24353 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Project Identlfkatlon PERMIT nNO, 4353
Building Addre : 2
TAI/ o�SZ- // 33 CITY OF CUPERTINO-BUILDING DIVISIONonr 1
Cm sN°^= 5 APPLICATION / PERMIT `V�
BIIILDINGQ.BCTRICALI'LUM9INGMF�HAtSICAL CATEGORY CONTROL I
Archkect/F grener. Lin Na,
'
QTY ELECTRICPERMFP FEE BUILDING PERMIT INFO
Addreu d _S7 7/ PERMITISSUANCE ❑ ❑ 1:1LKENSED CONTRACTORS DECLARATION
Ikrebyefirm thattam llcmrd und<r provWonedCkper9(commm APPLIANCESRESIDEMIAL JOB DESCRIPTION
Ingwlth Section 7000)d Div on3ofthe Butlrasand Profeval.Code,and my
Iimnsc b ie(un for¢ d effecL .3 0359 PANELS
Lbense�Lle
Dale Contractor t
ARCHITECTS CLARATION �
0 O I understand cry plans.han be u u public re u de. OVER IODD AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
E LlceruN I'mfesbnal SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCIJIT/MIPs
Zt. � Iherebyefirm ¢
that am exempt frnthe Contractor'.Llcee Lk
rawfort
following mason.6ection 70315rofmbro M
,Boerne am PCode: y city or
TEMP.METER OR POLE INST.�� oaynmmCipq toiap amd coorequ altrr,bnprov4demnWM1,or repair
any a<actedsteeentthe be
aboregdruthe.t to
the
rewcumof to POWER DEVICES
a tlgned tlatement that ha b II¢nsed puramt to tk proN.lons d the
kk..GContractor's License Law(Ckpier9(commencing with Section 7DW)of DM- SWIAhING POOL ELECTRIC
5 tlon3aftheButlnmandP mbmCode)orthnhebexempttherefmm" VALUATION
y.' thebee for the alleged exemption. Any vlolatlen of Sactbn 70315 by any OUTLE7SSWITCIffSFLYCURFS
7g� 06��j applicant fora perndt hnt
aubjectstheapplto°civil penaky elect moretkn
E ..t Byjhundred dollar(M. C/V
u NEW RESIDENTIAL ELEC7R
I,sa owner of the property,or my empbyen with wages as tkU Bale SQFr. STORIES TYPE CONSTRL'CIION
C mrperoaHon,wllldothe workandtheuwGurebnat lydercedor offered for
'S O °ale(Sec 70K Bee Tess and Pra(esbro Code The Cmuractoe.License Lw
3� don cot apply to an owner of pmpertywho bulldsor lmprwn tkreon,and OCC.GROUP RES.UNITS
whodoeswchworkhim.elf onthrough hisoweemplgeee,provided thatweb
Improvemcna am not Intended or offered for sale.If,hcwev the building or TOTAL:
improvement lis sold within one yearofcompletbR the owner-bunderwill have
t rden of proving that k did raw bond or improve fee purpose of sale.). QTY. PLUMBING PERMIT FEE
Lj 1,as owner of the property,am excheewly contracting with li erased FLOOD TONE APN
contractor to mnrtrvct the project(Sec 7DK Busrm and Profembn.Code: PERMIT ISSUANCE
The Contractor'.License Lw don rad apply to an owner a(property who ALTER-DRAIN&VFNf-WATER(EN
hulld°or Improveso mm
thereon, and who fee such p�ojeaa with a
IT'dar(s)n¢nsed pursuant to the Contradoes Lionee Lw. BACK FLOW PIm7'ECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B& P C for this renin
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N
Owner Dee RECEIPT I
WORKMAN COMP ENSATION DECLARATION I hose•¢ FI.CN PER TRAP S(T-IOOL TAA Y_ N_
❑l here
affirm that rtlRnte d tarot to self-insure, • RFLFBf
¢rtIR01<olWorken'Comperwtbnlwnn as¢railed copytherco(($ec.
3R0,Lb G) — ./ RKFFE Y_ N_
laity l 7" RECEQPr;I
fir^ y GAS 'CI BUILDING DIVISION FEES
I
Ce copy `rc lo `d' GREASE P NCHECK I n
rtNed copy I°flied with the city Inspection c[Nislon.
CERTIFICATE OF EXEMPTION FROM WORKERS' G ATE ID
COMPENSATION INSURANCE SEWER SANITARY-STORMF 2I(IFT. Date Rcc i t#
(This.e need eat kc¢npleted if the permit bf¢one hundred down
(In 00)¢Im.)J WATER DATER W/VENT/ELECTR ENERGY FEE Y N
Imrtnythrtrthe per(oman¢o(the week for wMch tM.pemdc ie burred, WATER
I-hall cot employ any.persan In any runner ro as to become abject to the WATER SYSTEM/TRFATING
Worker;compenatlon Lwsd U`Iifomla.Date - PAID
O Z NOTICE NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
ZO NOTICEToesubpct tote,armor.klompenentionkaraf Exemption,you
should become wbFct to the Worker'Comperoatbn provWoro o(the Labor � TOTAL:
~ N_ Code,you meet forthwith comply with such provlobns orthb pemdt.hallk U
dormed rewked. BILDING FEE
O CONSTRUCTION LENDING AGENCY SEI MIC FEE I_
I herebyaffirmkfothattkrc 6amnsNrctlon leMrgagerKy(ortk r(ortry
Z .ncodthewarrwhkhthbpermdtbbmaed(ser_3on,Cw.C.) TOTAL_ ELECTRIC FEE
(,) O IerWer'.Name PLUMBING FEE
LL F Lendee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE W IcrAfy that l have read thleappliotbn.nd ate,that threxove indica abm
bcorrcct.l agree to comply with an Myand munty,edman¢s.ea.ale l.w° PERMITLSSUANCE FEES PAID:
r N mating to building comiruction,and hereby eathab mprc,crte,cs ofthis
= city to enter upon the above mentbrad property for impectbn purposes. ALTERORADDTOMECH. Dale Recel t#
V — (We)agree to ave,Wiemnlfy an d keep ham,•_the city of Cupertino
against llablEttes,judgmens,coa.ard expenses which may In any.ya.. ATR HANDLING UNIT CIO Ill,"CFM) SUBTOTAL•
apirmt said yin eequeroe of greurg oft permit.
AIR IiANDLING UNIT(OVER 10,000CF:M) CONSTRUCTION TAX
SlgnatunofApl¢nt/Curt rate EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PA ID:
HAZARDOUS TERIALg ISCIOSURE
WBltheapplla morfuwre ding ocovpant tlort or,kndk hvardow HEATING UNIT(TO IL0,00)BM Date RLYeI 1#
material as defined by the Cupertico Municipal Code,Chapter 9.17,and the
I Irahh and Se&y Cede SNion 25531pWG)t FIFATUNIT(OVER IOg000 BM
RYes MN. IOTA
d[the°ppliant¢lowne bunding occupant uea cquipoent or devkxs VENTILATION FAN CSINGLE RESID) ISSUANCE DATE
which emit hannicos er mntandnants as deRoad by the Bay Arta Air
Quality Maragcnx:nt Dbtnlni BOILER-COMPOHPORloo'"BM
4 Yns No If' W 6J
have recta the havr our creariels requiremenb under Chapter" of BOILERCOMP(OVIR t00,QU RIIJ)
tk Gbfomh Heahh&Safety Code,Senbro 7S5C5,25533 and 255M.7 NOV
urdmtand that if the building dons out correctly have a tenant.that It b my NEW RESIDENTIAL MECL SQFT 12 W2
rnsponsibndy to notify the occupant of the requirement,which rex be met is7'31C
prior to tauarur d a Certificate of Omrpanry. ^{�J
CI I Y(A' I:UfC I I I1'
Owners¢auth¢Ieed°gent Dat. ISSUED BY:
TOTAL
OFFICE COPY