21898 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PmIed Idendfkalon PEl"T NO.
BuddinAddreas: 21898
ZR .4�,qc ��
rcre ��'' ` ' me
AL.egl� 7• CITY OF CUPERTINO-BUILDING DIVISION
Cont" N Lk.Na APPLICATION if PERMIT / L
powTiAl� ✓ �2� BUILDINGELECTRICALPf UMBING-ME{HANTCAL CATEGORY CONTROL a
Anhke t/Engtneer. Lie-No:
QTY ELECTRICPERMTP FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
Dna heuz1/�aBeenuedi under prwWweofC9(mmmm A[R.IANCESRESmENML
ingwith
Seetion70W)afDfvhdo3.fthd BusysandProfaailexaCode,and JOB DP
I.e. aIn( 111��y��orrraaaand effect. PAN�LS
Lie.aor ,A G` U��
ConUP TO 2COAMPS
ARCHITECT'S DECLARATK)N201-1000 AMPS
�q+W Q] I undenfand my plavehall be u.:d 1
n publlcre a OVERIWOAMPS SQ.Fr.FLOOR AREA $/9U.FT.
E j Licemed Pmfesbnal SIGNS ELECTRICAL
<< OWNER-BUILDER DECLAIfATION SPECIAL CIRCUIT/ML9C
V. a Ihuebyaffi.thatlamexemptfrmnthe Comraeorb Lit`neelAwfmthe
p�y folbwing rcumi.(Semon 70)15,Bueims arid[Profulov Code My cityor
O .E 3 TEMP.METER OR POLE INST.
r countywhkh requima per Wt tomrwruct,alter,improve,demolish,oreepair -
F.O6 anyMm=mprlortoibL arce,aborequimtheappbantf«sudtperndtto TOWER DEVICES
r.U file a dgned ane e"M the he b Iloenaed pursuant to the provbbru of the
7� w Contnnor's Lkeve Law(Chaptdr9(mmmendngwfth Section 7000).!pv4
"'30 abn3of the BuelnesandPmAesbvCodc)arthe hebdadmp[thertlromand SWIMMING TOOL ELECTRIC VALUATION
Q the beab for the alleged uempHon. Any vlelatlon of Section 7MLS by any
�A appBuntfor a permit subjeGa the appheam toe civil penalty deet more than OUTLETS-SWITCHES-FIXTURES
$ flue hundreddollar, .
1,-1owner of heproperty,or my employ.n with wage as their uk NEWRESIDEJIIALELECTR SQFT, STORIES TYPE CONSRLIMON'
peT7UZwill Bothew«ksedthes Code:rcbootImactor oromeLaw
dm wt apply to an owner of property who bilNa or lmpmves thereon,and OCCGROUP RES,UNITS
whodmeuchwork himxlf orthrwgh hlaownemployaes,provbe i thatuch
Improvements are not Intended creffered for uk.U,however,thebrliding or TOTAL
Improvement 1asoid within oreyeorofcompletlee.the owner-buaderwW love
relen ofp,wlog that he du one build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
er owner of the Property,am eaWh,ely,Busi contracting with lleemsed!Code, PIRMIT 65I)ANCE
meCrierMeter,to m).leen the project(Sec 7044,Burnes and Proferbro Cade
The or Int ro s therLw Bern not apply to ane sue of property who ALTER-DRAIN VENT-WATER(IA) _
ogSdPa t r Imprwv thereon,and who mmraRs(«such p(ojMs with a
°gRyacYar(.exem t unde,uw to the Comndar.Llmve Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
OUT%IDPFEET
LJ I am exempt urdn Sec B 4 P C for this reason
IXUIN&FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner E RECEIPT I
WORK MAN COMPENSATION DECLARATION FDCTURFS PER TRAP dAi00L'17 X Y_ N
M1 hereby affirm the I love•artiRote of cosset to seU-Iwrt,m a RRA,
nxntWLate ofWorEeri Competunbnlvunn«ma«rtlffed mpytheavft5n.
Lab GGAS EA.SY57EM-1 WCIOURK TLETS PAFEE Y N
3gW, ,
Cd[ GAS-
W�.BDSIS'� GEA.SYSTENOVER a(EA) RINEPf1
'n - Ltd A.S BUILDING DIVISION FEESCertified copy b fiercbyfumbhN. GREASE/WDUSTRL WASTE INTERCEpToR PLANCHECK FEE
rtNed mpyb(iled with the city ivpeRbn dldeim. - i
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
the pemdt b(m orc hundred dollen SEWTF SANITARY STORM EA 7fNET ecc
Date -Re t#
(DdseMbn need eat be compined U
alao)mlm) WATER HEATER w/VF /EECTR ENERGYFEE Y N
1«not mPlOYhat in anhe p penton many m work to a to enepemwl.lto there, _
I x]B not<mpby any Peron f any manner to u to become ubjdu to the WATER SYSTEM/TRUTING
W«k<n'Compevatbn Lwe of6W«nh.Dee PAID
Q Z Applicant NEWRESIDRMALZP B. SQFT. Date Recel t#
Z O NOTICETO APPLICANT:If,after making thisCeraitnte of Exempjxmyou
shouldbcomeubjedtothe Woh m'Compevebnpmvbbmo(the Labor TOTAL
~ N_ Code,you eustforthwith comply with such prosisbvarthis permit shall be
Q > deemed revoked. BVIL12INQ FEE
ap CONSTRUCTION LENDING AGENCY SEISMIC FEE
=
I hereby 91frm that there b a mvtullon lending agency for the perform TOTAL ELECTRIC FEE
•� anoe o/Rhe workforwhichthh pemdtb Weed(See.?Off7,CH.C.)
V O larders Name PLUMBING FEE
LL H LeMer'a Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W _ I ordltythat l have readthb appaotionaM stinformationthe above information
(1 lammed.lagmtocmplywhhWtltyaMmntyordlnan¢ andeateUws PERMIT ISSUANCE L'Z—& . FEES PAID:'
} N relatingte, vtrueion,aed herebyauthorleerupreaentativvofibb
f.. Z tlty1 V11heaberw-meed Property for hupeetton Purpoen. ALTERORADDTOME{H. Date ReCei t#
_ e) save,hdemm a d p humim the City of Cupedhu ps buil ud meet nanwhiehrruyinanywayamue MRFLANDUNGIINITH010,000CFW00 SUBTOTALager Wt a ntinge(thlnperrnd.
AERHANDUNG UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SIPw App LAZ RDOUS« Date EXHAUST HOOD(W/DLC]) CONSTRUCTION TAX PAID:
IInt,Rfx)USMATE IALSDISCIOSURE
Will the clued by the ure Wdding oavpantoc, hapten le 91Z andvus EIFATEYG UNIT(N 100,fgO BTU) Date Rmei t#
nukrhlu defraybythe Cupemiro255 Municipal Code,Chapter 9.11,and the
Ekakn and Suety code Sectlm 255dzG)r HEATING UNIT(OVER 1W,000 grin TOTAL: k•cXP
F7
Yes No
Illthe applloruaair Wilding ottvpantus the Bay At«devices VENTILATION FAN(SINGLE RE9U) ISSUANCE DATE
which eMt ogtox us air eonhmW me as deRvd by the Bay Area Alr
Iltyhfavgemem Dbtri l7 BORER-COMP 100,000 BTU)
Yn ❑No
aharHealthhe
mode,Sectio lnemenbunderC 25534. 95 of 1)OII.EA{OMP(OV1R 100,000BM
the Californialh Health&s,(my Code,Senbv 25505,25-933 and 755X. I
undenhed that if the building don not eumently have a tenant.that It is my NEW RESIDENTIAL MECH. SQ.FT i".L1Ii
mpovmOfty to notify the.pam of the requlrcmenta which rtun be met ,
prim to bsnrcu a.CertiOote of O.Paruy. /�sa p{/ __��
Owneroraulheriud a gent Date ��a..a^•.
TOTAL: ISSUED BY:
/ OFFICE COPY