21119 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY kv7—tcj
Building Proem Identification PMLWT NO.
Building o s or e co a PHZ�u S a 21119
ame: A
hPla—mcut CITY OF CUPERTINO-BUILDING DIVISION O
APPLICATION/PERMIT 0 L D
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QW ELECTRIC PERMIT BUILDING PERMIT INFO
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Address:
PERMRISBUANCS
LICENSED CONTRACTOR'S DECLARATION L(� LP
)hereby affkrtsthat l sen Bo used uoder pmeWonedQapter9(mmmen APNIAMESRESEDEM7AL J B RITION
IngwlthfMbn7000)ofDM iw3ofthe Bu .cod PralesdmsCodeand
Ibense b inb and dfect. \q PANELS
D+teUPTOWDAMPS
Coctndm BII-1
ARCHITECT'S DE RATION
o�uGz ]u d my Flaw slugheused as public rK«dA' OVER IOOOAMPS SQ.FT.FLOOR AREA f/SQ.FT.
F LkensedPMerbnel fIGFIBN.BCIMGAL
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OWNER-BUILDER DECLARATION SPECIALCMCUIT/MISC
I herabyafOm shat l s Sectles 71111.mpt frmms and ProasoAL1«saw law f«The (�b
F77 fol btywhkhoquimaprndtW minsad PimpmrsCadr.Mycttyw
SI emntywhkh requheaapemRlomtubuq,aller,hnpm«,dennlbh,«eepalr �.MEI'LItORPOLEA`SI'.
soydnrdureprWWIUima«a,alnrequi theappBaafwsuchpemdtro
S file•signed mate at that he b Ibmsed pursuant to the provisions of the POWER DEVICES
Contractors Lkerw lAw(Chapter9(mmmncingwtlb Section 7000)dDid- SWA/MINGRIOLELECTRIC
sion3aftheDushmmdPramlamCode)wthahebewmpttherefmmand VALUATION
the basis for the alleged emmptbn. Any violation of Tactim 7031S by any OU7LE7S.SWITCHF&FDCOJR6
app11«ntfora permit subjabthe applicant to to a civil penaltyd mass ass then VTVS VAC
0,RIundred dollars OSUM. NEW RESIDENTIAL ELBCIR SOFT.
�rr UL an owner of the property,or my employers with wages an their sole SIOMES •IYPECONS7RLCTION
c, compensation,waldothe work,and Bu structure lam Wended or offered for a •0"1
Ole 03m 70K Buahaus and)#dealers Code:The Cordncters U.Lw
jg dam ndapp to an owner d property who builds or Impactor thermn,and .
^ whodoes workhlmwff«Nmughhbmnemploye pmkbdthalmeh OCC.GROUP RES UMTS
Improvemewanmllntmde4woBendfwmle.ILhowev«,thebullding« T'O'TAL;
ImprovemedbWdwhhinmw)ynrofo.pldi gtheo r-buaderwalhave
t rm d «
dendpacvingthathedidnotbuild«bipacvefwpurposeofmle.). QTY. PLUMBING PERMIT FEE
L owner the property,am ebshely contracting with licensedFIAODZDNe APN
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omtrartwa b mrnnrct the project(Sec.70K Busies Band Prolamines Cade: PERMIT ISSUANCE
The Codndars Liman lAw dorm sad apply ho an owner of property who W
bull&or Improves thermq and who commits for such pmeeb with a ALTER-DRAIN&VENT-WATER"
DEMEor(%)IimwdpursuantmlbeCmindora Lkeaw Lm. FEE SUMMARY
m ewmpt under St. B&P C for so
this resume gra«plpp/pgpy�•y
Owen ILre DRAINS ET.ODR,AOOF,ARBA,ODNO SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT
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meby aBirm that I have•certificate of amend to cog-bwre,«a FVCTURES•PERTPAP SCI'IDOL TAX Y_ N
mrtlaabof WorkeW Cssmpenedanidmranm«amnifkdeopysbftvd&r. RECEIPT F
3B00,LbCJ GAS EA.SYST &I IN"OUTLETS PARK FEY Y N
poky Y RECEIPT 9
Co ny GASEA.SYSTEM-0VBRdffA) BUILMNGDIVISIONFEF.S
CCedRled copy b heed with the
GRBA.SE NDUSIRL WASTE ENTERCPFron PLAN CHECKFEE
CJC.d copy b Nedwishthe city Inspection dlvWm.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAr PAID c9
COMPENSATION INSURANCE SMVMCSAMTARY•SIORMEA.2<IOr[ Date Receipt 0. L
OhLe aectbn need not be completed if the permit b Forces hundred dollars
O70(0«1eer.) WAIFRHEATEYW/VPM/ELTCTR ENERGY FEE Y N
ImdlfythKinthapedormr oftheworkf«which Wspermitbbond,
I shell net employ my person In any manner an as W become subject to the
A
W ATFR SYSIII.I/TRETING
w«kerrGmpeneulan)Awad GM«nle.D,te PAID
O ZZH Nglms ANEIL drs maCedgnmplbry you
NEW RESIDENTIAL PLMB. SDFTDate Reel
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O should
Immune
subject blhe Workera'Compertion provisions ofthe Labor IOTAIr
N Codeyoand forthwith mmplywlshsoch powiclunecwthh,
pemdt shill he
W j dremed revoked. IN t
CONSTRUCTION LEfdDING ncEVcv ISMIC FEE
a G IharebyaNmthetsherebammtmctlonle iat 309,Ctv.ChepMona .IOTA ELECTRIC FEE L
Z anmdlhew«&for whlehfhb perrmtbbcod Lgoe 30P/,Cb.C3
V O lander.Nam PLUMBING FEE
LL f lenders Add resa Q7Y. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 'lostlyth llhevermdthisappllatfonsddateshallheabo inf acusim , �er�a
bbeingt.to building
conmlywith ancilyad muntyodinencorand ebte lows PERMIT ISSUANCE lJs.r FEES D
} U) rehtlocawupont a construction,andd reby property
or In repnwndattum purposdthb O
j. W dsynenterupmsheabove-menlbnedproperty!«Wpedbnpurpwes. ALTFRORADDTOMFfli.
z (Ve)agree trave,Indemray an d herrrdea the city of Orpedhw Date Receipt#
V agabd Olin, ndnb,adsand s1. hmylnanywayaomre AIRHANDLfNC UNU(TOIQOOOCFb1) SUBTOTA
ago se9u of • IngdlNs peewit.
` hi AIRHANp1NG UNIT GOVFIt1Q000CFM) CONSTRUCTION TAX
Signature o p sal/Contrat« 1iDitz EXHAUST HOOD(W/DUCD CONSTRUCTION TAXP
AZARDOUS MATERIALS DISCLOSURE
Will the applicant«future building compact dare«handle hazardous HEATLNG UNIT CIO 10Q0M BTU) Date Recei Zt
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the /
Ilealth and Safety Cade Section 755U7W7 HEATING UNIT(OVER IOUM Frl 0 TOTA :( sLv
nn Yn No
Valtheippliani« are building occupant uweialpmad«devlm VENIILATIONFANOINGLERESID) ISSUANCE DA
which arms hazardous air muadnads as cleared by the Say Am Air ,
Q�ua1ftyMawgmrzmtDhddck? BOLLER-COMPOEg'OR IOQOOO BTU) �` •.7'�
ha
LLLT Yn No f'k.
I vemdlhe hara�mumatedabrequlmmabunderChapter6.95of BOIML.COMPB7VEILIM ITA
theGlf«nfa Health It Safety Code,Section 75565,7SS33 and 755M.1 A1el +r'�'t���
un tad that If the budding does ml currently have a immi,that It b my NEW RESIDENTIAL MEKH. SQ.FT NOq{/ 2
rapowiWily to notlly the oonrpad ofthe requirement which mrd be and
prior to imam da CedlflotedOcarpanry. l city.Bf(�tI'�t��Tk��I.t
Owner«authorized agent Data
TOTAL: ISSME)BY: v WFNr VFW
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OFFICE COPY _� cL,