAID:
} N relating to building matroaion,and hereby Authortu nepnaenhdve of this ,
Z dty to enter upon the above-mentbrrcd property for inspection pu rposea. ALTERORADD'IOMEChl.
_ (We)agree to
a ' ewaMdekpharmls the City of Cupertino Date Receipt#
pbou llabiatn, naa
whichm.ymaoyway.cmre AIR HANDING UNIT DO 10,000 aTd) SUBTOTAL:
age 1 b nceofthegnntingofthbpemat. -
e AIR Iq,ANDulvc tm7r mvEe lo,000cFkD � CONSTRUCTION TAX
Nmre of Appuoet/Cmtracm bQ LAUST HOOD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appEcantorfutun beading omupant atom or hurdle ha udous HEATING UNIT(TO IM,0M BTU) Dale Revel t#
moerbl as defined by the Cupertino MuNtlpal Cd,Chapter 9.tj and the
Elnith.MSafetyCode Seaim255324)7 HEATING UNIT(OVER 1M,"BTU) TOTA . 225
FlYnNo
Wllltheappllontm More building occupant use equipment or devkes VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
whkh emit harardous air centambunts a defined by the Bay Area Air
Qu Ilty Marugerrcnt Diatrk -0
t7 s BOrLFRDMP(311P OR IMM((]BTU) /�
4y
have read the hazaPZmaerials requirements underChapler 6.95 of DOnXR-COMP(OVER Im,000 BM IO
<k Gafnmtha t tithe
i t h 6 Safety Code.Soalem 25505,have a tenant and 255.14. 1 jD/?
ndcaardtlut notify the oce partingdrem oft .requiree,ntswhiththatb rery NEW RIDDENTIAL MEl7i. SQ.F7. iY !�
raporolbWtyto reify the oavpant of the requlremeniawhkh menta met 2g
prom to Lasuarceda GrtllhbofOmrpmy. {re r ^ /y
Owner or authom la agent Dale r
B TOTAL ISSUEDB����U '
OFFICE COPY