22372 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY,
Bdidl Fm'ed Identification I PERMIT NO.
Build Ing Add nes: V '1
len er vn Ll7x q9 T Pe 'V 22372
rcrs ante. one: AL DATE
CITY OF CUPERTINO-BUILDING DIVISION
. Co^naw'•Na^i: • Lm.No APPLICATION / PERMIT 7
BIIILDINGELECIRICALPLUMBINGMECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Llc,Na
CITY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I'ERA4TISSUANCE ❑ ❑ '�/i ❑
LICENSED CONTRACTOR'S DECLARATION I/V
Iheh by Sedl.rmtwtl amllcroseduMnIneaa.dPmfddterod,. dm APPI.IANCFSRESIDFNITAL BD N
It..I Semon 7000)ol l affect ofthe BuslrcmandPro(esslovC,.ode,,nd my �Q.Y` 1 ^IQJ
Liceve C/yn full(t�o�(�•J�d elect. � PANELS � � 1— ,.a.7�1✓ G./`
D,IeCoMndoj� )a+yLM 10 2DO ANIPS
—PI J �16,T /
ARCTIM DECIARATION MI-
Po+
97 ]understand ery phv,hall be used as public¢mrtl> OVER 1000 AMPS r�SQ.FT.FLOOR AREA $/SQ.FT.
Fi Licensed Profeabral SICNSELECTRICAL
OWNER-BUILDER DECIARATION SpECIALCIXCUR/MISE
^1✓``-P 1
Ihcrebyaffinn Wm mnd
t l aexempt from the Coor'•Lica se law fee the l e� Il r
pp following rtaaon.RM1an 7011 S,Buslneo aM Pmfesbna Cnde:Mydty or ✓n
TEMP.METER OR POLE INST. Q
r" W cuuntywnid�nn WIUp arm mrorequ l eapbmnifmoW pe opsin ��
q'y 57 anyetmcturtpdarlolts bsusKe,,bo requWthe,ppl¢ntf¢sud permit to ppyyp.R DEVICES a Q
d1 lail af file a signed statement thet he h 11¢vM pursuant to the pmWbv of the
34 ComraGa/s Lkevelaw tCwpter9(mmmendng with Sed1on 7000)ol EBvl- SWIMMING POOL ELECTRIC VALUATION
O elo basis fo the alssnd Pempito . Any violation
of exempt 7031.5 by any
kS<i ibebarb!orthedkged pecmptlon. Mytto.cinofStttlon7Q115 n,than
applicant for.permit abjedsthe,pplb,nitoadNl pevhy a(nd more than 0[JiLEISSWIPCF1SFlXILRkS
O five hundred dollars($SM.
❑La,ower of the property,or my employers with w,gn as their sok NIEY.'R�SIDENTIALEIECTR �� TYPECONSTRUCTION
compenwim. Bldotheworkandthestmd m brot mteaded or offered for
O %+k(Sd.70K Bu, nM
b ,aProfesbv Code:The ContnctL¢v
ofseiaw
�$ whod applymrkhw Udth p hhisob em ori ,p esdh tit t and
whodaemv rm;.ork t Info rthwgh hisown e.If,ho ees,pmAded ihatsuch ff- '
UNITS
ME
Improve ant Iarcdl Intended esrom.ffmmpletik.I!,homer-b deer 4dl hang w Improvement tssold Withinorcyurafcrmipletbrl,theavner-builderwW have _
ttiLtI+nlnn ofpmvtng that he dm rot build or lmprwe!¢purpose of„le.). QTy. PLUMBING PERMIT FEE
"L as owner of the property,,m exehodwly detecting with 11¢vd FLOOD ZONE AI'N
coot Aden to construct the project(Sec 7014,Bushes and Prose:lov Code: PERMIT ISSUANCE
The Contndm'a Lid.Law don one apply to an owner of property who ALTER-DRAIN VENT-WATER(Ex)builds or toy.thereon,and who..m for ad p'e'at with,
oQ +do,(UI¢nxd pursuant to the Condor's Live law. BACT(IIDWPROTCCT.DEVICE FEE SUMMARY
L�I am exempt under Sec B Is P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date R�pII•T#
WORKMANI haw cSATION of
RATION FDCrU2FS-PER.TRAP SCI{OOL TAX Y_ N_
1 hereby affirm that I have•certificate of covert ro self-loon,or RFLFFdPT a
¢bC.)' rYen'Campenutlonlvunn¢aa¢rtl(Ied copytFe�eof Esc. GAS FA.SYSTEM-I PJC40UlLE15 PARKFFP Y_ N_
P.1klab CJ' Z—. RECEIPT,#
lo14Y n CAS EA.SYSTEM-OVER MA)
Cq �pa y BUILUINC DI VISION FEES
LY1CertiO on bite ytarwa RGREASE/IDUSRL WASTE INTTRCEPTOR PLANCHECK FEE
ed mpyb flied with the city inspection dlvWon. '
CERTIFICATE OF EXEMPTION FROM WORKERS dCREASETRAP PAID
ON I
A
CAMPENSTINSURANCESEINER-SANITARYSTORM E.A.NXIET Date Recei t#
(Thhuactlon need nd
COMPENSATION
Bt he SURAbila one hundred delta.
(5100)orlesJ WATER HEATER W/Vl yr/ELECTR ENERGYFEE Y N'
I¢rWythd In the penforrtan¢of the work forwNch reds permit is hsued, —
I shall not employ any person N any manner so n to become subject to the WATER SYSTEM/TREATING .
W¢keri v
Compeatloolaml
ws of CaWoa. Date PAID
PP NEW RmOFNITAL PLMB. SQFT.
A 11¢nt
Z OZ NOTICE TO APPLICANT.to
after mking this Cartll¢leofonempteLyea Date RecvOTA taY
should bemme,forth to theworker:Comprmrisaupmvbbvofthe Labor TOTAL:
LU N Cade.you 1odl.forthwith Amply with such prwbbv arthb permit shallbe
W > armed revakea. 13UILDING
coN5lRurnoN LENDING AGENCY S IC FEE
d IherebyafBrtn thattherebamvtnuniw lending agency for the Perform, TOTAL ELECTRIC FEE �1 1
Z an¢ofthe work farwhlchthbpermB b hved(Sec.30Y7,Civ.CJ YYT`P\1 nyS!
U O I<ndcri Nam PLUMBING FEE
r Lenders Addre„ QTY. MECHANICAL PERMIT FEE
ILdad MECHANICAL FEE
O W ¢dt.Iwgr wvcomply , hallcit1an.Mrtate thattheaboveil sale laws
4 bmnect.I.ildingcomplywo,andtyandmuhorteeWnmandq,tekws IsFRMR]SSUANCE FEES PAID: 1�iQl
} reht�tabulponthe construction,and hereoperty Mze repmenlatiw of this Q�
Z dtyto Wea to saw,
pmperty(¢i the
purposes. ALTER ORADD TO MFI:I I.
V — (We)agree to svU,IrdemNfy an d keep h,rtNes the Clty of Cepentlro Date Recelptq
agaime Halo Rb,judgmenb,m,ts and expenses which may in any way aaxue AIR FIANDUNG UNIT(TO 10,0)0 CFM) -
agamt dCly ���o f the g¢ming of this perosis.. SUBTOTAL:
J ;pJ1 _ /%/L/ AIR HANIwNG UNIT(OVER 10,=CM CONSTRUCTION TAX
Si-gvtud.f p 1,C6 t6o SCLO'6y`/7y/ to-! EXI-IAUSTHDOD(W/DLIM CONSTRUCTION TAX PAID:
AIARDDUS MATERIALS DI URE
Will the applicant or future buldingoccupant store or handle havrdoue DATING UNIT CTO 108000 BTU) Date Recei [N
material as defined by the Cupertino MunicipalCode,Chapter 9.12 and the
Heaithand SafetyCode Ion7S532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. o
Will the applies r tore Wildingoafoa upantumequipmentordevVENTILATION FAN(SINGLE RES?D) ISSUANCE DATE
which cMt havrdvus air taminants as defined by the Bay Area Ab
e Q.Ifty Management District? BOILER-OOMP OFI'OR I0BD00 BTU)
Ym ��I1r�p}�.w��
have read the ha4Srddu•msted,b requirements under Chapter 6.95 of BOILER.CC)MP(OVER 100,000 BTU)
tMGlif¢ t tifthk S,fdy Code,SUctbvtefth� ntly veatand255]0. I
undo i ytorohe bolding doesnot errenlywves hick ustbernet NEW RESIDENTIAL MECH. -SOFT
repo bllyto ndlfy thU as occuparequlrtments which Rust be real
pd o an i olOmrparuy. C
neroramagent to TOTAL: ISSUED BY
OFFICE COPY