21498 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Prred Identif"tion PERMITNO.
Building Addreut: b3 �. �.� - 21498
fief. ons:
1;9/4C&/-7/ CITY OF CUPERTINO-BUILDING DIVISION30
0-6-Ai-_M �u 'Na APPLICATION /PERMIT
/L LDING-EL RICALPLUMBFING- HAMCAL CATFLOAY COMROL,1
BUIC
ArehBed/Pngloeer. H Lk.Nee
/4v//5z QTY ELECTRIC PERMIT r'�FEE BUILDING PERMIT INFO
Address PFRNITISSUANCE1:1 1:1LICENSED CONTRACTOR'S DECLARATION
(hereby affirm that l am lkenaed under provblmn of Claplerli(eomnsm APPLIANCES-RFS11)ENTIAL JOBD N
In ose,I 1.hallf.m,e anDIvfeet. the BuJreuand lhafeeJavCade,and ��
11¢tae b In fait forte and dfere. PANELS
Date Clams cuu _
Date Comramr UP TO 2DO ANTS
ARCIIMCPS DECLARATION1201-10DO AMPS
Q CZO
NI utd,,Mard mv
y ph .hall be used as public remdi OVER IOW AMF7
PS SQ.Ff.HADR AREA 5/SQ. .
(0 LImvM Prdsbnal SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION
t.., Iherebyaffimnthatiamexemptrr¢nthe COMr .e.Lke.Ui fmthe SIAL CIRCUIT/1`16C
K2$$� ggoSfollmving mene.(Sedbn 7(015,Businm and Profmbv Code:My efty or
�4�t 9 muntywhlch nqulrnapemdt to mvtrud,alter,Imprwe,demoWh,orrcpalr TMP'AfEI'F7t OR POLE INST.
anye mmprkrtoila low e,abomqulreatheappUl tforauchpe to
file a signed statement that he b B¢rued POWER DEVICES
pvmunt to the provisions of the
cxI�,,Ou CentrodoreBuk el�w(Clfpem mm)orthgwM Sedbn7W.f f..vl-
��Og ebn3ollhe Buslnm and ProfmbvCade)orthrt hebeamptthercfrom.nd SWR.1h9NG1'OOL ELECTRIC VALUATION
thebasisfor the alleged exemption. Any violation of Sedbn 70315 by any
65. a ppU�.ntf.r.pemdl.bia the•pplkantt..d 1pe.Ity4nd.o than OUTLET-SWITCHES
r. O five hundred dollars(SSDQ.
❑ an oee.
I, owner of the property,or my employwYh wafi
ges..their b NEWR®FMIAI' SQ'FT' STORIES TYPECONSIRUCTON
C ¢ a«npeveat M.Hld.thew«i a.dthemu core otlntendndoroffemd for -
� ❑ vie
GS^ dnm 7 pyywu n ow nerofp rompaluv Co buLd.orimpers them Rlaanwd
whodoouuzhwork hlmaBathnvghhisonnemplyeex,provided thatauh
OCC.GROUP AES UNITS
Improvements art net Intended oroffeni f«.Wc.If,hmvever,thebulWing orr TOTAL:
improver baoldwhhlnoneyesrofcmnpldbn,theowner4maderwWhave
t" enofprovingthathedWnm WBdorlmprovef«purptucofuy:t, QTY. B P RMIT FEE pLDD ,NNE APN
u L.•owner or the property,•m exehoew y mntrading wfth 11¢noltde% P
mntnd«n to mvtrud the pmjed(Sec.70K Bunlnem and Pmfesslo
The Comndor's License Law does fid apply to an owner d pmapedy wh RAN W
Wildn or Impro.e thenen, and who mmnds for such pPjede whh a,
cga¢act.,W lkenmd pursuant to the Contrador'.Lloa eLaw. FEE SUMMARY
LJ I am exempt under Sec B k P C for this recon
NS FLOOR ND. SANITARY Y N—
Owner RECEIPT
WORKMAN COMP D95ATLON DECLECL ARATION PER SCIILXI TAX Y— N_
❑1 hereby afflrtn that 1 have•¢ditkate of cmamt<o selGiwn,«a
¢nifleate of Workeri Competent.Imuran¢or.¢rifled copy themof RECEIPT 3K0,I.b C.) GAS FA. til PARK FEE Y N_
PdkyY RECE9'f
CgCenanWed copy b hereby y GA -04(EA) BUI LDING DI VI S ION FE ES
e
❑CedBied mpybfiled with d,the
city S -0 e mYinspection dMJmr. G / WASTE lNrpxcEProA PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS PAID
COMPENSATION INSURANCE -SA ARY STORM FA Z(%BrI' DdIC RCCCI IM
Ghi..ectlan need not he eompided lithe permit b f«ore hundred doBan
��Of1yth WA HEATER W/VENT/M VrTR ENERGYFEE Y N
1nnor employ
pxrot,performance the for tohthe.pemb)oloved, —
I shell nm employ.n person N any me r ro u to bemrr�arb)at to the
Worken'C lnw.o
WATER SYSTEM/TRFATING PAID
n — �r Date_
O Z NOTICEt �C NEW RESIDENTIAL PIMB. SQ,FI'. Date RCeei tq
Z O NOTICETmnesubC totheafter ng thisCttoopr vbdonsmption,yw
ahwld become subjttt to the Worker'Compansatbn proWslev of Rha Labor TOTAL
.-
ccN Code,you must f«thwhh comply with such provisions or this permit shJlhe BUILDING FEE
LU 7 deemed revedud.
LU
O CONSTRUCTION LENDING AGENCY SEI IC FEE
= eofthe eoIherebyafrmttutuch bamruwdland(Sec. ,Civ.Cj pedono- -TpTAL ELECTRIC FEE
� an¢o/the work forwhkh Nis pemNe bLwed(Sec.309],CW.C.)
(� O Lender'.N.mae PLUMBING FEE
Iyl— leedee,Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W !¢nify Nrtlhevemndthb.ppBa narddatethetheab einformrtion
b mrmi.l agree to comply whh.11 dty.rd onomyordlnanm and"m law• PERMIT L95UANCE FEES PAID:
} IL
rd.ting to bulWWg mrutrudlon,and hereby aulhorlu reprenentaJves o(thb
F W dty to enter upon the.bo.cmenllovd prepertyror Wpedbnpurpoen. ALTERORADDTOM Date RCCCI IN
— (We)agree to save,hdem dfy an d Peep harmlm the City of Cepntlno
agaWtlhbNJes,'rdgrtrnte,mnand expenses whkh my Nany wayamuc AIR HANDING UNIT(1010,000ffhf) SUBTOTAL•
.galnstnald Cityln ease( tingdthhpermh.
AIR HANDLING UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
Sigvvn of AppBo Date EXHAUSTHOOD(W/DLCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllom¢future building oavpant store or heMk hazardous HFATINGUMT(TO IW,00011TI)) Date RttCI IN
maorud an defined by the Cupertino Murddpal Code, pt
Chaer 9.1 Z and the
He❑.nh.M Safety Cade Secthm 2SS32h)t HEATING UNIT(OVER 10),000 BTU) TOTAL:
W Yes fn toNn
Bl the applicant w re building aapant use equipment or dev4m VENTILATION FAN(SINGLE RESID) ISSUpTxA ATE
whkh colt hazardous air cmmrtdrunb.s de0md by the Bay Area Air �J-�T-a
Quality management Dbtrid7 BOILER-COMP OFIP OR 100,000 BTU)
4Yes �We Nov 3u1
hevenadthehv matedeb requlrcrrcnb under Chapter of BOILER-CO.MP(OVERIW,OW BLV)
the C.IBomh Health 4 Safety Code,SMiov ZS5W,7SD3•fid 7SSU. I
underxtaM that lithe building does fid cornntly have a tenant,that it b my NEW RESIDENTIAL h¢CH. SQTT
ropavlbilRy to nduy the aaxvpard atlas requlramenb whkh must berM �.
prlmtolawae rally
the era of OccuW nNu W
Owner or auth«lad agent Date
TOTAL: ISSUEDB
OFFICE COPY