20431 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Rulldln Project Identifiestlon PERMIT NO.
Building 9_22 20431
11non'.
CITY OF CUPERTINO-BUILDING DIVISION O
Comna«'aNane Lie.No':ase. APPLICATION / PERMIT o
L� 99 S�4b BUILDING-ELECTRICALPLUMBINC-MECHAMCAL CAVORT CONTROL#
Amhftea/ glneer. Lie.Na
Add. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
if
- PERMITISSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION
Thereby il(Irmthatlam BceaueduwerprovWoru ofCMpter9(evaurust PANELS CESRESIOENTIAL B RIPDON
Ing with Section 700D)o/pvftlon 3 oltM1e Budws and PmleaYomCyde,and
Lice is In full rm defied. PANELS
Late ora
Date Contrador UPT02DOAMN
ARCHITECTS DECLARATION 1-1 AMPS
10+�0 CZOC I uMerwM my plane shall be uaed as publlc records. OVER 100D AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
U0 U Licensed Prof mbvl SIGNSELBC7RICAL
OWNER-BUILDER DECLARATION SPEOIALCIRCUIT/A1LSo
y � lherebyaiRrmthatlamexemplfmmihe Contactor'.LReraelawfortha
S2E. followlegre..(Section 70315,BusinessandProf.1o..Code:Anydtyor TEMP.METER ORPOLE INST.
rr county which rNulrena permit tomraUud,alter,Improve demolish orrepilr
`1 county
anymmmrnprbatolbb ameaborequirmtheappBcent!«mchper to POWER DEVICES 7766
1.5 0k•signed statement that he b 14rnsed Pursuant m the pmvLsloro of the
Ow Contnnor's license law(Cha er9(ca..cln with Section 700)of DM.
SWIMMING IX]IX,ELECTRIC+O don3aftM Business and Prd�bm Code)orth�hebeu theaefromaw VALUAnON
4t y.'S the bash for the alleged exemption. Any violation of Section 7015 by any
0� applicant for a permit subjects the a ppilcaut to a dvil Pena icy d not man,the o OU7LEISSTVI7C}IFSFIX[URFS
fiv h.dmddollana5M.
�n �I,a.owner of the property,or my empbe yewith wages as their sok NEW RESIDENTIAL El«,.I.R SQ'FL STOW�� TYPE CONSfRLCT10N
mmpematlon,w ldo the work,and the.aueun b oat Wended or offend for l
O .I.Sec 70K Buelrcm,na Pmfebv Code:The Cori nc[or.License Law
�$ does cot apply to an owearof property who bulld.or lmprwe thereon and OCCGROUP - ES UNITS
w�..h.^odoewchwork himael«thrwgh h a.nemploym,provided that Lich
...yrovemerdA an vat Intended Lino/fend for eek.If,however,the W IWing or TOTAL:
imprw<m<nt baold svLLM1b orcyearo/completion theowner-bullderwW love
tl)Lkurdeno(prwingthathedid mtbulldorlmprawf«purposeofub.). QTY. PLUMBING PERMIT FEE
LI I,as owner of the property,am excluaWety contracting wBh llmm
nd FLOOD ZONE APN
contractor to construct the project(Sec.7014,Bu,umss.d Pmmrn
floCode PERMIT ISSUANCE
The Corrcnctor.Licence Law doe net apply to an owner of property who AL7IItDRAIN La VEM-WATER SiV
Wilds or improves theme?, mm
and who rana p
for such tejee -
a with . FEE SUMMARY
c9a4actor(s)licensed pursuant to the Contractor's License Law. BAIX PIDWPROTECT.DEVICE
L j I am exempt under Sec B k P C for this reason
Owen Drte OtJTSIDEFEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_ -
l�.��� WORKMAN COMPENSATION DECLARATION s
LL.ooeby affirm that I have•certificate of consent to elf-Insure,«e FIX URE&PER TRAP SCHOOL TAX Y_ N
RECEIPT/
cenl0La of Workm'Campercmlmlmurance«a cenlfkd copy thenal Sec GAS EA.SYSTEM-I INC4 OUTLET PARK FEE Y N
3Bm,IabGO awSC a��4o RECEIPT
Pdky a GAS EA.SYSTEM-OVER 4(FA)
Com rev�� tlBUILDING DIVISION FEES
�Cenffldmpybfimb umladty GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CertlBed copy b filed Mth the dty Irapettbn dW Wm.
CERTIFICATE OF EXENI ION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER.SANITARYSTORM EA 20mT Date Reed t#
('171u,section need net w completed U the permit b fee one hundred dollen
a1I met lee.) WATER HFATERW/VENT/ELECTR ENERGYFEE Y N
I ll nor the N the persuouin an the work so as to became
eemdt Is to the —
I.hal not employ any.Lawn f any runner n n to become mbjen to the
WATER syslrM/TREnnnG
W«FerY Compeaesatbn lave o(GEomla. Date PAID
O Z NonciApplicant NEWRFSIDEN7TALPLMB. SQFC. Date RDeel t#
Z O NoncEroAlaaleANT':I,.B<rmaking LM.eertulnteofFxemptbn,you abo
ehmldbecome forth totheWywit Compenartlanp.,this oaths L.we TOTAL
~ N Ceeeyou coast(aihMlh cmnply wllh wdn prwlelom or thio pemJt shill be
W > deemed revoked. rBUILDING
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyafBrmtlatthenbammtmllon krdingage�y forthe pn m, TOTAL: ELECTRIC FEE
7 = anm of the workfor which this permit b issued(Sec.3097,CW.C.)
() O Lerclere Name PLUMBING FEE
LL H IeMer.Add ram QTY. MECHANICAL PERMIT FEE
W lwnifythatlMECHANICAL FEE
O M1 wme thbappllcetbnaw santhrttMabovelnfomWlon
bmrred.l agnetommplywlthallclyand muntyoNhunm and late laws PERMIT ISSUANCE FEES PAID:
} N relating tobulbing commuctior,and hereby authoHu repnsentative of this
F U) city to enter upon tM nosed property fee inspection purposes. ALTERORADDTOMEQL
_ (We ga«t ,IwenW n d keep hamn1.the City of CupertW Date Receipt#
agai bi s,Pdg— ein
,coq. des penawhichmayanymyacvue AIR HANDLING I1NIT po IO,Om CFM) SUBTOTAL:
:gal ly eo! a g-eEtl�pertNt.
,TOSS IiANIX1NG UNTr(OVER LD,DoacFM) CONSTRUCTION TAX
Ap u Date EXI]AUST HOOD(W/DLCO CONSTRUCTION TAX PAID:
A DOUSMATERIALSDISCIOSURE
511. h
theappiiont future building occupant atom or handle havrdou. HEATING UNIT(TO 10,000 BTD) Date Recd [#
Ia.deRaed the Cupenlm M.NdpalCode,CMpter9.IZandthe
aw Safety � Swim 25532(.)? HFAnNGUNIT(OVFR1m,0DDBTLJiTOTAL:
es ,LL++�--11,�No
Will the applicant or futum buDding omrpant use equipment«devices VE1,M IATION FAN SINGLE RFSTD) �,L7��r�Ay^NCE DATE
which emit hamndwsbcontaminants aas deRrcd by the Bay Area Alr ^-/7lLs
Quality Management Diu? ? EOR,FR-ODMPOHPORI(X,X9BTU) L
❑ Ye No
I have read the h s`h'onuterlabnqumnmrtsunderChapler G95 of BOILER,COMP(OVM 1m,000 BTLT) '_�f' Z O i(t�'1
*the GM=WHealthkSakty Code,Smiom ZS505,ZD3and2SSU. I V J U
uMmtaw that lfthe huldingdoe not currently have a tenant,that it is my N'EWFESIDFNTIALMECH. SQFT
—pon@WtytonetlfythL.pant ofthercyuinment.whthnerstbemet (���sa
prior,to itau..da CenlOcateofoccuparey. MY 0saD/s,'
n",,
!,
Owner«mM1«ind agent Date TOTAL: ISSUED BY�/����X
OFFICE COPY