22954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY .
1W1ldlAg Project identification 7 PgMT NO.
Building Adds
ao3�� \� ,c%.v \c , --\-g_ 22954
ne"Name: \ c;ione:
„ 1���' CITY OF CUPERTINO•BUILDINGDIVISION 1
• • Llc.No: APPLICATION I PERMIT e�
A 3m
BUMMNCFMBCITUCAI.PLUMBINGMBCHANK'AL CATEGORY CONTROLS
m r Lie.Na
C'—sr'�aa
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
Ikmbyafflrmtktlam BaenadundupmvWm ofChapem9(cmm APPLIANCES-RESIDENTIAL B DESCRIPTION
Ingwlth9r df=70W)ofpWdm3dNeBuid sandPmfvabmCod4and 1\'{
ikanss bin fuf(orrt ed f PANELS
Lice. ClLku#
se an
Date Contnmr
• ARCHIT CIrSDECLARATION 2I71-I0D
Q�v pZ lurdendad nyplamekBkn
udupuldle A. OVERIDOAMPS SQ.FT.FLOOR AREA S/SQ.FI.
H IZ Lbemed Prd®foul SENSELBCIRICAL
OWNER-BUILDER DECLARATION SPBCIALCTRCIIT/MI9C
Iherebya(RrmtktlamvemptlmmlkComnpofeL4emelawfwtk
' fofawing rtason.(9eetWe 7031$Business and PmRalmisCodw Any cityor
the
77MP.MEILROR
POLE INSf.F con whWrequboa mBWwmtrLp hmrtpdr
fileantmprissbhabmomtheaplkantfoaucdpemdt
statement be Inikwdpersonal:to the p0)d theMWER DEVICES
cant mALkemelaw
(Chapter
9(coWmenMg with Seed.7000)
of Divi. SWN44INCPOW.k]WDUC
El <.7 the
ebasis FoBudnosandPmfvsbn. Any violation of enmpetk1.5 by any VALUATION ,
�' apbasbfes a p alleged exemption. Myttdri of Section notmmany
appllrcollwapemtlt subjeaLtheapplkanttoadvilpnefy d���rcorethan OU'fIk1555VRCHSSFUCTURFS
Bundred ddlan(f500). SQpL SI'OW6 TYIsECONSIRUCTDN
R (_f 4 as owner d tk property,or my employees with wages u theirsole
NEW RESIDENCIALFI.ECTIt
t: aumpensatlon,willdothaww9k adthestrdure bass lnlerded or ofendfor
O .1.(See.7014.Bushwss ad Prdesslosu Cody.Th.ConVadoh lJcorea lAw
s$ dm sen apply ben owner ofpmperywho bull"orbnprwes thenen,and
EEEE wdmnwhwwkhb.fwthmugbhbownemployev,pm klodlktsorh OCC.C�[Ar RES UNR9
k
Improvements rovemes am net Ntendedoroffemdfmsale.ILhoweveylkbulMinger TOTAL:
Impro.MW Wdwithino y rdf a.Tldik thew ,6buWerwiHbane
tlLiturdm of powIngthat he dM nm build or 4nprow fwpurpmeofsolea QTY. PLUMBING PERMIT FEE
U 4 an owner of the property,am euWhvly emtrxYing with Ikamsed IDBY NE ANN
mntrsotorsbmm'n tkPm)ed(Se-70KBW....d ProfsbmCod.. PERMIT ISSUANCE
,S
The Cmnnm o n Charelaw doer sat appy to an owner d property who ALTER-DRAIN 4 VENT-WATER"
buildsbuildsw 1 eherwl,and who mntnda for suM p\o(eab with a
(lamed puonrmttathe Contndoes Lhame Law. BACK PIAW PRDIEC1'.DEVICE FEE SUMMARY
I am exempt under See. B k P C fes this mu m
•
'DRAINSFI.00R ROOF,ARFA,COND. SANITARY Y N_narrmripm—
Ownw_ �s RECEPre
WW KMAN COMPENSATION DECLARATION FO(IMM,PER TRAP SCHOOL TAX Y N_
❑I hereby a/firms that I have•certificate d caress b opRlosore,ora 1 , RBCWT B
38M IAbC4 wksYCmnpemntlonlmursortwaesnfled eopythemf6ee. OAS EA.SYS EM-I INC4OUTLEIS PARKFFP Y_ N_
3olicy0 y
Policy 4 GAS FA.SYS EN1AVER4 CEA) DING DEV
nY BUILDING DIVISION FEES
nmed Dopy le hereby furnished. GREASE/PIIX)SIitL WASTE INTFRCFTrIDR PLANCHECK FEE
rind copy b filed with the city Inepedlun division.
CERTIFlCATE OF EXEMPTION FROM WORKERS' GREAaETRAP PAID
COMPENSATION IN Cfi SEWER•SANTARY-SIORM EA�T Data Recei tf
(ITbssd edn cop ed l(
pe' foranehudrddolbn
OI00)°rl I WATERHEATERW/VENT/ELBCTR ENERCYFEE Y ' N
Ion ytM inlhap nates he for khthbpemdtbblued, —
O W WIsha Comp. W so bkcome sobjed to the WATER SYSTEM/TREATING PAID
In"A
Z 0 NOT( : a th1.Cees b Exemptkuyyon NEWRESIDPNMLPLMR lnlT. Data Rtxel tf
Mould dub the Workn'Can"e impovlsbuoftheLbw TOTAL:
~ N CadC hoompywlthsoM provbbuorlhb pemntshallk
Lu > deemedBUILDING FEE
CLC CONSTRUCTION co LENDING AGENCY SEISMIC FEE
l hanbyso rest tkrtbamminralan kdlogage fwtk podornv TOTAL: ELECTRIC IEE
7 Z anwoesNa rkforwhlehthlspermltblasaxl e.31M,eiv.C� %— PLUMBING FEE() Ladets Name
LLI lande/sAddms QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImtifythAlha"mdthbappllatbnand awthattkabovelnfwmdion
bwrnd.I agrcetoeomplywltha0 dlyand rounyordinanm And slate laws PERMIT ISSUANCE FEES PAID:
>_ N relatingtobulMlog conemrdiorL and he@by authoebe rcpresvnUvesdMb
F U) citybenterupontk abw ationed popedyforlmdlo
pen Purposes. ALTMORADDTOMBCH.
z (We)agree to As Indemaiy an d keep harmless the Chy of Onpertim Date Receipt#
against lbMftim j,' AM cods and expend which my in anyway scene AIR HANDLING UNIT'CIO 10,030 CPho SUBTOTAL:
d ItY loemssque the granting dlNspmnt. NR HANDLING UNIT RIVER IR(DCFM) CONSTRUC'IIONTAX
iii-
Sign turedAppfont/C trades mcHAU9THOOD(w/DUCi7 CONSTRUCRON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumrtbuilding&=pant shrew handle hazardous HEATING UNIT(70 IOUM BTU) Data Reeei tit
material a defined by the CupertlsoMuntdpal Cods,Chapter9.IZ and the
Heahh and SddyCde Sedion 7S533W7 HEATING UNIT(OVER 100,003 BTU) TOTAL:
❑Yo r]No
WBltk ippgmntwfum.bulldb,ga p..tu.eequlpmenlwdvlm VENTILATION FAN(SINCLB REED) ISSUANCE DATE
which emit hazardous air rmntamunts An defired bythe Bay Arca Air
allty Matugement DWrkaT BORMU30MPOIC-OR IOgDO BTU) PAI D
Yat ❑❑No
wread it.beez.materiab mWiremwnbunderChaper 695 of BOB.ER•COMP(OVER 100,000 BTU)
the California Health A Safety Coda,Sedlow 25909,7593 and 25534.1 NOV =8 19
n udnd.nthat Ifth.buOdlonm g doammently have a tenant that it b my NEIN RESIDENTIAL MKHFT
. SQ
mspsnmuyto nilly the occupant ofthe requirement,which count be met
prior to issuance of a Carlillesb of Ocdnpa ny.
CfIY Ur Uurcnut Q
OwnerormthoLze agent Dab
TOTAL: 19511L•D BT*�� I
OFFICE COPY