23031 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
flulkilrx Project Identification PERMIT NO.
iBdinkji;2 ,veno 23031
er am<: ( ane
CITY OF CUPERTINO-BUILDING DIVISION
m' 'N
No APPLICATION /PERMIT
(� fA BUIIDINGELEK-TRICALPLUMBINGMECHANICAL CATEGORY CONTROL 4
Ited/En r. Lie.Na
.In QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmc I I N: ��11 5 I I PERMTIS5UANCE
LICENSED CONTLA
CONT'RACTOR'S DECLARATION
'hereby
affirm that lam Ikensedi under provblma of Chapter 9lmmrrlm APPI]ANCFSRF9DEN71IAL pit D6LRB'IlON
Ingw11 In n70o0)of Dividm3ofthe Buslnmand PnalesdaneCade,and
license nle In f deft PANELS
Lf¢ C Lk.a Q�
Date Cor4ractor (11YUP TO 2DO AMPS
ARCHITECTS DECIA ION 701-1000
Nez ]understand rryplace.lullbe used upubliereeonis OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Licensed PrafObral - SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SIPECALCIRCUIT/MLSC -
z�., 6 Iherebyaffirm thatIunexempt freen the Camracore Lkcenw Taw for the
p lolbs wing--.(Section 70315,Bu.lnuand Profmbns Codr.Any dry or
FqqAq g ocuntywhlchrequbeaapem mmmtmMq ter,improve,demolbh,ormplr TF]�'M 7F7 OR OLE INS.
anymmMm prbrto Its bauan¢,aba requlrntheappBont for such pemdt to [OWER DEVICES
file•signed statement that It,b licensed pumusot to the pW loss of the
Contractors License lsw(Chapter 9(mmmentlng with Section 7000)of TEA. SWIMMING POOL ELECTRIC
alon3ofthe Businmand Pro(mbmCode)orthd he b exent"enYmmarad VALUATION
See•77 the hasb for the alleged exemption. Any WdNbn of Section 70315 by any ,
a'e +Pphontfor.pkj the.ppllcanttoativllpe.Uy of.d.mtlun OI)TI%ISSWHCFPESFTI(TURES
rm
five hundred dolhm(S500).
�n ❑I,a.-1ofthe property,or my ees mployewith wages as their sole NEW RE�FN7TAL ELIK"fR AFI. STORIES TYPE CONSTRICTION
mpensa0on,willdothe work,and the.truclure le not imeMed or offered for '
Osale bee 70/4,BusLrna end PrMmbu Code:The Contractor.Llcene Law
does not apply to an owner of property who build.or improoa thereaM1 andOCC.GROUP RIS.UNITS0.0. whn
odo .uch work hlntself or through his own emplo/en,provided that such
Improvemew are not Intended oroHared fou sale.If,however,the building or - 'TOTAL;
Improv<rrcntbsold wXhlnoneyurofcompietbn,lheawrierbulldrrwW have
t rdenofpr ngl thedtdmo fldorlmprovefmpnrpo.eo(.ale.). QTY, PLUMBING PERMIT FEE
Lj L u ower of the Property,sen exclusively�tmdkng with licensed FLOOD7DNE APN
contract.to mnswct the project(See,7014,Buttress and Ndmbv Code: PERMIT ISSUANCE
The Comment's LI¢rue IAw don not apply to an owner of property who ALTER-DRAB)kVENT-WATER IT:A)
bnOda or Improves thereon, and sob mmracts for such pna}va with a
onaltuct¢(s)hotr punwnt to Ne Contractor's License Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE
IJ I am<xemyt ruler Sec B k P C for this mason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Avner Date RF�mR a
V\,..,� WOR"AN COMPENSATION DECLARATION FO(ITIRFS PER TRAP - SOTOOL FAX Y N_
I hereby afMn that I have a certificate of..t to self-Isom,or a RECEIPT
tote o(Workeri Cornpnuatiornivuran¢¢a¢rtRled mpythemo((Sec. GAS EA.SYSTEM.1 INC-4 OUTLM PARK FEE Y_ N_
3B00.V �
Parryn�yp �J� �—�_ — GAS E.A.SYSTEMTOVER 4(EA) DING D1',1
Com any - BUILDING DIVISION FEES
rtl(led ropy b filedIt wtumbhed. --c GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertNed ropy b filed with the edY Inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS CREA.SETRAP PAID
COMPENSATION,plif INSURANCE SEVER-SM4TTARYSIORMEA:70(1FT Date RCOCI t#
RMaless.) need fiat 4completed If the permR bfororc hundred da0am
(f1 I0 nffy J WATER HEATER W/VENT/E.FLTR ENERGY FEE Y N
I¢not that employ
any do on bra an the finer so as to b tMs porde b issued,
I .1,hAU.' empby any Uws f .ray manner at u to becorrc subject to the WATER SYSCFM/TRFA,DNG
worker:compenvtbn l�wm o(C.Wamb.Date PAID .
PP NLWRESIDENTIALPLMB. SOFT. Date Rcecl t#
Z ZO NOTICE TO APPLICANT:If,after making thisCertlfieateofExemption,you
should become mbj d to the Workers'Comperuaebn pcovbbn of the L.abor TOTAL:
W~ N Cade,you moue forthwith comply with such provision or this pertrdt shall be BUILDING ,
> deemed revoked.
CL c CONMUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that than b a m=mdbn kMing agemy torthe Fedor ELECTRIC FEE
m Z anteofthe woZ.r which this permed b lnwned(Sec.307/,Civ.G) TOTAL:
V O Ie dcr'.Narne PLUMBING FEE
LL H, lender'sAddress QTY.I MECHANICAL PERMIT FEE
O w IcedBythAIl wmedtd appll¢tbnaMeatethetheabovelnformatlon MECHANICAL FEE
bmrned.lagmetocomplywhhaUdyaMm ntyordlnanmsandlatelaw. I PERMIT ISSUANCE — FEES PAID: '
} N M3 tingtobulldingmrutndim.aM mbyautha mpresenUth afthis
U) tlty to enter upon the abo rrrntbred property for Inspection purposes ALTEtORADDTOMIECH. Date ReCCI t#
— (We)agree to save,bd<mrdfy.n d k<ep Wrrmm the city of Cu prtbo
.gelnt BabiBtb,judgnmtq met a and expense whish muyb any way amve AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
erg Id City b mnaepr f the, of tM pmdLt�
T_ AIRHANDUNG UNrr(OVER 10,0D0CFM) CONSTRUCTION TAX
54 ot1preofAppumnt/Contractor Oeste FDOIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAURDOUE MAT I LSDISCL UR
WdItheapplkornte, uuebullding pntdoreor I<hazardvus HEATING UNITED 100,W0 BM Date Rete) t#
rnterbl as dc(Ircd by lk CupeNm Mumtlpl Coda Chapter 9.17,and the
Tbahh.MSaI ty Code Sedlon7S537(s)? - KEATING UNIT(OVER 100,000 9MTOT
❑
Y. ,1+J—,No
Wmthe applicum or future building oavpnt uu equipment or devtm VENTILATION FAN(SINGLE RESID) 1$$IJA[+J DATE
which drdt hanrdous.0 mnbmwnm as defined by the Bay Ares Nr J_ /1{ E
Quality Mangecrem District? BOILFRNMP OEBPOR 100,000 BTU)
Irl Yn Fj No ' n
huveread ch h& mu mode,Se reqs 25505, 5533underand 25534.
6.95 of BOILER-COMP(OVER tW,000 BTU) APR O 199
the l B rkdt Hef the
kSafety Cade,SMbrre75505,ve a trans,that I
uMerdand Wtlithe Wle ingoce don of tcurrently quirencent,which
trust It roes NEW RF9DEJ7TAL MEIN.-SOFT
r¢ponlbsato ram ifythecavpma(thenequlmmemswhich rand be first
Prior toWuan<'e of Certtfinta ofOevpmy. _ VUrC/!"I IJfy'I�Y�� -
Owner or aulhanued agent Date ISSUED ..
TOTAL: Rqo "'V�✓�y
OFFICE COPY "