22024 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project lecrulknion ( r-' PLTt.WT NO.
Building Addre,s: `� '�C 22024
ZIIZS SCVE/J S IN S �� ujowtk� isno
am: one.
D N �/ZIC� 73S'�d 78 CITY OF CUPERTINO-BUILDING DIVISION q
C/glnl °r APPLICATIONIPERMIT
BNLDINGELECiRICAI MLTMBINGMECHAMCAL CATEGORY CONTROL,1
Arehikct/Lnglneer Lie Na
Q ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Address: �.� ON� E PFRMH7ISSUANCE 1:1 El LICENSED CONTRACTOR'S DECLARATION
IhertbyaffimnthatlamlkeveduMepr wv .fChapur9(amumi AMJANCESRIDDFMIAL
tng Mth Sectbn70UWot Dl m3oftheBwlr =dPmfese Code,and Ir I N
Ilcense la In foil, d effect. N1S13Z PANELS '/rrnrj `led �- VJn
Llce.c LInI /J lJ
Dee Contractor ARCHITECT'S DECLARATION MI-1000 AMPS
Q7 ]undentard my plans shall be used as public rands OVERIODDAMPS SQ.FT.FLOOR AREA $/SQ.FT.
COC
sty U Licensed Professional SIGNSELECTRICAL
Q OWNER-BUILDER DECLARATION
Z i.., / Thereby a(Ormt tlameaemptf.the C°Mraear'.License Lwfmthe SI'FCIAL CIRCUIT/hBSC'
following reason.(Section 70315,Buitnes and Profeslov Code:Any city or
F �� coo oy,which requien a permit to mnstmct,ahce Imp e,demolish,or repair TEMP.METQt OR POLEINST.
any structure From to lb lsuarcq also requires the,ppBmnt for such permit to
g66 0k a al ed statement that h as licensed POWER DEVICES
K U gn puicing to the pmvbbv of the
��tn CantedthaLk ..dse Law(Chapier C( rrcndngwhh Sedbnherefm7000) f arul SlYAtMNG POOL ELECTRIC
the 3ofthe BupnmeedPrdesbvCaye1daleheb eumpt 7MI.5 by any VALUATION
the b..t for the alleged eaets thea My violation d SttYbn net m by any
sppBcantfori permit sub)ttistheapplkanttoa ctvil penaltydne mom than OUTLETSSWTICFIESFIXTURFS
E cave hundred dollars 0$500). NEW RESIDENTIAL FI TR❑ rc
I,as owr of the property,or mw
y employee with wages as their k SQFT. STORIES TYPE CON'STRU'CTION
t compewtlon,will dothe work and the avucum b neat Wended or offered for
5 O uk O,,7064,Bwbeu,nd Pr f.b.Cade:The CoM do?.Llmree Lw
P,Z: does net apply to an owner of property who builds or improves thereon,=it OCC.CROIJIa RES ANTIS
whod.ruchMm
workhultthruagh hlaowne,ernplcyeprovlded that such
imp wemcnle,art out intended proffered fmsate.If,however,the building or TOTAL
Wpn,v mart bsdd withinovyearofcamplenbn,theowrcr-WIlderwlil love
t"nien of proving the In did m bulla or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE
"L a owner of the property,am escWeNely contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCEISSUANCEcuntrac oe to certelYct the pruj ct(Sec 70K Bushes and Prdesbv Code:
The Comraaor i License Lw dm not apply to an owner d property who ,��DRAIN 6 VEM-WATER(EA)
builds or improves thereon, and who contracts for such pelo)ects with• ,
c9nus,ctura)Brensed pursuant to the Contractors Lim.Lw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sea B 6 P C for this reason
OUTS I DF EELS
E'LOOR ROOF,AREA,ODND. SANITARY Y N_
�• Owner Dale DRAINS ,
WORKMAN COMPENSATION DECLARATION
RECEIPT R
❑[hereby aHtrm the I haus•certificate d consent to self-Inure,or a FIXTURES-PER TRAP 54100L TAI Y N
mrtlf cam of Worker,'Compevaren Insurance ora certified copy thereof(Sec. REEIPf a
38(0.Lb C) GAS EA.SYSTEM-1 INCA OUTLM 'Z�� PARK FEE Y_ N_
Pdky� '7NwCSD63o6-0001 RECEB74
nY� L GASEA.SYSTE?vFOVFR/(FA)
Com diJ weed BUILDING DIVISION FEES
reified copy b hercbytuml,hed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CertNed ropy b(fled with the city IvpMbn dlvWon.
CERTIFICATE OF E)(Od 'ION FROM WORKERS' GREASE TRAP
CMI INSURANCE
RAE PAID
(Thbctbnneenmbcompl&edfftepembTmorchundeddoBus SEWERSANITARYSTOM EA 700FT
Date Recd tM
(SIM)mles.) WATER HEATEx w/VExr/DPCTR ENERGYFEE Y N
I certify that In the performanmof the work forwhich thispemot bov
led,
I aliallnon employ any peaces in any manner n as to become ub)ect to the
WATER SYSTEM/TREATING
Waken Con�penutbn L.v,of GlBarnla. Date PAID
NEW RESIDENTIAL ELMS.
A Ilcant
Z O NOTICETOMPWGwt:g aper rs'Co thbCrnBhteofons,Exemption,Latour
SQFT. Date ReceOTA til
Ccdc,you
subtestnothe Workwit ComperuatbnpuWabroofDie Lab or TOTAL:
WF H deemed umuefmthwith comply with such provisions or this permit shall be
> a«red revoked. BUILDING FEE
SEISMIC
CONSTRUCTION action NG AGENCY FEE
CL Z Ihemey rk(orwhfirm that fl,em hth ape trucilon kMNgagency for the perforrry ELECTRIC FEE
� Z anon°(the workforwhkhthb permit bbued(See 3091,CIv.CJ TOTAL
U 0 Lender'.Name PLUMBING FEE �-
LL I- l.crider'.Addms QTY. MECHANICAL PER FEE MECHANICAL FEE
O W Icertlfythelhau<read thio appBcatbnard care nhatthe above lnformnlon \- -
bcorect. reetocomply whh aBdtyerd munryordlnanc,send sate lawn PFRMITISSUANCE FEES PAID:
} a id.tingtobulldin9 corms on,ab herebyauthadae rtprtsenbth+e olthb
r N enter upon the ntlened property for inspect bo purpose. ALTFRORADDTO MECi.
z gree t say,lode fy an d keep harmless the City of Cu pert ion Date Recel t#
V against b10t1 V mew, sandeape.whldmayloanywayacvue AIRHANDLLNGUNTTPOIg030CFM) SUBTOTAL:
erg uldC b usque of the genting dtNa permit.
1 AtR]iANIXLNG UNrr rovpR lD,000cFn CONSTRUCTION TAX
S tore err p Bo C rtff IF Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZIMIDOUSMNECRIALS61SCLOSURE
Will theappllcam or future Wilding occupnt eortor hindk hawdous HEATING UNIT(TO 10D,WO BTU) -Date RCC1 [)1
matnrlaludcfia bythe Cupertlro Murddpl Code,Chaper 17,and the
H,Ah and Safety Code Section 2S533(a)I HATING UNIT(OVER 100,000 BTU) AL:
F-1YesJo
c
Will the applkaMmQture building oup, equlpmeM devices VENTILATION FAN(SINGLE RE SID) ISSUA�I
whlcheMthazardous ak mntaMruntsu defined by the Bay Arta Air , �ea 7 gtaI
Quality Management Dbtrkt7 BOrt FR-COMP DITTOS 100,000 BTU) �( 2
❑ Yes No
I)uve rcadthe3 mterlab req u nder Chaper G95of BOILER-COMP(OVER 100,00OBM ��
IM GIIlornb Health 4 Safety Coda Sectbv 75505,25533 and 7553/. I
uM.ut dthatifthebuildingdoewme nttyhaveatenantthatitlsmy NEWRI9DEKDALMECH. SQ-FT.
ropovmui.oce f.c, aoavpMdiherequWmcn(awhich roueW met - - i ^
prior b lsuarce d a Cartlflvtc of Omtpnry.
Owner or awhoomd agent
TOTAL: ISSUED 3TJ17CU1 HYW"e�
OFFICE COPY