22040 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pm ea Identifkatlon 1'F7rhBT W.
Building Addv: 22040 GO4O
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neve .me: me:
v CITYOFCUPERTINO-BUILDINGDIVISION /�yy
CmbaaWaName: Lk.No: APPLICATION /PERMIT
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
ArchRea/Englreen l.fc.No:
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add
PFRh91'ISBUANCE � ❑ ❑ ❑
LICENSEDCONTRALTOrp DECLARATION
I knby ro7000firmthat l am Bcm3.fthvsed .ad..dI m eemer.9(comment, APPLIANCES JOB D6CRI TION
Inense i Scalon force)of DhdtlmJ olthe Butlrinsand ProfntlmeCode,and my
Livens is I.mB lora and effect. PANELS
Date Clan LICI S y ��
Date Contnaor
ARCHITECT'S DECLARATION n-1999 AMPS
�2 Iumdentand my pWashaii be used u public menace, OVER1000 AMPS ' FTkT.�H .FT.
O AWL
Licensed!Pmfeubral SIGNSELBC7RICAL U Q
OWNER-BNLDER DECLARATION SPF�LC�TyMLSC n
'1p..,�, TherebyafBrtnshat l am exemptfrom the Contractor'.Limnee law for the O
6gFppp following maem.lsunion 7MI 5,Busines a rel Profenbne Cock My city or Tp,)p.MElIIt OR TOLE INSF. Jq C
F�a� muntywhkhrequimape tomra d,Ater,hnpmve,demo h,ormpar
enyatucturc prbrtolb beuarce,abo requlmtheappBuntfm such p:rmHto POWER DEVICES DATE
O�+ Bk a signed statement that he is licensed pusuant to the proviabro or the
7uu. Commuter's License Law(Chaptm9(commencing with Seetbn 70 W)of Divi- SW1vf MINGIWLELECTRIC
-
hin3ollhe Buabemand Pmfmbro Code)orthat he Is exempt therehvmard VALUATION
_ the basin for the alleged ettmpllon. Any vldatbn of Section 70315 by any
los vpph.t fora permh subjects theappheant too civil penalty f.d moretheo OUTLETSSlY1TCHEST%71)RES
nv£,hunared ddlan property,
NEW RESIDENTIAL ELFS'[R
�n mpenWiwnerdthepupek,and my rmpbym whhwage as thein sole ��. STORIES TYPE COn'SIRIICI'Ion'
cwnpenutlm,willdotEe w«k,and the suave Is not Welled or offered for
a o uk LSee 7004,Bualnm.M Prdmebm case:The cawacar.Llave I.w
Gjsfa; dao not apply town ownerd property,who bulldsor imptoveithermR and OCC.GROI RIS.UNrm
0.0. mhodanachworkhlmeelf«t ghhbownempi ye pmvldedthatmch
improvements are not Intended oroffered f«uk.If,however,thebulldIrR or TOTAL:
irnprovementbsoldwithlnorcyordcompIetlon,theownerbullderwWhavc
�en of proving that he did not b2 or lmpmve fee purpme of uk.k QTy. PLUMBING PERMIT FEE f D7DNE AI'N
•owner of the Property,am exclusively oantraaing whh Ikenaed PERMIT ISSUANCE
taxon to comtuect the project(Sec 7014,Bushes,and Prdesbv Code:
Contractor's Lkenee Law don not apply to an owner d Property who ALTER-DRAIN 4 VEnT-WATER(EA)
IWa or tmprvma thereon,all who mntncb for ouch projects with a
CrIW(aaor(s)limned purauant to the Contracts s License Law. FEE SUMMARY
I_l I am exempt under Sec B 4 P C for this reason BACK FLOW PROTDCT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N
Owner Data
WORKMAN COMPENSATION DECLARATION RECEBT 0
c ❑1 hereby affirm That have scent/late of cmrnt to self-Iwn,or• IRFS PER 7RNr SCHOOL TAX REzEiT E
mNBaWorken'C«npeoalminwnnceoracenl(led ropythened(Sec. GAS EA.SYSTEM-1 INC4OULE15
Iibh CJ PARK FFR Y N
Policy If RECEDING DI
Co ray GAS EA.SYSTFAf-0VER4(FA) BUILDING DIVISION FEES
1 I Certified copy b hereby mrnbhed. CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Cenhied ropy Is Bled with the city inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM E.A.330FT Date RCCCI tN
CI'hlswalan need race be completed B the permB b(«orae hundred do0an
(f100)mfythat In WATER HEATER W/VENT'/ELECTR ENERGYFEE Y N
Ianor employ
an pervonIany of the work fora to rrv,mdlbbo theed, —
I cr nm employ any person f any Trainer at n to become object to the WATER SYSTEWTRFATIKG
w«ken'campenutmn Taws or California.Date PAID
O Z NOTICE NEW RESIDENTIAL NB. SQ.FT. Date Recti tit
Z O NDApplicant APPLICANT:If,after mating this CenBlatedEtempbn,you
should become subject to the Workemi Compensation proviaium of the Labor TOTAL
CCN Code,you cont forthwith comply with ouch provisions orthb permit shall be BUILDING
] deemed newked.
W p CONSTRUCTION LENDING AGMCY SEISMIC FE
a IherebyaMthat there b a communion lending agency for the perform
7 Z anmoflhewark(orwhkhthbpcmJtbh 5ec3097,CN.C.) TOTAL: ELECTRIC FEE
02 Tender-Name PLUMBING FEE
LL F Lenders Addma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcenl(ythatl have read thin appiatlon and etatethatthe abwelnfomutlm
ncanra.Ivgreete,complyv,hhaB dtyand muntyardmanmand state laws PFRhffI ISSUANCE FEES PAID:
} N relating to bol Id ing conalruaim,and hereby authorlae rtp.ruBvn of thin
Z city to enter u Pon the above-mentioned Property,for Wpodon purpo—. ALTERORADDTOMECII. Date Recti IN
— (We)agrer to aavp WerrWfy an d keep harMn ethe City of Ce penal
.gal bBltks,}sdgmrcNa,awsamd expense which may Nanywayamue AIRHANDIINGUNITCDOMMOCFM) SUBTOTAL-
agai t id&itym encs of k t gdthb pends.
1 AIR HANDLING UNIT(OVER 14000CFN) CONSTRUCTION TAX
maxi Appuant rotas« Date E)CHAUST HOOD IWIDLCT) CONSTRUCTION TAX PAID:
4
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant atom or handle ha,ardous FRATING UNIT(TO IOOAW BTU) Date ReCCI IM
maeMlae dc(im dby the Cupertlw MuNdpal Cade,Chapter 9.17,and the
Iieahhand SafayCode Socluen 532fA)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
n Yn M No
Wthe appllad orfumn building occupant use equipment or devfas VENTILATION FAN(SINGLE RESID) I�$IJ�j�ICE DATE
which emit havamdous air mntamlmuntau defined by the Bay Ana Air eY'tl�/S�7
P»IIIy Management Dl.vlrktl i BOIIFR-COMP OFB'OR 100,000 BTU)
❑ n No
l have mdthe hav'mene,maerfab requirtmenb under Chapter 695 of BOILER-COMP(OVER 100,000RQN) APR t 5 JR91
the CGllfornblieahh4SafetyCode,Sealoro75.5m,Z5533and755M. I APR OJ
undentamd that l(Ihebullding don wt omrrcntly have alenant,that ltbmy NEW RMDENTIAL MECH, SQ17
rriortob abnastythe accupadcctherequWmedawhich neat be mel
priorne Ewnnce dtiythenateo/ toftheroq 4f1VY
Owner or authorized agent Dale ISSUED BY: I
TOTAL
OFFICE COPY