19884 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Idendf"tl® PERMIT NO.
Bu IIMiRq Add rens: _ 19884
/o s a:3 F,9 ey[L oNE 7�.e. dPBR T%Mu
6Eo. 1 JANX7-yoeJAIZ„61( xsz-1 CITY OFCUPERTINO-BUILDINGDIVISION ' 1
NS yl APPLICATION / PERMIT -C
IJe N. BIl[I.DINGELFC'[WCALI'LUMBINGMFLHANICAI, CATEGORY CO
ArchBed/Engineer.
QTY ELECTRIC PERMIT FEE `—BUILDING PERMIT INFO
Addresv PFRMITISSUANCE IN a� - ❑
LICENSED CONTRACTOR'S DECLARATION �f
T hereby affirm that l am Bc sasf under provldms of Cbapter 9(mmmec APPLIANCESRESIDENfIAL )UB DESCRIPTION
Ingwlth SedbWm
n 7000)of Dlv3ofthegroa
ualand ProfeaalonaCodp and
Ibeveelalnfullt andefii: fl�� PANELS
Lkense Claa_ Lk.a_ 6
Date(.(7.. /a-a� CoNradorUP TO 2DOAMPS
I_X7n 1T�ARCHITE47I•S D ON ') AMPS V ter v t
�gvNV IuMemarldmyplaroshagbeusedaspublicre 1s OVERI000AMPS SQ.FLFLOORAREA S/SQ.FT.
}i2 Lkenaed Pro(eaianal SIGNS ELECTRICAL
«<<QLu OWNER-BNLDER DECLARATION
I hereby afCnn that l am eaempl from the Comradora Lkense Lw farthe grECIALCIRCUIT/M1SC
pO GI folbwing reawn.(Section 7m15,Buelness and Proleeebv Cods,Any dry or
TEMP.METER OR POLE INST.
KSI muntywhkh requbn s beaus
th.impmcant foraueh. sTmb to
r
S Q any assigned!statement
otthat he
nre,aboragWmNent to
he famions of to POWER DEVICES
5 O G O Cie a algned statement that he b r 9(wo Pursuant it the pmWbm of the
Cn3ofore tic 1•w(CWpier9(mvurcnthming wLL 'Section7IXp)ofaM SWIMMING POOL ELECTRIC VALUATION
F, O DM-
don3af the Buslvw and Proteebro Cade)orthat hebessmp NerHromaM - "
Q S the baab for the alleged exemption. Any violation of Sedbn 70715 by any
Q� applfont/ora Perm bXc theapplfunttoadvilpemkydndmorethan OII7LETSSWITCHESFATURFS 2 I oo�Oe..y.AsQO
{q� Cv unarM a r of 18506. `--''UVJ
�I,.a owner of lbs properTy,or my empbyee wdh wages as their sole NEW RESIDPNMLELECTR 9QFT. STORIES TYPE mNSIkUCIION
Qmmprosation,wWdothework,and theseroduro b not bdended or offend for
O ole(Sec 7011,Business and Professions;Code:The Conb.d.e.Uceroe Law
doer roe.pply to au,owner of property who builds or improve thereon,and
EE who dm srh work himself or through hlaown employee,Provided that such OCC.GROUP RES UNITS
Improvsmema.re not Intended oroffered(or sale.If,however,the bulldingm AL t
Improvemem badd WWInoneyurofcompletto,t owner-buCderw Iurs
rden of proving that k am not wild or Improve for purpne of rule.). QTY. PL I GPE FEE
I_J L as owner of the PLOOD ZDNE APN
mntrad wmrotmdthe arty,am Kw x e..,.dingwah lfm M,. P Ill
project(See 014,Businee and Profnalo t Code:
The Comndoro es thn law don eat apply to f owner of property who ` D VENT )
wBas or improves Neear,and who mntrada for such plojem wflh a eC.rj
ryR1T+�m(e)BmrwNpueuant tothe Cmtndar'a Liaise Lw. BACK E FEE SUMMARY
L,J I ion esemp uMer Sac B tr P C /or this renin
DRNN R P, ODND. SANITARY Y_ N
Owner Date BBC=R
WORKMAN COMPENSATION DELLA RATION I'ER 54100E TAK Y N_
❑1 hereby affirm that I have a mnl/{ate of consent to self-Iwre,m a - RECEIPT
mnlQote of Worken'ComPneaHon Ineunna a•aNfled copythereuf(Sn. .SYSTEM-1 /OUTLETS
3800,Lab CJ PARK FEE Y N
PWq�
RECEIPT/
FA. VER4(EA) BUILDING DIV]SIONFEES
lmpedion dlvlalm. /R'1 LWASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF UO PTION FROM WORKERS' G PAID 3-{s's{a
tv COMPENSATIONINSURANCE
(TSEWEy ARY-STORM EA.po-T Date Retci tqZ 77
Ms sedbn need nil be completed lfthe pemdt b for one hundreddollars,
(SI m)alew.) WATER ITEATER W/VENT/accTR ENERGY FEE Y N
I anonffy that bNnpMomunaof Newark so sts to btco penultbbo the —
i. I or nn employ any person In any Hunner o e to become aubjed to the WATER SYSTEMr EATING
O Aar.t onipvnsatlon Lawn of Call(ornb. Dale PAID
PP NEW RESIDENTIAL PLMB. RT. Date. Recd tH
Z2 AOTICETOAPIbjdto t:e mier.kingthis Ccrtlflprois Ez, fi,eLyou `'4
HN sodt,yohould more mrthivit the Warken'Compero isio provbbror Ne all s TOTAL:
Cede,you olo,cforthwith comply with such provbloro or thio permit shill be
j deemed my-okra. BUILDING
CLE CONSTRUCTION LENDING AGE,Jv SEISMIC FEE
CL Ihemby.(fiworm NattherebamrutmdlmkrdingagercyfortF perform- ��' ELECTRIC TEE
= anaof the rkfor whb kh this permit issued(See 3097,CW.CJ TOTAL
O, O Lenders Nene PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
LL U Tenser.fy atl MECHANICALFEE
O W Ianlfynutlhacornpl hb.ppgnt stul ootate thatthancesi bformalton
IL bmingto ild tg omplywahaBd boountyonlmprn ndemelavn PFRMITI%UANCE FEES—PAID
} N relatoent rupontheaboemn,aMMrogenyhorb repreor purposes.
Wthb
I— = illyWenterupon eve,mdcnoify a.d progeny for Wpe Cit of CupJ. ALTER OR ADD'fO MFfli. Date Recei tk
— (We)agm to Jade,Indemnity.n d keep tgfte the in sof Cupertiro
agalot s.idCitync...qJudgments,
e.ofheuperm wfihis may Nmywayamue AIRHANDLING UNIT(COt0,00DCFM) SUBTOTAL:
aga Wt said City b cmrqurria of the granting of this Permit.
AIR I-InnNDUNc cmTr(OVER lo,aooCFM) CONSTRUCTION TAX
Slgrawn,of Applicant/Contractor Date IXFIAUS'T FIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applura or future wilding oaupant store or handle hazardous HEATING UNIT(TO IW,"BTU) Date Recei tk
material as deCrud by tho Cupertino Murddpal Code,Chapter 9.1 7,and the
Fkalth"'
ril Safety Codr�sylion]55.77(a)r HEATING UNIT(OVER 10QW0 SM TOTAL: I
11111
—I
yes, ml'y(D!o
dimes rd Nrt whums as defined!
bythe ay Area
devices VFNTILATK)N FAN(SINGLE RFSiD) ISSUANCE DATE
whkhcMt S,,.msair mnt.Mrumsas deCnrd bythe Bay Area Alr
Quality Marugemem Wt n si BOrR-COMP MIT OR 100,000 BTU)
Y. No
IM, ad the h o maten.b nquirements under Cha pier 6.95 of Boaz. WMP(OVER 100,000 BTU)
the California Health h Safety Coag Sedloro ZSOS,75533 and 2553/. I
utdent rld that ifthewllding don rw mrantly have a tenant thaeltbmy NEW RESIDFNML MECH. SQFT. 'r�1,� n
rnporoi Itytanai/ytheoaupam fNe nyulrerrcma whkh Haut be rrad J 0 jy�r7
Pnor to o/ Certi"t a V
'
Ke �rez� crit'of
vim
Her thanssd agent Date r ^e��
TOTAL ISSUED BY
OFFICE COPY
CITY OF\9E�«oINSPECT6
N DIVISION
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