20062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ro Pd Identi iceien (e�-doh PERMIT NO.
Building Address: 0 0 Caen 1 TS s? 5g 6Y 20062
r�SP—urt ('fLa U P
me CITY OF CUPERTINO-BUILDINGDIVISION nn
C¢ntract Na is � � APPLICATION / PERMIT
rpt / glrccrQ . ELECTRIC PERMIT FEE BUILDINGELECIWCAGPLUMBING-MECHAMCAL CATEGORY CONTROL
BUILDING PERMIT INFO
Add. � n"
CENS.DONTRACTO ♦ PERMITISSUANCE ❑ ❑ ❑ .�
LICR'S DECLARATION
Ihereby ofImo that l am licensed under provlelons o(Chapter9(tommenc APPllANCESREEDFMIAL
IngwithSection 700)of DlvWm3o(the BuMrcasandi'rofeWmnCode,and my ' S' 01
)r CRE1
LE¢n lain/all req Id�ect PANELS �r(_M1/e'MJ
Drte7�T� L• CoMnanr ,e (—I
ARCHITECT' ECLA ATON �"00 l•
p�v�]. lundemtend my plum aWBh uxd upubtcrecvde OVE 100()AMPS SQ.FT.F1,OORARPA f/SQ.FT.
k o�j Llrenxd Profeslonal SIGNS ELFOTRICAL
OWNER-BUILDER DECLARATION' g'ECIALCItCUI.I,/MLSr
[hereby a(BrmtOWNE exempt ER DE LARATIO License Law for the
following reaem.Ciellan 7015,Bualnes and Prof�ba Cade My tlty or
O f. TFMP.MET[R ORPOLE[NSI'.
J manly wMch requlrmapemdttomnstroct.atter,imprwe,dennWh,or repair ,
mr,� anystructurt prlorm lb bwarme,abo rtqubesthe appBcantfm wch pemdt to pO0,VER DEVICES
rt 6 file a signed statement that he b horsed pursuant to the provbbm of the
O tt,� Contractor's Lkense obs
lsw(Claptactio0)
9(comnencing wth Sen 70of DIA-
�J abs 3 of the Bu siness and PrbraCade)orthat he Jet exerrps thertfromaM
SWIMMING POOL ELECTRIC VALUATION
Fh ..777 the Web for the alleged eaemptbn. Any tolatlon of Sccticm 70115 by any
Q� appgcantforapamdtwbjaUtheapPRcattoa Wllparuhyana.a than OUILETS-SIVTICHESFD(TURFS
Iva undyed doliara($50D).
'9..' I,as owner of the property,or my employees with wages as their sole INEWRESIDENTIAL FT PCTR SQFr. STORIES TYPECONSIRUCDON
cunpan.atlam wW doth work,and thestrolure b not intended or offered for
$,J ❑ ask(S r.7014,Bminea and Pmfesbm Code:Th Contractors Ihme Law
ps8 does not apply to a n-1 of property who builde or bnproea t hereon and .. OCC.CROUP RF5.UNITSe. who docs.uciwork hlmaei!¢
through his own employees,provided that such
ImprovemeNs are not intended or offered foreale.If,however,the building or TOTAL:
. Improvement b wH within one yearof completlom tithe owner-builderwill have
t rden of proving that hedid ro
dt wild or Improve for for purpose of sale.). QTY. PLUMBING PERMIT FEE
�I,a owner of the property,am sacI.N,ly contracting wth[¢mad FLOOD ZONE ATN
mntnectma to construct the project(So,7066,BusinesaM Professions Code: PERMIT ISSUANCE
The Com r.lore License Law dices outapply to an owner a property who
wild. or improves thereon, and who contracts f¢such prop ts with a ALS-DRAIN Is VENT-WATER(EA)
MARY
ter, .or(.).emptdnder p. SM
the Contract«.LI¢nse law. BACK FLOW PROTECT.DEVICE 'FEESU DE FEES LJ i .m e.empt wrier sec B e e L for this reasonOUTSI
Owner —D"'.
DRAINS A.N
FLOOR,ROOF,AREA. SANITARY R�EfT1
,,,}}},,,��' erWOR KMAN COMPENSATION DECLARATION FIXTl1RES PER TRAP SCHOOL TAX Y_ N
heby af(Irm the I have a certificate of cauent to aB-Wort,¢• RFOEPT
10crte of Worken'Compsmatlonlnsura¢maartlfi copythenW(sec. GAS EI.5YSTEM-1 INC4 OUTLETS PARK FEE Y_ N
Vb ) I 0 RECEIPT 4
Pdky Y GAS FA.SYSTEM-OVER 4(EA)
Ca ny BUILDING DIVISION FEES
C rt10e mpyb ere y(umiahed. GREASE/IN'DUSTRL WASTE INTERCEPTOR PLANCHECKFEE
crt1flN ropy billed Mth the dty Impectlon dlvWm.
TTTT CERTIFICATE OF EX FTION FROM WORKERS' GST TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY-MRM Ea mmrl. Date Re i t#
RMs cellon need not h completed tithe permit b f¢one hundred dollar
(gl(1(B¢Iyth) bENERGY FEE Y N
1¢rtlfy that the perf ¢
ormanof Mwork tWs permti.bvN, RIOTER HEATER W/VFM/EFiT'R
I.WB na employ any peremn in,any manner so as to become subject to the WATEi SYSTEd/TREAT(NG
workers Campematbn laws of California. Date PAID
itcard
Z 0 NOTICE TO APPUCANT:I ,aNer nu king shb Certlflute of Exemption,you NEW RESIDENTIAL PLMB' SQ'FT' Date Recei t#
F N should become subject to the Works.Compensation proAsbns ofth.Labor TOTAL:
Cade,yw mist!¢thwth comply with such pmvbbns or thio pemdt shall h
W > deemed re.mkea. BUILDING
CL F) CONSTRUCTION LENDING AGENCY SEISMIC FEE
lhembyaflrm thattherebamnstmctbnlendingagenry fortheperform
Z ancaof the wohfarwhkhthb permltblasned 6ec 30Y7,CIv.C.) TOTAL ELECTRIC FEE
U O Lender.Nor¢ PLUMBING FEE
LL F Lender.Addrma QTY. MECHANICAL PERMIT FEE , A
MECHMCAL FEE
O W brrtl
I¢ntifythat l have mad this application and atatethal theabavelnformatlon 00 FEECHANI
co .I agreeto comply with W and co
hcity aunty ordinance wn and state laPERMIT ISSUANCE
} 1 relating to wilding comtructlon,and hereby authorbe repreentelva of this ,
F Z aty to enter upon the aboTmentannsd Property f¢Wpectlon purposes. ALTERORADDTOMECFL
(We)agree to as mntfy an d ken m the C of Cupertbio Date Recei t#
V agobstlbbWtles,' g bnoru Me kh nv yamrue ADtHANDLING UNIT(IO 10,000 CFM) SUBTOTAL:
ago Wtcmc n¢a gra n' athi.
M _ AIR HANDLING UNIT(0 E 10,0000CFM) CONSTRUCIIONTAX
Slgrutureaf Applicant/Coe - Datey� D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Wllltheapplicantwfutune wddingocupant stomor handle ha,callous HEATING UNIT CFO I0,0D0 STLE) Date Rccei t#
material..&fi i by the Cupertino Mu Nlpal Code,Chapter9.IZ and the
Fleath.nd Eatery ion 25532(a)7 IEATIN'G UNTT(OVER 10,000 BTU) TOTAL:" a ,
Yes
Ilitheappllont tum wlldingaapantuae Nuipmerdcuch,ins VGTIILAHON FAN(SINGLE RISID) 'ISSUANCE DATE
which eMt hnvmous air mntamW nta a deBri by th Bay Area Air
Quality Mamgemcm Wct7 BOILER-COMP OEE OR I00,000 BTU)
-
� YesPAQ
4heKread heh wsmaertbrequirementsunderCWper6.95a OLE COMP(OVE 10p00BTU
th Calffmnb Heath A seto Code, ions 25505,25533 and 75534. 1
undrntard flat if Ildingd rtently ha a tenant,that It i.my NEWRESIDENTIAL ME01. 9QFI. ,��p � 199as
rnponslbWtyt a [hc stn ha requl ma which mast be met 'L
prior to tau acct pa
T(aff n I
Owner a autharired.gem Date TISSUED BY:
OTAL
OFFICE COPY