20046 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
folming Pw en Identification - PERMIT NO.
Building Addrfv: to S 1Q.� d /1r
ar. anp. me AM
CITY OF CUPERTINO-BUILDING DIVISION
• CslactursNime: U No: APPLICATION I PERMIT
B[JILDINGELECfAiCALPLIJ.NBINGMECHANICAL CATEGORY CONTROLY
A It r. Z Na
,'C" QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— S I'FRMITISSUANGE El EJElLICENSED CONTRACTOR'S DECLARATION
IlrrebyaffU tlutla LkmaeduMnprwWl of Cluger9(mmmen APPWANCESRFSDEMIAL _
IngwithSttl n7000)ofDWiebn3ofthe Bualasaand PenfeselotaCode,and n7y JOB DESCRIPTION
Ikeru,V In full force and effete PANELS
Llmnseclaa.�/+y}-.36-Le.0 292562 .
oate_6/GL/ LLcordrvdor rnan Mart,
xaTanical UPT02DOAMPS
ARC M(=S DECLARATION AMPS
2. I undeneand my plana.halbe used as public records OVER 1000 AMPS - SQ.FT.FLOOR AREA $/SQ.FF.
�j Licensed Profrmional - SIGNSELECTRICAL
«<�< OWNER-BUILDER DECLARATION SPECIALCIRCDIT/MIS
L., 1herebyaffirenthatlamexanpt fmmlhe Cordractor'sLberue Lwfathe
7p G following reason.(Sedbn 70315,Buslnese and Profaeion.Codc My city a
6 2 E- i} IX]NP.MErOR MICE INS,.
F� muntywhlch rtqueesapemdt tomvwd,alter,impmvq demolleh,or repair POWER DEVICES
anystwcture priori.its ieuance,abo requlresthe applcantfa ouch pemdc to
Wc. /lie a signed statement that h b Irerued pursuant to the provislom of the
u. Contractor's Lkerue law(Chapter 9(commencing with Section 7000)of Diet- - SWIMMING POOP.ELECTRIC
O J elon3.fthe Budneuand Pmfesebm CWd )orttwb.b.mnlptther mmand VALUATION
♦ti ...777 the basis for the alleged exemption. Any violation of Section 7m15 by any
O<� appBcant fora Permit subjecte the applicant to a civil penalty a not mom than OLr LETSSWFICFIESFlXfURF_S
^ fU,Irurdred dollars%SM. NRW R6IDFNDAL Fr crTR ST RIES M'E CONS[RIICTRJN SQFr.
A
UI,as owner of the property,or my employees with wagesan the sole
compensation,willdo the wale and the structure Is not Irderded or offered for
p ale(Sec7plytoelansardfpmpebroC WilhCinip o the , law
Ides$ dm wtapply toanowrcrofpmperty who Wlfda or lmpmves thrmq and OCC.GROUP RES.UNITS
0. wprovemetsaer workhlmaede Nrwghedowne.If,hoc, r,theb building
gor
ImpwvemrmbwW tintendedoroffcor for sale.t ho neer- Ude wdinga 71}rAt: - r.
Improvemeru beold svithinoneyearofcompletbgthowner-W IlderwW love
tryspudm of proving that he dw riotbwld.,improve fa purpox ofsak.). QTy, PLUMBING PERMIT' FEE -
U I,as avner of the Property,am eschuNaW
ely contracting wlicensed! FLOOD DONE APN
contrwers to construct the project CSL,70//,Busoeseand Pmfeulom Code: PERMIT ISSUANCE
The CordrxloYs Lkenae Law does not apply to an owner of property whu
builds or Improves thereo., and who contade for sod pAukm with a ALTER-DRAIN A VENT-WATER(EA)
.3az+t'torts)Ilcerssand pursuant to the Contractor's Licerue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
o
U i am exempt under Sec B k P C for this resan
DRAINS FLOG ROOF, SANITARY Y_ N_
® Owner Date R AREA,MND. R2ZEI7 9
WORKMAN COMPENSATION DECLARATION pgFq PER TRAP SQi00L FAA Y_ N_
hereby aHtrm that 1 have a certificate of coonsent to self-Inure,ora RFL--
3900, abofWorkers'Compevatlon irwrranceaacertlled copy thereof(Sec GAS FA.SYSTEM-1 DNG/OUTLETS PARKFEE Y N
38 W,lab C)
Pdky0 0610040779 �5n1ta1ovE.e/cFA) RFLFTPI'i
Cnrmr�� nv auS all TIO. BUILDING DIVISION FEES
3cSiCerlined copy is hereby fumlahed.
LFccertNed copy Is filed with the city impectton dlvlMon. GREASE/INDIISIRL WASTE"IFERZEP OR- PLANCHECK FEE
CERTDFTUTE OF EJ(E1IPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYEA.20OFT Date Recti tit
(Inds section send rad h camplcted Ilhe permitfaara hundred cicalas
Riao)alea3 WATER I-IEATER W/VENT'/EIDM ENERGY FEE Y N
Icertlfythat lothe perfomana of thewakfor which this pemdt is hued,
1 dull not employ any penin any,runner m u to bmome object to the WATER SYS117d/TREATING
waken'Compewtbn Laws o/f GlfarNa.Due PAID
Z D NDnCE OAPPLICANT:U,aftermakingth6C nftoteof Exem n you NEW RESIDENTIAL Pi FT. Date Revel tic
h' N ahwid become object to the worker:Cumperuatkn proWabv ohne labor TOTAL
Cade,you rave[forthwith comply with such provislom.,this permit shall be
W > deemed revoked.
d O CONSTRICTION LENDING AGENCY SEISMIC FEE
the by affirm that then Is a comtwdlon lending agency in;the perform
Z anmuflheworkforwl hthlapermkbt 6ec3097,CW.C.) TOTAL: ELECTRIC FEE
LL0 LeMels NameUMBING FEE
l— I<ndte.Addrea, QTY. MECHANICAL PERMIT FEE MECHAMCAL FEE
O W I tertlfythat l have mad thbappllatbn and satethat theabose informal.V corrM.]agree to comply with al dty,and county ordinances and sate laws PERMIT�I3ANCE FEES PAID:
}.y relaWgto WlWing mmtwdlon,aM herebyauthorlrerepreentst rsofthb
1— = city to enter upon the abmementloned property for Wpectbn purpoes. ALTER OR ADD TO MSH. Date Recei tq
— (We)agrm ave,ve,indemrdty an d harmless harthe city of Cu peril.
agabut llaMBtks,judgments costs and expenses which may to any way a. AIRHANDI1N1GUNITrrO10,000CPM)
agaimtuld Cuymmnsequence o th gram ing of this permit. SUBTOTAL:
k D ' �l. /. 6_• 5 _Qct AIRHArrouNG UNIT(OVER loo)ocEai) CONSTRUCTIONTAX
Slgruture of AApppBManta/Co seta Date DUTAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
11AZARIJOUS MATERIALS DISCLOSURE
Will theappllant or future,bullding oavpart store.,handle It.rdoue HFATING UNIT(T0100,0M 3TU) Date RCcei tic
material as defined by the Cupertino Muriidpal Code,Chapter 9.17,and the �A
I leallh and Safety code Section 25531(s)] HFATING UNIT(OVER 100,00)SM � TOTAL:' Oa
❑Yea No
WW theapplantm tort Wilding occupant use equipment ce cl vi VENTILATION FAN(SINCLE RISA) ISSUANCE DATE
which emit h urooloue air oonlamimrus as defined by the Bay Area Ab
.
Quality ManagemrntDistrict? BOILER-MMPOEIPOR 100,000 BTU) PDD
Yes No
l mrssd theh moue materials requirements under Chapter 695 of IIOILERLOMP(OVER 1W,000 BTU) p /�
th Ca Womla Health&Safety Code,Soctlom255R5,75533 and 7553/. 1 JUN 9 b 19S':J
uMmtaMlhtifthe WldingdacenotmrrentlyloveatenanLthat Itbmy NEW RMDFNFIAL MECFL SQ.FT
responsibility to notify the occupant of the requirements which must be met CUDWON
M W
prbrto fmuaae o(a Certificate f ay. GO 4
go
Owns authorleed agent' Date A
TOTAL ISSl1EDR
OFFICE COPY