22371 APPLICANT TO FILL IN IN FORMATION.WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemlfbtlon 7a5 PERMIT NO.
Building Addrem: VI�
2 gip" i E5 1en o I,. 15 Liq 7 tv 22371
re . .me cone CTTYOF CUPERTINO-BUILDING DIVISION
Contractor'.Name: Lk.N. APPLICATION / PERMIT 7-�
BUIIDINGELFL]RICAGI'f.UMBINGMECIUhTGL CATEGORY CONTROL
Archked/Englroer: IJc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ X, ❑
LICENSED IamI under'SDECns of Chapter
J��
Iher.by affirm that DiAgmuefthe B" vbldI mfehapler9(commmc AI'PLIANCFSIZE9DENIW, I"'a eJOB Q
PIeX
lin, hSedbn 7000)of Dlddm3otthe Buslremandl'rofodwuCode,and - e .YJ
II¢ve bin(u-�dka. .mss PANELS
License as Lb e r �' ^'r L rn
Dale Corrtrador� GK,y( l.! bl11
ARCTFTD=S DECLARATION 1"1000 AMPS
W I understand my plans shall be used as public remrda OVER 1000 AMPS SQ.FT.FLOOR AREA S/$.FT.
OCO
xu Llansed}hdemlorul SIGNSFT TRICAL _� Replaces
< OWNER-BUILDER DECLARATION SPECIALCIRCUTTRA19Z - t !a\-�{a s 1
F,�3 Ihereby+f0rm thatI amevemptfrarothe Contractor'.Lice.law forth. r VY'rnI r .
7p following or..(Smdbn 70715,Bualoe a and Prefe.abn.Code:Any dty or '
_ TEMP.META OR POLE INST. -
ntywhkh requlma pemdHomvso requinit.rempmve,de rsuch,ar repair
Ilkatalpedetatemelhbathela neraed purtheappBant far.sionspermit the Ig1YpR DEVICES11 W
prim,to LA
rL1 5 ole a signed mtemem that he b B¢n.ed pnuant to the proWforo of the
O� �• Comraetore Lceme Law(Chapter 9(mmmencing with SeGlon 7000)of Divi- SWItAl UNGPOOL ELECTRIC
1 don3afthe Buvinemand Profembm CWe)orthahebewmptthemfmmand TER VALUATION
y.'.•33 the baais for the alleged eaemplbn. Any violation of Section 70715 by any
applicant for.permksubjects theapplicant toadvil penakyd or not mothan OVD.ETSSW17Ch�.TFl
c, fi�"hundredddbrs(S ML NEW RESIDENTIAL ELECoaI
TR .
52 u LZ owner d the property,or my employm with wages as their sole TYPE CONSTRUCTION
7 cmnpensadlon,w{Ildothe work.and thestrurnrrt Is not Wended or offered for
Osak(Sec 70K Business and Prdesbv Codc The Cowv e.Llame Law
don not apply to an owner of property,who build.or improves thereon,and OCC GROUP RES.UNITS
F who dae m
such work hlnelf or through hb own employees,prodded that such
Wpmv ntaarerotbtendMoro((emd(orsale.ILhowever,thebulMNgar TOTAL,-
Improvement
OTALImprovement its w hM omrarofcumplebr thewvner-buildmMU have
t edan of proving math.aid not baud or tmprmve tarp rposeof sale.). Qty. PLUMBING PERMIT FEE
LJ L a.owner d the property,am e.luslvely not... log wW Ilvrued' FLOOD ZONE APN
mntraet.to mvtruC the pro)M IS,,70K Bush.and Prd®Ionu Code: PERM1T15SUA14CE
The Contradar'.Liarue Law does nor apply to an owner d property who ALTER-DRAIN A VENT-WATER(FA)
huilds or improves thereon, and who contracia for such p"with a
agagactrWi1renxd pu..t to the Contractor'.Lloe.Law. BACK FLOW PRDITCT.DEVICE FEE SUMMARY
LJ I am.tempt under Sec B 6 P C br thh recon
r'o ITSI DE FEES
DRAINS FICIOR ROOF,AREA,GOND. SANITARY Y_ N_
�• pvn.r Doe RECEIPT a
WORKMAN COMPENSATION DECLARATION FIXNRF_S PER TRAP Sai00l.TAX Y_ N_
I hereby affirm that I have o r.rtl0ote d a certified
to o y-hwor,(S a
n ed Worken'Comperoatbnlnaunnororaa:rtBkd ropy thereof(See .RECEIPTI 4
polis Iib C.)- - G9�,q�AiB7 GAS FA.SYSTEM-1 INC{0[TI7.Ef5 PARK FEE Y N
1'dkyl RLCE'B'Te
Gemr
��L�� Cy GAS EA.SYSFFM-0VERA(FA)
• BUILDING DIVISION FEES
ertBdM copy Is herebytumWed. GREASE/INDUSIRLWASSTEINTERCEPTOR PLANCHECK FEE
ertl0ed ropy b(flfieded wwith the city Inspection division.
CERTIFICATE OF 13(FMPTION FROM WORKERS GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 3TQ,I. . Date Rcecl l#
(Thioaecilonneed not be c plded lithe permit bd
forom hundrdoBry
.
(SIM)or less.) WAmc]-CATER w/VENT/ELECTR ENERGYFEE Y N
I mrtify that In the performance ofthe work forwhich this permit is issued,
I shall not employ any person In any munner so as to become subject to the WA77R SYSTEM/ntFAnNG
Worker.'Cumperuatbn Lawaaf CBf.Ia. Date PAID
O Z Applicant NEWREIDEIMALPLMB. SQ.ET. Date Recei t#
Z O NOTICETO APPUCANT:If,after making thio Certifcateof EvemµlaRyaeu -
.hauldbecomeaub*dtotheWor m'Comperoatbnpm Wmofthe Labor TOTAL
QN Code,ymmstf«hwtl plywthwchprov morthbpem MWlbe DI
W > deemed revoked.
CONSTRUCTION LENDING AGENCY
SE15MIC FEE
Il Iherebyeffbmthatther.bamrotrucilmi lcndbgagenry fortk pedomrf TOTAL,-
00
o'rnL: ELECTRIC FEE
7 Z anmofthe w
o
rk(or which thlspermit b l.ved bee 3097,Civ.CJ
U O Lender.Name PLUMBING FEE
LL ~ Iender'.Addr.m QTY. MECHANICAL PERMIT FEE MECHANICAL FEES '
O W I orrtBythatl have madthb.ppllcatlonand natetF.t thmabove lnformallan
bcom .I agree to comply with all city and county oedlranca and rate laws FEtMiTISUANCE FEES PAID:
} Mating to building mrotrudion,and hereby authorlss representatives dthis
Z
ay to enter upon the above-mentioned property for bmpe ioo prpoenD
. ALTFRORADTOMECH.
(We)agree to save,Indemnify an d keep hanNas the City of Cupertino Date Reed [#
V agabut Nabi tka,}idgmmb,mem and evpeves which maylnan way.. ADI HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalrutsa Ity n ns m ¢ f egrantingdtlW ✓R /
!yg/� ' _ aRxnhrouNc UNIT(OVER 10,W0 CFM) CONSTRUCTION TAX
r CONSTRUCTION TAX PAID:
Slg t of pp est I to E)(HAUSTHOOD(W/DUC77
H RDOUS MATERIALS DISC U
Wllltheappl mrfuWmor ldingu pantstomorhandle"doua IJEAnNG UNIT(TO 100,000 BTU)
malerbls.dafied by the Cupertino MurddpalCode,Chepwr9.17,and the Date Recci t#
fkoith and Safety Cod:,&eetIun 75532(a)7 - FLEATING UNIT(OVER 100,"BTU) TOTAL:
❑Y. , /-hj No
Will the nppHaA or Aman,building occupant useequlpment ordevkce VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemith rdousairmnl.mhunta..def1red bythe Bay Area Air
Quality Management Dis 7 BOILER-CTMPOINORIMOMBTM Y. No
i have mad the 1, muteriab requ4emints underChapler6.95 of BOILIRCOMP(OVER100,000BM '
the California Health h Safety Code,Seelom 25.505,25533 and 75536. I
understand that ifthe building does not currently have a tenant,that itbmy NEW RESIDENTIAL MECH. SOFT
rnpmibua.to notify the oavpard of the requirements which most be met
prlorto sat(b fOocupary. /'.��////,�l
t7wno or au BeaD r 1$UHDB cu
TOTAL,
OFFICE COPY `