22499 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Projed Ide.11i"tloe 7 PIRMIT NO.
Building
a od,Y,3v 22499
rens Name: CITY OF CUPERTINO-BUILDING DIVISION �y 1
•N•nelS N �7 j I�IIys�f�P�y APPLICATION /PERMIT
`j F�ry'C) / J YJ �D a BufLDiNaE1.L�rwcAl.pLUMBINGMFrr1,.rncA7; CATEGORY CONTROL.
T•' Arrhned/En Lk.No:
Qry ELECTRIC PERMIT FEE, BUILDING PERMIT INFO
Add.
❑ ❑
LIC BNS ED CONTRACTORS DECLARATION I'FRMITISSUANCE ❑ 1
lharel,yWim,that amlkeNunder provWlr9 m MPWANC6REIDEMTAL )Ob D N
Ingwlthaiun7000)ofDdm3otheBurcandPmfsswsbeand
JIM I. full f d offetf. q PANELS ' 1
LbeveC o LIC( S 1. 31s 3
Date Corttrador LLL III
ARCHITECTSDECLARA N -1 M
OceQ I understand my phm shall be used a a public read& OVMIf AMPS - .FL /D I 5/SQ.Fr.
U e L alts d Prosbvl S GNS ELBCTR GLM E T E
61 OWNER-BUILDER DECLARATION SpECIALCIRCUIT./MESO
ZF, a I hereby aH
bm that l am exempt from the Contractors License Law fee the
p following rtasm.(Sectlm 7Qf15,Bvints and l'rofmbv Code:Mydty or �/� /��
OZ pq�y TISIP.METER ORIOLE WSI. /
F� 3 mrntywhkh requnvapemdt tomrvtruh alter,bnpmvs,demoWh,orrtpalr
7 anya alpe a tateme U hart he Is sed pu sumt t the f«ouch pert t to p�pR D�� !
g�d � file a Ygned ratemmt tM1rt k L Banned pursuant to the provbbv o/ Ne
Q3 t; Contractors Llceve Law(Chipter9(ammmdng with Section 700D)of DIVi- SWI�U9NG POOL ELECTRIC
N sion3ofth.Business and PmferyonsCode)orthrt hale exempt therefvmand
VALUATION
�"_ the barb for the alleged exemptloo. Any Violation of Section 7mI5 b/any
<a
applicant for a permit subjects the applicant to a d"I penalty dna more than OlIILEISSWITCHES-HXT1JRES
fiN,,ndred dollus WEIE)j.
Lf I,s•owner of the property,or rtry employees with wages as their sole I`�Eti'RE9DFN7T'11'E['ECIR SQFT. STORIES TIDE CONSTRUCTION
compresmon,wllldo the work,andthe structure b sot Intended or Offered for
Osale 6ec 70K llu• ae a and lirerfeselov Code The Contractor•Wave law
pydon not apply to so owner of property who builds or Improves the.,and OCC GROUP RFS AMTS
0.0. who doer truth work himseU«thrwgh his own employees,proelded that such
bnprovements art not Intended orotferM fa ssk.It,huwever,thebullding or TOTAL
Improvement bsoM wtlhlnorcyearafcanpletlon,tFe owmerbullderwW have
t rden of proving that he did not wild or lmpruve for purpose of sale.). QTY. PLUMBING PERMIT FEE
Li L u owner of the property,am esshratvely contracting with licensedFLOOD ZDNE APN
eentradora to mM1mct the projed(Sm 7094 Bushes and Pmfeebns Codc PFRMITISSUANCE
The Contractor's Lure Law dm ea apply to an owner d property who 4C.(/
Wilds or Improve thereon,and ww mmmam for such pPJeN with It ALTER-DRAW 4 VENT-WATER IFA)
�ntrac�m(s)Bared pursuant W the Cmmdor.Liao.Law. BA!](PIDWPROTEGT.DEVICE FEE SUMMARY
LJ I im eumpt under Sec B k P C for this reason
OUTSIDE FErS
DRAINS FT.00R,ROOF,AREA,GOND. SANITARY Y_ N
Owner Date RECEIPT y
WORKMANIhaO a LNSATION DECLARATION FIXTVRFS PER TRAP SpippL TAX Y_ N—
I hereby•rke that I have a Isms of eoruent to op theme,«a RFLErrt
3900,ab of worker'Compewlim Ivurance m•artlfkd ropy thertrof 6a.
3800,Lb C) GAS IA.SYSTk].1.11NC.OUI7.EC5 PARK FTE Y— N_
Polity. a"M217S-01 RFJ=0
COnY LI` CAS EA.SYSIQd-0VER4(EA) BUILDING DIVISION FP.ES
ECertifledcopyb hereby tuMahed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�certlned ropy b rues Ydm the dty wpectbn&Islam.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONANCE SEWERSAuETARYSIURM FA.&'LIFT Date Recti tic
ONs lection need not be cornpkicd tithe perer mn b/m orae hundrad dollue �`
(SI00)afyth WATERT ATTR W/VENT/ELECTR .W ENERGY FEE Y N
]artut auto the pe e.iaorthew e,for which oomemdtb bailed, —
I shag nal employ any peraan f any miner at as to become erbject to the WATER SYS TEM/TREATING
w«kern enmpenaatlonlawsorcaur«nb.Dae PAID
Z NOTApplICE NEW RESLDENIIAL PLMB. SQ.FT. Date Recef tM
Z O NOTICE TO MI'LK:AM:R,after making tM1b Cerdfkate of Exemption,you
F N should become subject to the worker:Compeu.atwn provisions or the Labor TOTAL:
Code,you mrA forthwith comply with such provbbv or this permit shall be
W > deemed revoked. 13UILDING FEE
CL cCONSTRUCTION LIENDLNG AGENCY ISMIC FEE
(hereby afflrmtluttkrabamvtrocUm lending egerwy(or the perforrry ELECTRIC FEE
= anceof the workfor which this permit Is ed G 097,Issuer.3CW.CJ TOTALO O I<rder.N.me PLUMBING FEE
LL Lender,Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LU Is
l ad uy that l have read t his appllatbnaM state that theabove Informal.
a Ismmot.l agree to comply with all elty,and county ordlaanta and slate laws PERMIT ISSUANCE FEES PAID
>. N relating to wilding mvtrudlm,and hereby authmi retivn
repentaof this
H U) city to enter upon theabove-mentioned property fee inspection purposes. ALIERORADDTOMECH. Date Recef I
(We)agree to nave,Indemnify an d keep harmless the City of Cu rtbin
V ,gat WtllabiBtles, d rrcnb,asrtn s ltd nx ern whleh may In any way...O AIA]iANDLING UNIT(TO CFM) SUBTOTAL:
agalnat ssl co=seme of th iuln this permit.
7 //'
JA/ NR 10,"ADLING UNIT 10, CFM) CONSTRUCTION TAX
Signature of Ap ntradorDate EL1AIJSIHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOBU E
WEI the appliemt orfuture building oaupant store or hardk havrdous HEATING UNTT CM 100,000 FEU) Date Revel tp
material as defined by the Cupertino,Municipal Code,Chapter 9.1 7,and the
FLeann.od Safety Code S .75532!,)7 HEATING UNIT(OVER 100AM BTU) TOTAL: Lk, CZ
E yesI`I No
01theappiiont«`�turewOdingoccupantuseNulpmentordevkxs VENTILATION FAN RINGLE RESID) ,ISSUANCE DATE
which emit hmardoue ab contemdnant.as deflrud by the Bay Are.Air PAIL
Quality Management Detr 7 BOELFFEC.OMP OHP OR I0QDa)EEM
Yes n No
Ihavereadthehanrdwsmaterials,rNuWmenbunderChapter6.95of BOILER-ODMP(OVER TOO,000 BM
+ the CalBomla Health h Safety Code,Scribe 25505.255n and 75534. I JUL� �
urdena nd Uutifthewlldingdonmtmmntlyhaveatenant,thatlthmy NEWRESIDFNTIALMEQ-L SOFT ,V
responaWBny to notify the orcvpant of the requirements wthkh mut be met
priorto Lvumte,of a Certifiato&t P ney. VVTy�, VV YY
City
of/a„pefto
Owner Or authmired agent Date ISSUED BY:
TOTAL
OFFICE COPY