20447 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification 1'F7fDRT NO.
Building Addrcs j 0 4 4 7
11V/�lVl-/\
h4e're�a HF
Owns( mr: one. A A A
1///�qaa CITY OF CUPERTINO-BUILDING DIVISION
I anraNr ur.No: APPLICATION / PERMIT [ 1
C`�n• /� BI.TLDINGELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROLN
Archimet/En neer. Lic.No:
1-I `'� 'y'yI QTY' -ELECTRIC PERMIT'. FEE . BUILDING PERMIT INFO��
Addrcm:132s in id �'"7J dcr -"- L, PFR4BTISSLIANCE ❑ ❑ ❑ ly{
LICE.NSEDCONTRACfOR'SDECLARATION App13ANCESRFSTDENRAL V�
I hereby affirm that l am licensed under provisions of Chapter 9(comment JOB DFSCK11111ON
ingwlth SecHOnI'Mof al sion3ofthe Buslsemand Pmfemton%Code,and my PANELS
licenseIsm full lone and rife..
Lice-sect-to
icenseC6m
Data- OVER I0W-A
ale0VER10W. SQ,Ff,FLOOR AREA 5/SQ.FT.
OZp I understand my plans shall be used as public records
SU
f. �j SIGNSELFLTRIGL
(3 Licensed Professional
OWNER-BUILDER DECLARATION
se law(orthe
t r A, SPECIALCIACIDT/M15C
��L IherebyafBrmthmm
atlaezempt frothe Contracim'1
loilow (Se
ing reason. 70315,Business and Pmfemb Codr:My city or TENIPMETIRORPOLEINST.
.vea� countywhkhr"Nu apemtittommtmctOter,lmpmve,demolbh,ormptlr
gg� stystructureprlortoltatsaaa ce,aLsorcq.l th.appu..tio ..Cli.e tto PpWER DE'�IL`Fy"
_G U file a signed statement that ts licensed pursuant to the proWlom of the t
O�� Contran.e.Llcema L.W(Ghi 9(com endng with Section 7000).(Divi- SWB.(MING BOOB ELECOUC
T er VALUATION
O sion3 of the But gross and Profe onsC.de)orthat hebexempt themlromand
"� 'S the basis for the alleged exam .Any violation of Sento.7m1.5 by any 611T ETSSWITCHESFIXTURES
%'r3',pQiQ sppllantforapermitsubjecbthe �pacanttoa�tvilpevltydnn morcthan t
W live hundred dolts.(&SOWN i j 11 /` READFNIIAL ELECTRSQ.FT. STORIES TYPE CONSTRICTION
❑I,as owner of the property,ortny emgpbyeeswith wage ss%lr sol.
roMpcnsation,wgldothework,andthestm22bbaamb� Intended or of redfor
10O cote(See 7040 Business and Profmloro Code:The Cordraciurs Llceroe law
$ don not apply to an owner of property who builds or i'mprvvp thereon,and f OCC.GROUP RES U\TTS
who does suchwork Mmseu or through hisown em)ilcyee,pro+ided that such
improvements are not intended oroffered for sate.Ihrrweveq ebuildim..r TOTAL
ImpmvemcntbsoldwuhlnoneyzarofcompldlogtMowner-W derwill have
ty,tra rden of pmvi.gthat he did cwt Wild or Wpro6e fcrpur ' ofvl.J. QTY. PLUMBING PERMIT . -.FEE FLOOD ZONE APN
"L as owner of the property,am c,m u dWIy contracting with H01maed PERMIT ISSUANCE
rontract to mm et the project(Sec.7064,Busmen and Prdeasiom Code:
The Contrenorf License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
_
Wlids cc Improv.thsrmo, and who rontncis for such pt,ojects with a ,FEE SUMMARY•-i='4t��
dV.ctor(s)licensed pursuant to the Contractors Lim..Law. BACK FLOW PROTECT.DEVICE - es
LJ I am esempt under Sec B h P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT I
WOR KMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
I hereby affirm that I have a certificate of convent to ulf-Insure,or a RECEPT N
®
Zlate.(W.rkeri emaHvm
Comp .nruranoa (Se
rctmfled copy themofc. GAS E.A. OUTLETS PARK SYSTEM-1 INCA OUTLPARK FEE Y_ N
3800,Lab C.) RECETT N
FaheyNGAS FA,SYSTll1OVER4(EA) BUILDING DIVISION FEES
Com
riany
Cenifiedropy L4herebyfumishd. GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E]Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION!FROM WO R KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.2XIFT, Date Recei tit
(this section need oat be completed lithe permlt Lsfor.ne hundred dollars
alo()^rles') WATER HEATER W/VENT/E3.ECfR ENERGYFEE Y_ N_
Icenitythatmtheperforma.ceoftheworkforwhlchtMspem ti.m ed,
I shall not employ any Person In any manner as as to become subject to the WATER 5YSMAMEATING PAID
Workers Compensation Laws of Caufomla.Date
OZ Appllant NEW RESIDENTIAL PLMB. SQ.FT. Date Re i tll
Q NOTICETO APPLICANT-.If,.1m,making this CenBkate of Exemption,you
should become subject to the W.rketi Comp nuatmn proalloss of the Labor TOTAL:
rp Code,you=atfort hwith comply with such provislom or this permit shall be I 1
CC j deemed revoked.
LLI _ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ilfl I hereby affirm that there b a construction ndingagenry forthe perform- TOTAL ELECTRICFEE
Zance ofthe work forwhich this permit Is dsurd(Sec.3097,Civ.C.) PLUMBING FEE
02 lender'.Name
I- Unders Addreas STY. `>;-,'MECHANICAL PERh1Cl .'�' , ,.FEE, ' MECHANICALFEE
O W I cenlfythat l have readthbappliationand state that above Information FEES PAID:
tscormen.l agree to comply with all city and countyordluanmws
cand state laPERMIT ISSUANCE � �
} 1 relating to Wilding romwcilon,and hereby authoriu yline, tativo.(this
t W est to anter. n the abovrmrntlo forW ion ALTER OR ADD TO MECH.
Z y po sty Purposes. Date Receiptq
J _
(We)agree is save,Indemcdfy pharmi a ,..,ycity Cupenmo W
NCIINTT(TOIO,000CFM)
pq.i.tuaI'd' ' mens sen expeses mayInanywayaccrue - SUBTOTAL:M n he grant this peILCONSTRUCTION TAX
NG 11MT(OVER IO,000CFM)of n/ •ntranor pate OD(W/DI1C'D CONSTRUCTION TAX PAID:
RDOUS ERIALS DISCLOSURE UNIT 100,000 BTU)
Will the applicant or future b ' ing onupant store or handle hazardous `� Date RL'Cel Ik
material as defined by the Cope oMunicipal Code,Chapter 9.17,and theHEATINGNIT(OVER 100,0000M
Health and SafetyCode Section 25532(a)7 TOTAL:
❑ Yes M No VENTILATION FAN(SINGLE RESID) N_
W ill the appllant or futum W ilding eccupant me equlpment or devices100 ISSUANCE DATE
which emit lui.nious air coNaminam.aa defined by the Bay Area AirBOILER-CP DFR'DR 100,000 BTN /��^
Quality Management District? PAID
4Yes No
havclead the haa2usmaterials requirementsunder Chapter 6.95of BOILER-COMP(OVER 100,000 M)
the California Halth&Safety Code,Sections 25505,25533 and 25536,1 .: i.•;;IJ
understand that if the building don not currently have.tenant,that it b my NEW RESIDENTIAL MECH. SQ.rT '
responsibility to notify the occupant of the requirements which must be met City
prIssuance to of a Certificate of Ocmpanry. Clay Cf ClIrfo
TfIRD
Owncr or authonred agent Qua TOTAL: ISSUED BY�
OFFICE COPY /