20045 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ms: In Proiji Wentlflcatl Q r 1 /� I PFRMITNO.
Budd Add �- e ` �{JV ` Ir 20045
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CITY OF CUPERTINO-BUILDING DIV ISION �Q
Crntna° .N.me: Llc.No: APPLICATION / PERMIT G -2g —07
Areh /EnRfne� �^ L No, BUILDINGELEC RKALPLUMBINGME LAICAL CATEGORY CONTROL$
—til->_(LI-r— BUILDING PERMIT INFO
A Q ELECTRICPERMIT FEE -
Add. �! {/ Y.��dU.f PFRMITFISUANCE 1:1 1:11:1LICENSED CONTRACFOR'S DECLARATION
Ihembyaffbmtlut T.mkmc dundepro Wonsof Cnapter9(mmmenc APPLIANCFSREQDENIIAL N
IngwBh Sealon 700ofDivDlvidfieR.n. meBYa
uneand ltafenlonsCade,and my
Hasand
nleinfuB forme a PANES
pmn�./—�/�c w$,nor ical Csol Q2
ARCHITEES DECLARATION
q�u wCeOwz I uwentand my plans shall be used as public rend• OVER TWO
AMPS SQ.FP.FLOOR AREA $/SQ.Ff.
E U Licensed Profe.elonsl SICNSE-ECIRICAL
t,< OWNER-BUILDER DECLARATION
ZI- ? Ihereby affirm that lam exempt from the CaNnttor's License Law for the SPECIALCBRCUIT/MBC
O9F^ (ol:owing rtaaon.lSerLon 7QI15,BwNer and Profmlons Codr.Mydty or TEMP.METERORPOLE INST.
K4u7� muntywhk requimapermktowru d,alter,lmpmve,demolbh.ormpair
q1 any aructurt pelaNWhat eeq aicente pursuant
of t e POWER DEVICES
Lee � 01e,signed statement that he b 11¢need punsvant to the provisions of the
P3 ti Contractor's Lkeme Law(Clupler 9(commenting with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O sbn3ofine BuNnsaaaod PrNesebra Code)orthrt he bexemptthenefornand VALUATION
PLS° the basis for the alleged exemption. Any vlal.tbn of Section 70715 by any
X155 <3 appBomfora permit subjects the applicant to a acdl penalty,of net mum than OUILEISSWI7L-3T6F1%TURFS
c. fivehundreddolWs0LW. NEWRFSIDFNIiALF.LECCR
�r ❑1,see owner of the property,or my employee with wags u their sole SQFf. SfORIFS TYPE CONSTMUCHON
norpensatlon,wDldothe week,and thest recture is not wended or offered for
SILO Is Cr.7044,Bu.innesew Prefinelnm Code:The Contaaors Lia.Lw
1{sg don rnt apply to an oweer of property who builds or improves therton,and OCG GROUP R6 UNITS
who dam such work himself am
mugh his own employees,provided that==
Improvements art not Intended oroff and for aide.If,however,thebullding or TOTAL,-
improvement
OTAL:improvement beold within oneyearofcompletbn,tMo ner-WBder Mll have
tlILkarden°f proving that he din not wild or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
U L u owner of the property,am exelu d ely mntraaing with IiceMruFLOOD TONE AIN
oosdc on to construd the projeet(Set,7Ui4,Badness and Professions Cade: PERMR ISSUANCE
The Co.' imp a License,thelaw don not apply to an owner or property who ALTER-DRAIN 4 VENT-WATER(EA)
a tTs or s)boos a mceaa, and who mntaae !a such ptojem with a
L_jIaorexampt under ankSee, heConuaadsllame law. BACK FLOW FROieCI'.DEVICE FEE
OUSUMMARY
EFEES
L�1 .m e:ampt ower sec. B er P c for role aa,an
Owner - Date DRAINS FLOOR,ROOF,AREA,COIJD. SANITARY Y_ N=
WORKTI
MAN COMPENSAON DECLARATION s
®1 hereby affirm that I have a otetl0cate of consent to eelf-Inerta
a , a FDCEURFS PER TRAP SCITOOL TAX Y_ N
artNate N Wararra'CamprnsaRmaCe a
on Insns Certified entry th.rta(Cee RILm'I a
3800,IabU GAS EA.SYSfFAt-LING OVHFIS PARK FEE Y_ N_
Poukya 0610040279 RECm'F$
Cam any_Wa S'tn. Tnc- n_ GAS'FA'SYSTIM{OVEt 4(EA) BUILDING DIVISION FEES
�CenNed copy is herebytd.
CeGREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE Certified!ropy b filedd with
the the eidty inspection division.Won.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gYyp�ropN(TnRY-SroRM PA p6,-P Date Recei I#
100)
(IM.section need nal be completed If the permit b fa one hundred ddollars(Sorle.e.) wATERIEATTR W/VENT/ELECER ENERGY FEE Y 'N
Ioertify that b the peAurmsnne of me week for which thio pemm is Issued,
1 shag nor employ any person In any manner so as to homers wb)ed to the WATER SYSIErf/TAFATING
Workenana
'Cnpentbn Lrd'Olifamla.Dae PAID
O Z Arpuant NEW RE9D NUAL PLMB. SQFI. Date Rccei t#
Z O NOTICE TORI'1'LICANp:U,after makingthisCeAffiat"Exemption,you
should become subject to the Worken'Compemation provbioro of the Labor TOTAL:
F N Crdeyou at forthwith comply withuch provlsbruormis permit shall be O
BUILDING FEE
> deemed revoked.
cON'sTRucrION LENDING AGENCY SEISMIC FEE
d .Tnerrby.f0em that them ba meatmalen lendmgagency forthe perform- TOTAL ELECTRIC FEE
7 z arcs of the workfor which this permit b burred(Se'c.3097,Civ.C.)
U O Lender's
Name PLUMBING FEE O
u. F Lender'.Add QTY. MECHANICAL PERMIT. FEE MECHANICAL FEE
O W ]mrtifym.t l have reed thatippllotbn and sv
tatethal theabove lnfomtlon _
Is correct.Iigree to comply whh.0 city and county ordinancesand state laws PERMIT ISSUANCE FEES PAID:
>. N reining to Entitling coroteuGlon,and hereby aume oruu,representatives of thatW eity to enter upon the abovementloned property for Wpectbn purposes. AUIERORADDTOMECH. Date RecCi t#
_ (We).gree to save,Ind emntfy an d keep harmlew the City of Cu partbw
aga4ut WbEftie,Ndgmentn,mets sew expenses,which may b any way aecrue Alit HA NDLIN'G UNIT(TO 10,000 CFM) SUBTOTAL.gotint said City In cons,eque�of the granting a(this pemdt.
AIRHANDLINGUNIT(OVFR10,000CFM) CONSTRUCTION TAX
Signature of Appliant/ t Date EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
]HAZARDOUS MATERIALS DISCLOSURE
WE[the applicant or future wilding oaupent store or handle hazardous HEATING UNIT GO 100,000 BTU) Date Recci t#
material as defined by the Cupertim Murdtipel Code,Chapter 9.17,and the
Health ew Safety Cade,Seetloon 75532W7 "EATING UNIT(OVER 100,000Bid)) TOTAL:
Wlllthe appear$orO(utua bulldingomnpant use ryulpmentadevlas VENTILATION FAN(SINGLE IT-SID) ISSUANCE DATE
whkh eros hanrdous air eentandrunt.as,defined by the Bay Asa Air. PAW,
Management District? BOLI-FR-NMP QHPOR 100,000 BTU)
Ym Q No
Iuveread the hazardwsm.terials requlmmenbunderChapler(OSof BOLI-ER-COMP(OVER 1W,00)BTU) JULY 8 6 199J
the Ci Efomb Health 4 Safety Cede,Sectiom 75,505,75533 and 755.)4. I
unde law thatlfthewlldingdomnetarrtntly have atenant,that it b my. NEW RESIDENTIAL MECFL SQRF
repo xflHlny to notify the occupant of the mqui,.ntswhkh at be met ^.. �
prior to Lreuance of a Certlflahe of pancy. ali CU
hotlxd agent TOTAL'Dote ISSUED
Owner m autBYE--]
L
OFFICE COPY