22497 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.M Ident114atlan PMNQTNO,
Building Address: 2249.7
ne came: e
a CITY OF CUPERTINO-BUILDING DIVISION
c.n °r•Na^,<: . _ I r No:• APPLICATION / PERMIT 7 uZ 7 BUILDINGS ECTRICA nP BINGMECHAMCAL CATMORY CONTROL 9
Anehgeet/Enginser: Lk No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aderr,< PERwT'issunncE E] ED 9 1:1LK'ENSED CONTRACTOR'S DECLARATION
I hereby at(I7000)olamllcmredhe Bup vlandn fh =srode, mm< A7'PWANCESRE9DEJf1AL
JOB N
inerts, in
fmm.!deffm ofthe BuJnessand ProlesdwsCude,and -
Lim Is in fuB foto and disci PANELS
License Chas_ _Lor S'J 9.S9 7 ` 'n
Date COnrsaOr U NC SQ �/✓e
ARCHITECTS DECLARATION AMPS
q�q�uu n:O Zp Iutdennnd myphv shuBh used upubllc reds OVER INO AMPS SQ.FT.FLOOR AR I.
S/9Q.F
d rJ(Oj Lisvad Profesbnal SIGNSELECTRICAL
<G
OWNERBUILDER DECLARATION
7, SPFCIALCDiCUIT h11SC
7�A ]hereby afgrmtlutlam xemptfmmnm L
the C.rnraor'a Lfmnwfor the /
0�..� follovrg e
reason. 7MI5,Bush®and Profesbns Code:Any city or TEMP MEIT]t OR POLE INST.
F� muntywhkhnqul apemdltommmcLalter,Impm ,de Ush,ormpalr
anystmctun prlorto Its Issuance,also requires the applicant foradt permit to ,• paypR DEVICES
•Jgned statement h stant that V Ilcensed pursuant to the prowbro of the
u� Contmetor'@LL:erw Law(Chapter 9(mmmenMg wth Section 700%of Divi. SWDAMINIG POOL ELECTRIC VALUATION05 abn3afthe Bovines and Prolesbro Code)orthat he besmpttherefromand
the basis for the alleged exemption. Any violation of Sectbn 70315 by any
applicant fora pemdsubpes the applicant too dull penalty foot mon than OUT1E1S5WIT'CHESMATURES
�.. five hundred dollars MWL NEWRE9DEVTIALELFZTR
�n
F-1 1,u e owner of the property,or my employewith wages as their sole -SQ STORIES T'I'E CONSTRUCTION
C < compero+tion,will do the work andthe structure Is em wended or offered for
❑ sale(sec 70K B.Mossa and Pm(esbns Code:The Conrsa.rs U.Taw
�S1R duce=apply to anowrcrd property who Wildsarlmprovestherem,and OCC-CROUP RES UNITS ..
Who doessuehwork himself orthecogh hlaownemployeet,provided thatmch
Itnprovcmewanrotlntendedordfendfwa le.If,howsver,the Wlldlugcf TOTAL
ImprosemeJ Issdd whhlnoneyurdcompleUOM thaowner W IlderwW love -
t"ndenhfpmw•gthnhadld ess WRd.rimprovef.rpnrpoaecf.k.). QTY. PLUMBING PERMIT FEE
LJ 4 as owner of the pmpery,am excheifvehy� W]lam
tmerieg wed FLOOD ZCINE APN
contncton to mnstrua the project(Sm 7014,BuJnes and Professions Code: PERMTTISSUANCE
The Contractor:Llai.Lw does not apply to an owner d property who
bu Bds or Improve themcm,and who mdntts for such p," wW a ALTER -WATER(PA)
�plj+aor(•)Beensed Pursuant to the Cmtnads Licame Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am eumpt uMer Sec B k P C for this rcuonQIITSIDEFEES
Avner Date DRAINS.FLOOR ROOF,ARF&COND. SANITARY Y_ N_
WORIUa1AN COMPENSATIONDECLARATION RE=If
❑I hereby Whom that I have a¢rtlfkah of consent to self-inure,or a FDCIUIRF$PER TRAP S iI 1,T" Y_ N_
cetti0ote ofworken'Compentation Insurance ora certified copy there.(I,— R EIPfa
3900,Tab CJ GA4 EA.SYS`EA-I INC40UILEM PARK FEE Y_ NPol _
Com4 GAS EA.SYSTEM-OVER DING DIVISION
y BUILDING DI VISION FEES
Cert Tied copy b hertbyfumWed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
CertNed ropy V(fled with the city Inspection division.
CERTMCATE OF UEMPTION FROM WORKERS' CREASETRAP PAID
NC
NSURA
I
COMPENSATION E SEWS-SANTTARYSIORM EA 2l10FT. _ Date Recel tat
(Chis sectbn need na h completed N NSURA Is fororc hundred dallan 0 0 V
WATER FATRw/vENT/TECTA ENERGYFEE' Y N
I certat certify thin le the perform.m.f the work for wMN m
this pett is Issued,
I shall not employ any pennn In any manner an as to become subject to the WATEI SYSTEM/TRFATV.G
Workcn'Compmsatbn TawsdC hforruo. Date PAID
Z NOTICETO APPLICANT:ILaRermaking thisCertlflam of Exereptbn,you NEW RESIDENTIAL PLMB. SQFf. Date Reeel til
should become ubF&to the Workers'Comperoatien provisions of the Labor TOTAL:
CCN Code,yno rtuat forthwith comply wilhsuch provisioropermitrthis permit ahJl be
W > deemed revoked. BUILDINC FEE
cONSFRUCTION LENDING AGENCY SEISMIC FE
O. I hereby affirm that then Is a construction lending ageny for the pedorm ELECTRIC FEE
7 = ,race of the work for which this Permit b booed IS-,30V7,CIv.C.) TOTAL t _Q
(.) 0
O <MeraName PLUMBING FEE v
LL F Tenders Add. QTY. MECHANICAL PERMIT FEE,W MECHANICAL FEE
O Icertltythatl Hvcrcad this appBretbnaM statethat theabwe Womatlon
a bmrneet.I agree to comply with all eity and county ordlnanm ES
and state laws PERMIT ISSUANCE FEPAID:
} relating to buRding mvtruesimr,and hereby autharom npraentatfves of this -
I_ N sty to enter upon the abase-menlbned Property foe Wpectionur
Purposes. MTERORADDTOMECI
? (We)agree to save,Indemnify an d keep harMes the City of Cu pertlro Date ReCeipHl
V agaNJBabilItka,Ndgmew,num,.d eapsnue•which may N anyway..e AIR HANDUNG UNIT(I010,000 CFM) SUBTOTAL:
agaltut dCByN eme941Jte Rna.Ng dlNs pemdt.
-i"115
VIP
n.✓
ay-y/ ' ATR HANDLING uNrr rovFR 10,000 CFM) CONSTRUCTION TAX
Signature of Apph.st/Contractor Date D(HAUSf HOOD(W/DUCT) CONSTRUCTION TAX PAID:
FIAZI R DO US MATERIALS DISCLOSURE
WBl the appli in or tow re budding o pant Jon or ha sod le harardous HEATING UNIT CTO 100,ODO BTI!) Date Recd t#
material as def.ud by the Cupertino Mu dcipal Code,Chapter 9.1 2,and the
Fleahhard SafetyCade Seaton25532(a)7 HATING UNIT(OVER 100,000 BTU) - TOTAL: 17, DO
T� Yes M No
Bl the appBcanor Nn Wilding omupant use cqulpmer¢ordevi.n VENTILATION FAN(SINGLE RESID) ISSIO "FfIATE
which emit havrdaua air contaminants as deReed by the Bay Area Air gA71 rYi
Qualgy m1rogemeM DW ria? BOILER-NMP(3FBP OR 100,000 STU)
❑Yes No
iluivere.dthvharuouanu, dais requirements under Chapter 6.95 of BOR.ER-COMP(OVER 1WpW BT" 1111 1081
tha CaIff.aHealth&Safety Code,SMbm7S505,25533and2S534. I JUL
`i��
understand that tithe Wilding does not eunnthy have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT `
respotaibllity,to notify the oaupatd of the requlnments which most be met sad^��"'
prior to issud o
ance a Certificate of Ocen pa my.
' r
Owner nrautho agent Dste
TOTAL ISSUED BY:
OFFICE COPY