22955 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALLPOINT PEN ONLY
Building Prom ldentifk lon 7 PERMIT NO.
Betiding Addrena:
a22955
o�s v
2:=c-10
one:
am CITY OF CUPERTINO-BUILDING DIVISION 11��]
trancYs Name: l,k.No: APPLICATION / PERMIT a
ab¢� �•-� b s 3$QS\ BUIL.DINGELBCTRICAI�PLUMBINGMFGHAMCAL CATEGORY CONTROL
Arci,kect/Fsglreer. 13e.No:
C-S3 InQ ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby am7(X0utlam Beenassi erpmvlabnaof Cssion. ode,ar�en< APPLIANCES JOB DF3rR�CfON
Ingwit 1,1.full form of Divldm3 ofthe Budveeeendliv(estlon.Cade,end my
Tiaras la In full fora and dfec PANELS -
LteeroeCla s Licit A-O
Date Contractor UP TO 200
ARCHITECTS DECLARATION 201-1 AM
WZ IuMeretand my plavahill be u:d as public remrd> EROAREA OVIODOAMPS SQ.FT.FT. OR ARf/SQ.FT.
O
u�z� Llansed Prolerobrol SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIALCIRCUE/ML9C
i.., Thereby affirm? tlameaemptfromthe Contm=esLlcerselAwforthe
Z 9_ (ollawing reason.(Section 7m15,Bwlnes and Ihofeabrs Cads.Any tlty or
�L muntywhk requl ape torovtruMOter,lmpmve,demolbh,orrepalr TF].'�'MEFFR ORPOLE INS[.
'y
aleprlor to lb ksuaroe,aLso requbeatbe oppllantfor such permit to POWER DEVICES
illi a signed statement that he to llmond pursuant to the provbloru of the
O w Comsat.".Uceroe Law(C,,Td'9(mmuneneog with Sedl.n 7,001 of avl- SWIMMING POOL ELECTRIC
t.30r^ don3ofthe B�at me dPrde re Code)orthathelaesemptthemfmmand VALUATION
y.' the basis for the alleged e.emption. Any violation of Section 7M15 by any OUILETSSWITCHESF1%T11RFS
<.e aPpb.t fora permit subjects the applicant to a dvd penalty of not morethan
a flv undred dellara($ruin. NEW RESIDFNTW.E.FLTR .FI.
p^, 1,a,owner of tAc property,or my employees with wages u their nolo STORIES TYPE CONSTRUCTION
mmpematlon,will dothe work,and theatructure is not Intended or offered for
Osale(Sec 7814,Be Wes.and Pmfadbro Code:The Cordran.?.Uame Taw
$g does out apply to an owner of property who Wildsor impr°"e'there.,and
EEE whodoessuchwork himselfmthrough hlsownemployene,provided that such OCC GROUP RFS.UNITS
ImpravemeMn are ret Intended proffered far uk.H,however,the W Tiding a TOTAL
Improvementiseddwithinomyurofmmpledogtheownerbudderw have ;
t rden of proving that he did not bund or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am o=hadvely contracting with Bomsed
mPERMIT ISSUANCE
The
-
ntam
ders to mmert Be pooled(Sec.7044,Bualnm and Profembns Code: ��—
The Coetraetm'e Liame Law does not apply to en owner of property who ALTER-DRAIN k VENT-WATER(EA)
bu0wa
d. or lmprthereon, and who contracts for rn ouch piojewith a
.)hoerw.d pumraet to the Contractor'.License Law. FEE SUMMARY
I am aempt under Sec. B k P C for Nis reran BAIX FLOW i'RO'CFST.DEVICEOUTSIDEFEES
Pvrer -
Data DRAINS FLOOR ROOF,AREA,COND. SA ARY RBCFII'CY
WORIQIAN COMPENSATION DECIARATION l pp�BES PER.]RAI'
❑I hereby affirm that 1 have a aMflore of current to if-imune,or -..� Sa{OOL TAX RECF71T Y
artEateofWorkeno'Compemadon Insurance or a artlfted copy thereof(Sec. GAS FA.SYSCFM-1 INCA OU'TUFM PALKFFE Y N
39 W,Lab C.) REO
CPI'
'cY�dhryo�Y GAFA.SYSFFM-0 "..
VER 4(EA) BUILDING DIVISION "
TiaeIt
enS lned copy is hereby furnished. GREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECK FEE
Ned copy is filed with the tlty W pedion diVWm
CERTIFICATE OF IXD.IPEION FROM WORKERS' GREA.SETRAP PAID
PEN ATIONI ' CE SEINER-SANITARY-STORM EA-20VT Date Repel t#
CIMn need out M rook forom hundred dollen
(6lao)er n.) ENERGY FEE Y N '
I fy that tathep o u f[h :forty ch RNs pemdttahsued, WATER IIEAIFR W/VENC/E.FL]R —
I s not employ Ii no to become subjed to the WATER SYS EM/TRP.ATING
W. in C.Pe v of PAID '
O Z APP 4 NrEWRESIDpAr(1,.EP),MB. SQ.FC. Date Recei t#
Z O NOIICETOA L he akar t ks oub sof the,abo
should loam Rothe Workers'Comperoatbnp bro of the tabor TO-FAL:
CCN Code.you ort hwith comply with each providoro or this permit shall be •E
deemed revoked.W mCONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby aflmnthet there h a construction lending agency for the perfomv : ELECTRIC FEE
aWTOTAL
= Z ance of the work for wMeh thin permit et bed(Sec.3D97,C
.C.) \ —
U O I nde?e Name PLUMBING FEE
IL F lender.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO Iartlfy Nntl have need this appIatbn and satethattheabove Wommlan
Sboors Y.lagreeto camplywlthalldtyard muntyordWnmandtlate law. PERMIT ISSUANCE FEES PAID:
>. Mating to Wilding matrudion,and hereby authorbe representative of this
F Z city to enter upon the above-mentioned Property fa inspection pa rprnu. ALTERORADDTDMISH Date Remi t#
(We)agree to mve,Ween fy an d keep her the Cityof Cupedlro P
V agabut habWtks,Prigments,mete and eaperses whkh may In any way amus AIR IiANDUNG UNCI(TO tO,WO CPhD SUBTOTAL:
Id 1[y In of the granting of W.pemdt
CIL I" $ AIR I-IANDUNG UNCI(OVER 10,000 CM CONSTRUC ON TAX
Signature of Appllant/C%rme,tor I Elm EXHAUST HOOD(W/Dun CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appi"ot or future buildirgamupart store or handle harardou. HEATING UNIT(TO 100,(100 BTU) Date Recci t#
material as dehre i by the Cupertino Municipal Cade,Chapter 9.12,and the
health and Safety Cade Scct10%25532(a)7, I-QATING UNIT(OVER 100,0D)BTU) TOTAL: oZ1—
❑ Yen f]NO
Will theapplantorfuture Wilding ottvpard uae equipment or device VENTTLATIONFAN(SINGI.ERFSID) ISSUANCE DATE
whkhemithaeenerd aircontamWitsan defirad bytet Bay Anea Ain p
•
Quality MnvgementDlatW i BOnFR-CAMPO}iPDRlOD,ONBTU) P A I D
Y n ❑No
have read the haunt rnuterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) -NOVhe Calhomb Health k Safety Code,Sneilom 25505,25533 and 25531.1 IY8 1991
understand that lfthebuilding does eol carreNly have a tenant,that It is my NEW RESIDENTIAL MECH. 5QpT
reaporubilhy,to notify the onvpart of the requirements whkh moat be met
prior to L»uancc of a Cenifiato of Omapancy. - -
CITYIF ly^iU GHAfIIiw
C.vncrorauthoriud.gcnt Date ISSUED BY:�V F \
TOTAL
OFFICE COPY