22480 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY .
Build) Project Idemifleatim PERMIT NO.
B.Ming Add.: ^^ I /"IO
2. EV0 t /N S Y 2248
• n s aeon: one: �. .
CITY OF CUPERTiNOBUILDING DIVISION
•Natant: rauoN�q[. APPLICATION /PERMIT
C. J ai BIIRAIN nD,MCALI'LUMBINGMECHANICAL CATFLORY CONTROL
.., ArdBa t/Fagin<er. Lie,No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ f�lr
LICENSED CONTRACTORS DECLARATION �j•
I hereby affirm that l am lk.aed under prm,W.mof(]upter9(mrrtm<n APPLIANCESRE.E[DENFIA Og u,,,,„�„
ingwlth Setbn7000)of DoIsdon3ofthe Budoessand RofesalmoCode,and r_RIP110�014 Jl
lic, le in full fpp��and elfecl,ttywwq ,r�`� PANELS r \ S 1 r' `
1¢rae Class Lbt 6 .
Date_�t— �comnmr
ARCHITECTS DECLARATION - 000
0$7� I understand my plana aurR be used as pum
blle read. OVER 1000 AMPS SQ.F7.FLOOR AREA $/SQ.FI.
. o Licensed Professional I SIGNS ELECTRICAL,
<� OWNER-BUILDER DECLARATION '
rn SPECIALCIRCUIT/M -
E, Ihercby alRrmtlotI am exempt from the Contractor's Liornse Law for the
following rteaer.5e on 70315,Business and Piefedona Code:Any dry or
cnuntywhlchnyuWapermktomrmtnc aHe lmpmve,demollahorrtpar �P'M=OR NS.
anyat mu prlortalisL ame,aborequlrutheappBantfm.dpe to IOWFR DEVICES
O a� 01e a signed mtement that he V lfcenaed punuant to the proWbns d the
p.� Contractor,License Law(ChapterI(mmmaneing with Section 7000)of IRA- SWDMNGIC)DL C VALUATI
� ON
�. o< abn3ofthe Budnea arM Pmferobru Code)ort)ut ha Revemp[Ihertfmmard
YE$o1 Yd.4.1 the basis for the alleged exemption. Any Wdation of Stolon 70315 by any � FlXTURES
appU.tf.r.p,r .bj,Mthoappkl ttoa Wlipenshyofnm=mthen
five hundred dollars( °
i �n I,as.wrier of the property,or my ar^PbYee'with wag.u theb sole NEW RESID AL ELECTA SQ.FT. STORIES TYPE GONSIROCITON
mm pe.tion,willdothe urork,and the Hrueture b not Weeded or offend for
prale 13ec 70K Businntand Prdmbm Code:The Comat.ea Line.Law
doeanot apply toano ofproperty who builds orimproacsthereon,and
c. who does aueh work himself or through losown employees,provided that sucb OCC.GROUP RES.UNITS
Imprwemcnta art n t Intended oroffened for axle.If,however,thebuilding or TOTAL:
tmprovemontprm,l gtbathcdW uatcompletion,theownervbuildrrwlll have -
tfL+Nenomerofgtharhedbnot exe orlmpmvefopngwith feeme PLUMBING PERMIT FEE
Lj 1 as owner of the property,am erchnlvely mntnging with Ilmnued FIDDD ZDNE APN
mntraton to mnstrotthe pmlect(See 7014,Busin..am Prdmbns Code: -PERMIT ISSUANCE
The Comntor.Lice.Law dm not apply to an owner of property who Ab9P.DRAW 4 VENT-WATER ff1J -
hulldn or Improv.th.ron,and who centram for such ptoicm with a
gWfaetcr(s)Blend pursuant to the Contractor'.License Law. BA wPRarEcr.DEVICE FEE SUMMARY
U I am exempt under Sec B 6 P C for this reason
OUTSIDE
DRAINS R ROOF,AREA,CONE). SANITARY Y_ N_
Owner Date RTCETera -
WOR"A.N COMPENSATION DECIakRATION
❑1 hereby affirm that I have a mtlfleate of consent to self-Insure,or a FIYIVRES. TRAP SCI100L TAX Y_ N_
cetlLote of Workera
'Co eperaro
ilnn Iuraece ora oenBied copy thereof(Sec. REGF3Pf I
3800,LabQ GASEA. -1 ING4 CUTLETS PARKFEE Y_ N_
Policy) 4(EA) RECEIna
Com GAS EA.SVSITTf BUILDING DIVISION FEES
enured copy b hereby tumlahod.
!
Certified copy hfiled with the city Inspection dhidw. GREASE/WDUSIRL R PLANCHECK FEE
CERTIFICATE OF EXENIPTION FROM WORKERS' O 'E''��AP PAID
COMPENSATION INSURANCE -
(hlesectbn need nd brcompleted Bthe permit bf.rune hundreddollan sFwER'SAMTARY- RN 70ff['. Date Remi t#
a1m1m1..3 WATp vwT/ ENERGYFEE Y N
Icertlry thnbthe perfomanre of lhewmk(or whlN this pemWbblued, —. — i
1 stallfiat empty any perste,In any manner sa u to become subject to the WATER /TREATING Wmken'Compennatlon Lawa.f C.Wamia. Date PAID
nppuant
Date R
Z p NOTICE TO APPLICANT:H,.her making this Certificate.!Faemptbn,you NEW DFNrRAL I'LMB. SQ
ecd4d Y
should become subject to the Worker'Compevatbn pro idons of the Labor T
CCN Code,you must forthwith comply,with such provisions orthla permit shall be
> deemed newkad. IN
lL CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebyalBrmthattherel..comtrommbndingagenryfortheperform ELECTRIC FE
Z onceofthe work(car whlchthb Prnr'W h issued(�cee 3091,CW.C.) TOTAL
LLO I<rderb Name
1- Lender'sAddren QTY. MECHANICAL PERMIT MECHANG FEE
OW Ioenlfythalluveme thbappLuH nandslatethaltheebovelNom as
d bmrret.l agreetocomplywith all etyand eountyordluonmand slatelaws PERMRISAIANCE FEESP
neking to building mnstrutim,and hereby auth«I: representatives ofthis
W tty toent.upon the abase-mentioned Property fo lmpetbn purpoe.. ALTFRORADDTOMECH. Da RfCCi t#
V — (We)agree to ave,bderenlfy and keep harmless the City of Cupertino
agabat WbWtln,}tdgmerib,mrsaod upenan which mymanywayacwe AIR HANDLING EINTT(TO lop $IIBTOTAL:
against Bald City in cvnseque otthe gnntingdthlsp.mlt.
AIR HANIXING UMT(OV 1B, cFhf) CON57RU ON TAX
7—-&z_
Slg.tureof Applicant/Contr or Date L D(HAUST lioOD(w/ CONSTR CTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willthe.pplicam or future bu Bdingomupsot,tmor.,handle havNaus IiE1TING UMT B D to Recei t#
material as defined byline Cupertino Municipal Cade,Chapter9.1;and the
EknaBh and Safety Coder.-Section 7553](a)i HEATING (OV 10q TOTAL:
TV Y. NNO
t WtheappBam mlowrebulldleSoavpaelutoolulpment mdevk. VFNf7 N FANSN'CL.E RFSID) ISSUANCE DATE
whkh rent has Nwa air cvntaenrums.a defired by the Bay Arca Air
jQ'Wy Managemem DnirM7 BO NMP OI-0sDR100,IXD BTU) ^
Yro ❑tab ^0\1 CG/rj`l
ahavemadtheh .1R.mNerlabrequlremenb under Chapter 6.95 of -COMP(OVER 100,000 BM
the G Womb health&Safety Code,Setloro 75.500,75577 and 75574. I w�1
unit UM that if the bu0dleg does not currently have a tenant,that it b m7 RESIDENTIAL woi. $QFf
r.pons@Bity,to notify the oeeupam of the requirements which crust be met
prim to issuance d a Certlfleate,of(kapa my.
Owner or authorlud agent Date ISSUEDBTy� 'Q+)
TOTAL:
OFFICE COPY