20084 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building;Project ldemlfkatio, PERMIT NO.
Building Add.: - 20084 0OnA
7MITTAL DATE
me:
CITY OP CUPERTINO-BUILDING DIVISION 90
coot m: x.No APPLICATION / PERMIT
BIIIIDINGL
ELECTRICAPLUMBINGMECHMG
AL CATEWRY
Archkayt(Fagf n Lk.No: '
«- QTY ELECTRIC PERMIT ^FEES BUILD NG PERMIT INFO
Address PERMITISSiUANCE 1:1 F-1 ❑
LICENSED CONTRACTOR5 DECLARATION
Ihereby dflrm that l am umaed under provbbn.
and
of Chapter 9( m
c APPLIANCESRF3DENIALV rJOB DE
SLC,JRIITI
ingwlthlcn7000)of Divbion3ofthe BusinmsanciPmfeWoCde, n
i'in fu (orad PA
LimvCV. ,,N 4
Date Conlyntlor UP TO 2DOAMPS
J
ARCHITECTS DECLARATION 2014000AMI5
qp±re Z I underslen f my pbv.hall be ueed!as pubucreconla I OVER 1000 -1 '1; SQ.FT.FLOOR ARCA' S/SQ.FL.
E Limnad Profeobvl SIGNSELECTRICAL,
G S OWNER-8111LDER DECLARATION SPECIAL CIRC MLSG IIV , �J 0 1
Ihereby affirm that l am exempt from the Conmartorb Lice.IAw for the
7P_ following...Geed.94315,Ba.lnm and Ihof®brat Cade.Any city or
6,zi"' wuntywhkhmqu4 apem tomvtmg Wm,improvedemolbh,orrepir TEMP.METER OR
VqWjIffT. 119-
6 anyneuRuld pno to In wnrce,.lweequim theappatant forwch prmRto POWER DM'Icps
C file a signed eteement that he is Ikxnacd pursuant to the proA kuru of the
Owy Contractors LlceveLaw(Chapter 9(mmmencing with Section 7000)of Did- SVI•�W POOL ELECTRIC
W
�,30J on 3 ofthe Buslne°sand Prd®Ifv Code)or that he bexempt therefrooaed VALUATION
the hosts for the alleged ezemptbn. Any violation of Section 9m15 by any
6i appu t(ora pemdt subject.theapplkanttoatlWl pevlty deo moRthav OVILE7SSINTCIINSFlXIl1RE5 t f+
Me pe lea,
-
-a,
owrcrdthe property,or my employers with wage u Uelr ante NEW RESIDFW7IAL ELECTR SQ.FT. STORIES TYPEMNSTRUCTION'
m, Idothe work,and theemeture b rot Wended or offered for
C kp6ec.SIDS{,Business am Prdesabro Cade:The Contractor.Lice.Law
don not apply to an owrcr of property,who bila°or impnovs theRaM1 and OCC.GROUP RBS.UNITS
who d...&work nlmu orou
°ethgh but ers
own employ ,pvvlded that such
improvemenb arc not Intended oroffered ferule.If,however,the building or - TOTAL s
Impmvem MN wIdMthinavy"rolcompletbn,tk er-builderwiUWw
t"rden of proAngthe he did not build or Improve fapurpo°°ofeate.). QTY. PLUMBING PERMIT FEE
u L u lv
owner of the property,am eamhuely contracting with IkevM FLOOD IDNE APN
con..to conubgct the project(See,70K B.,u m end Pmfesslnv Code: PERMIT I%UANCE
The Corrcneor'.Lkxve I.&w dm not apply to an owner of property who
1 builds or Improve thereon,and who contracts for such ptn)eGa with a ALTER-DRAW 4 VENT-WATER(A)
r�n¢aciae)lleensed Ito..I to the Contractors Llamae Law. BACK pIDW]'RO'[TTrf.DEVICE FEE SUMMARY
TT
I am exempt under Sec B A P C for this R
ewv DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
OwneOLITSIDFfIES
r_ .......,� _ Doh i' R�EPTI
�WORgN COMPENSATIONDECLARATION F0(TlTf�S PER TRAP
SC1=LTAX Y_.N_
❑1 heRbya 1 ILt I lu m a ar i0ate of oven to sale-NRnRr o a �L�.,
certifieme ofWorken'Compevation lmunna a°certified copy thereof 6ee
3804 Lab C) GAS EA.SYSTEM-1 BJC401131.ET5 PARK FEE Y N
Iblky 0 GAS EA.SISTEM-OVER 4(EA) RECEIPT'/
om ny BUILDING DIVISION FEES
CcZyn-ropy b hereby fumbled. GREASE WASTE INTQiCEPTOR PLANCHECK FEE
' ❑CertN<dropybfiled Mt],thecity lv /
pectiondivision. O. 7J
CERTI HCATE OF EXEMPTION FROM WORK ERS' CASE TRAP PAID
e COMPENSATION INSURANCE SEWEILSANITARY STORM FA 2o4rI.: Date Recd tk
a'hbsenbnne,dndbecompleted Bthepemdtbfaovhundm doatan
(5100)arlm.) WATERI�ATERW/VENT/Flume ENERGY_ N 'Ol0
Illnoy bthe nrmanaof the work far whichnMs prmhis wiled,
1 hall nm employ any Fpeerson f any runner n n m become subject to the WATERSYSTEM/TREATING
Wolira Compenutbn Lowe o/Gllfomla. Date PAID % 0
O = Appellant NEW RESIDENTIAL PLMB. SQ.FT Date Recei HI
ZO NOTICEca APPLICANT.If, orifter mkingthbsation andons often,you
� w emote bemm anbkct to the worker:compenutbn provbbndthe l„mr TOTAL:
CC
Cade.you nustlonhwhh comply with such provbbv orthb permit shall be
domed.1ced.
W O CONSTRUCTION LENDING AGENCY BUILDING FEE L
0. SEISMIC FEE
:) lneeebyafflorkMr which
hthiaermit aisiamdrding ,CW.r.) pnomm ,T,ty ELECTRIC FEE
7 Z anaef.the Nenek brwFJchtnb pmJtbweed 6ec.3ov/,ew.c.) ..
od
LL O Lender.Nam PLUMBING FEE
LLL) LendersAdarm QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OIU urroa. thaH have empty
a-ppll dOandoaunt that tnemaand suatelan
b mist.building comply with all tltyard muntyoee mpasand Eatelaw. PFRMI'I'155UANCE FEES PAID-.
} a Ry ing toenobuiter pont ealxr lon,aM by Sopeby rtyforunpreinntivn of thio
Z cXyWeaipeeosa.e,lovo-mfy a.d property for to Cit purport. ALTFlf OR ADD TOMECH. Date Reccitp
V — (We).gra no save, ems,eoty an d keep harm].whkh the City y CuprtW
agaWtllabNtfm,jndgercnn,aata and rapenre whkh may in anyway accrue AIR HANDLING II[.gT(TO 10.000 CFM)
aga to dCxym eunsequerceoltne granting atm.permk. SUBTOTAL:
I AIR HANDUNc uNrr rovExlo,oaocFM) CONSTRUCTION TAX
v a ppuan/cotranor to Ela uuST HOOD(w/DLtiD CONSTRUCTION TAX PAID: -
HA2ARDOUSMATERIALSDISCLOSURE
will th2 applkdnnofutune Wllding ocvpnt stoR orHMle hawed., HEATWGUNIT(TO100,000BT1n Date RCCei tk
mnerial.de0vd by the Cuprni.M.Wdpl Coda Ch.pter9.I7,°red the
Fleahh and Safety Cot,Stolon 25532W? HEATING IWTT(OVER IMODD BTU) TOTAL:
RYes No
ill the ippllana tore buatding anvpet use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which,mlt hared.,sir mntamivntaas defin iby the Bay Acta Air
Quality Maeugemnt Distnct7 BOILER COMP OHP OR 1040(10 BTU) ,
Yn ❑No pA�
have Health
Safe°mahnah Rqu Uemnb5S33 an 25534.95 of OB FRNMP OV Rl00,000 BTU �1 YD
the,,i,ta nit Heahh l Silkily Code Secnot ionamm ntly have
at and 25534.1
uMentardthat n notify
the oma
oea oothe renin nentswnan411ut It boy NEW RESIDENTIAL MECH. 9QFT.
• mpovmatu. to nc.Ce,ti aata.f ine RquWmerts whkh=9 be met
prior to wuanco a.CcrtlRate of Oaupeuy. 1
to l9
Owner or authorlad°gent Date ISSUED BY I l
TOTAL
OFFICE COPY