23719 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPro Identlfweon FR
Ph9TNO.
Building Address: � •. 23719
Typ;Zer. � m .
r� c?(6—tal CITY OF CUPERTINO-BUILDING DIVISION
'® Con Name: Lk,No: APPLICATION / PERMIT
ArNeM/Engineer. BUp,D[NGELECTRICALPLUMBINGMECRAMCAL CATEGORY CONTROL#
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrv> 11
PFRM1RTISSUANCE ❑ ❑
LICF.NB ED CONTRACTOR'S DECLARATION
I km teal.rn that 7")cd ivtiot,3aue er Buusi tel d Pm ChapterC(mmmm APP[lANCESREStDENTUL JOB DESC
Ingwlth SLdlon tome ofd effem 3ofthe#uses##�pdPrelntlauCode,ua
license tela luB{ora and u"' PANES /
Sc� G
Llanr Llc I r,
nae_ cmtmdor
ARCHREuA sed DECLARATION A.1-1
p�+ ffS
��Ondmm
• Iutand y phroshall k unpubllc rtmAda OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
Fi o� Lkened Prd®bnal SIGNS FI eCTyrrar
<L
� � OWNER-BUILDER DECLARATIONthat I SPEMLCIRCUIT/MLSC D I N
Ihl,,grr Br (Seeti.m31,5,Bfmmthe Co ofeaiu Lhere law lurthe
folbwingrtumuires amrod,to oabmaa tmetand Pmferbr Code: dryer TEMP.MEIEiORPOLErNrST.
county which rcqukesapemdtromvtmd,aller,Impmve,demoWh,or r
�� 6 any AtrudurtprbrmitabAuance,.Immtprirvtheappllont(orwch permftto IOIVER DEVICESVA I
D a U fik A AI&rM statement that he b licensed punu.nt b the pmvlatev of the
Corn aelorb License Taw(Chapter 9(mmmendng with Section Tom)of Dvl- "rAV
Ater,3 of the Buslneuand Pmfeabro Code)orthat k is exempt therefvmand SWU(k9EL
NG POOL ECTRIC E VALUATION
tk bub(or the alkged ezemptbn. Any vidatbn of Section]0315 by any I
�pr5j appU.tf.rapvM bjllh,.ppB .tt..dvllperultydnM.o thin «m'ErSSV4TCBES-FIX ES JI
five hundred dollars NEW RESIDENTIAL ELFLTR
Fj I,AA owner of theProperty, SQFC. SIOMIS TYPE CONSTRLCTfON
rani willdothwalen the employ en with w.geutkbwk
t 'wnPe oM1 kandthe structure tercet intended or offered for �
6R
J O ilk(Se,t apply
to an owner
(pmpor ro Code T"Contmnves IJmw Lw
donnotapplytork ownerd Lh=gh who WIllsorImprovedh tm t and OCC.GROUP RFS UMTS
as whodmwdiare ontirn.Mothrwghedow ),,If, owevr,11mbthatwdr
Improvementsamnot Intended earofcodforilk.IChowever, Elder l lingvE TOTAL:
Improvement I.edd wtlhln oneyearofcanpldbn,lkownerbuiderw111 have
t retenofprovingthat k dm neat builder Improve for purpa,.ofaak.>. TY. PLUMBING PERMIT FEE Ir D NR
Lj C u uvner of thepeopclty,An,exchnlvely oor r rg with BaredAPN
root ea to meoteud the pm(ect(Sm 70K Busteeu and Pecfertero Coda, PFRMITIS5UANCE �•
The CoMnctore Lkerue Law doe not apply to an owner d property who �,�DRAIN(r VENT WATER&JO
bu Bda r Imprwn themon,and who mMrada fm wch p(ojeas with a
rynlTa�tar(A)llama purwut to the Cmtradea.Llnnae law. BAOCFIDWPROTFiT.OEVICE FEE SUMMARY
L.J'lice exempt under Sec B k P C for this maven
Owner DDRAINS FlDD{ROOF,AREA, ND. RFd EM#SANITARY Y N_
WORKMAN COMPENSATION DECLARATION FTXTIIRFS PER TRAP SCHOOL TAX Y_ N_
❑I hereby ornrm that I have a IruurA to d mnrnt i aelf-Inaure,of(S• RECEIPT 9
certificate of Worken'Compenutlmlrwrana wacenlfled mpythemrr(Sec. GAS EA.SYSTEM-1
IWL,Tab CJ - PARKFEE Y - N_
Com ny GAS F.A.SYS7FT/-0VER4(EA) BUILDINGDDIVISION FT.ES
Cen10ndmpy"Z1wfu=LW GREASE/INDUSIRL WASTE INiF7iCE'lOR PLANCHECK FEE
Cenlfind mpy b filed with tk dty IvpMbn dW Wm.
CERTIFICATE OF C(EMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWF.ILSANITARYSTORM EA.2TOFT Date Recd t#
(ThbeMbn need net k complded R tk pemdt b(orerc hundred dollen
t51m)mfethatr.) WATER HEATER w/VENT/EDCTR ENERGY FEE Y N
I snot employ
In Any prhe omuna of the waksfor
As to be or PLrmit b Mond, —
1 nrll net ur pby my-Lawn b my manner w u to benne wbjed to tk WATER SYSTEM/TREATING
wwrker:eompLwtmn lawnd(sluomb,one PAID
O = NOTICEAppU.TO
you NEW RFSIDEJTTAL PIM#. SQ.FT. Date Reeei to
_Z Q NOTICETO A,PLICANT:eW0,16makingpe CenBlceleof Fsemptbn,abo
Ahmldbenne wrth to the Worker,'.o pwtbnpvvbloroorthe Labor TOTAL:
�F N Code,youu oleed.forthwith comply with each pmvbbro or this penNt"I be
] deemed revoked. 1311ILDING FEE '
CL G CONSTRUCTION LENDING AGENCY SEI MIC E
_ = eofter work for tthertbamreatrudlmleMNga97,cw.rtk pedorm T ELEC'I•RIC FEE
Ana of the work for which tMs permle b bKmd(Sec 3097,CW.Cd I
u2 I<ndee.N.rre PLUMBING FEE, rL
LL F I. Mer'.Addree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U IcenRythatl have and thio appliratbn.nd nah thrtthe abovL inlormatlm !•
O a bmrna.Iagrcetocomplywlth all eftyard muntyorawnmsandNate awA PERMIT ISSUANCE FEES PAID
>_ N misting to bulHing mrutvdim,and krtby authadr rtprtcntativn olthle
F U) dty to enter upon the obese-mentioned property for lropedbn purpoen. ALTERORADDTOMECEL
— twee.gne ro ave,IndemNty.n d keep hrMer the City o/Cupertkm Date Reeei tN
.gahmF+la LLlI dgmenn,tneeK-�+udeP�xP,,q,gAewhkh n�ybany wayamve AIR HANDLING UNIT fro 10,000 CFM) SUBTOTAL:
agap _rmb
J AIR HANDUNc uNrr rovFR lo,000cFan CONSTRUCTION TAX
de� pPBont/Cmtr ner—r- Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR USMATERIALSDISCLOSURE
/W the applicant mfuture building emupant nom or handle haardous HEATTNGUMT(TO1m,000fflUl Date RCeei tM
euterbl u deflnM by the Cupertloo Murddpal Code,Chapter 9.17,and the
I kallh and Safety Code Srctlon 25532p)r HEATING UNIT(OVER 1m,m0 BTUI TOTAL. �e
1 Ye r]No
WtheapPBOMmfuumbulldingwaupant..e qulpmou ordevim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haardou..ir antenna MA as defined by the Bay Area Air
Quality ManageneM Dtrictl BOILER-COMP OHP OR 100,0(10 RM YLPAI Y,,, ❑No
rhaveread thehaadwAreaterlabnyulrtmentaunder Cha er6.95of BOILER-COMP
tk GW.w HeshhkSafetyCMe,Sedbv2r5(15,25533and7 M. I BQ MAY 22A
unduntand that lithe building does not owvmreently,haveatenanL thatlt tem NEW RESIDENTIAL MECR FT 1
respondbelty to notify the paM of the m lufmoemmrn s which rbe trod es77
Prior to Wu-no,of a Cenlfiate of O¢upanry.
CI T Y ur Gurcn uI
Owner m wthorlied agent fAte ISSUED BY: �
OFFICE COPY