19487 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Yroect Identiflatlmt - PEILMIT NO.
Buais53 V" Lone 1<08/- b 19487
�raIn one:
LDA ()R. /V'Q,r CITY OF CUPERTINO-BUILDING DIVISION
�^ •N•nx()/�f Lr N APPLICATION / PERMIT — L
BUTLD1NGELFi'IRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROL a
Arahhect/Engin¢ Lte No:
Qly ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtst' I'ELWTISUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
Z.
I Mreoctloor70 that)of lkmsedundmprovblonsof Chaptrr9(commen PANELAPPIINCESRF9DEMlAl B 6CRIPTION
Ingwlth ScVbn70(D)of DlvLWw3of Bud«van rofeW«uCode,and .�
ikenssbin Z I'ANEIS
LI¢nse b Lb I 7Y/J P , L
Dale Cortndor UP T02DOAMN
000 AMPS
ARcrlrrgcrs culurwN
otOZp IRnderwnd my plan shaBbe..w aspubltcrtmrds OVER 1000 AMPS
SQ.FT.FLOOR AREA 5/SQ.FT.
Licensed Prafea•lonal SIGNSELECTRICAL' .
OWNER-BUILDER DECLARATION SPECIAL CIRMT/MISC
Iheebyarflrrnthatlammr¢n
exept fthe Cdh fa
ordraoLfoc.IAwrthe
O t- following reason.(Sedan 7015,Business and Pons Code My city or TEMP.METER ORPO ST. '
K� countywhkhrequbesape t'wmratruct,alter,imprn ,demolbh.ornpalr
q anyatructure prbrto iia buirce,aLwrequlmtheappllantf¢eudiperoutto POWER DEVILS
L5�a a file a signed retement that he b Ilaenaed pursuant to the pravbbns of tis
3u Contactori License Law(Chapter9(mmmenWgw4th SecUon7O0)ofDivi.
�OS sbd
n 3 of the Buness and Professions Codb e)or that he exempt therefrom and SWIMMINGFICAELECTRIC VALUATION
6 5 the bash for the alleged exenWtiai. Any violation of Section 7015 by any OVILEIS TCIBFSFTXTURES
epplicent fora pens@subjedstheappB tto.dullpenaltydnot morethan
a � livr�undred dollars NEW FNRAL PT TR .
L�I,as owner of the property,or my employees wdh wages as their sole SQ FT. STORIES TYPE O0NS 1tU(7T)ON ,
�^ rvmprnsatlou,willdothe workanelthestructure Isms Intended or offered for
Osale(see 70K BueErss and Professions Code.The Contractors L¢ue Law
@ dm not apply to an owner of property whn builds or improve thereon,and
who dmeuchworkMmself orthreugh his.nemplvym,provided that udrOCC-GROUPRFS UNITS
ImprovemeNs arc ant Intended oroffend for ale.IL however,thebullding¢ TOTAL
Mprovement beald w4hinoneyearof�platbn,theownm-bullderwlll lave
d�¢¢Nen afpmving that he db not baud on lmpro.2f«purpo.e nfakL QTv. PLUMBING PERMIT FEE
LJ I a•saner d the property,am a Iuah,ehy contracting w h 11¢nsd FLOOD ZONE APN
PERMITISSUANCE
ntadors to construct the project(Sec 7051,Business and Pmfub ,.rm Cad
m
Thr Contractor's License Lw does no apply to an owner of property who ALTIIt-DRAW&VENT-WATER IFA)
build•or improsca thereon, and who comm fee such pto)ecus wish a
ryntf+dor(a)Ilcenard puranant to the Contacts License Law. FEE SUMMARY
LII am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,Cb SANITARY Y_ N_
Avner Date RECOPY Y
WOR]CMAN COMPENSATION DECLARATION
,�; ❑1 hereby afllrm that 1 have a¢rtlfhte of consent to seV-Inuit,«a FIXNRES PER TRAP Sa100L TAX Y N_
R�ETPf Y
¢rtBlabC.) rkea'Compermatlon Wuran¢oramrtl lei ropythertaf 6rc. GAS FA.SYSIFk14 WCC O - PARK FEE Y N
380.LbCJ �wG,_.�l 839;
1'dky Y /1 DING DI Y
GAS PA.SYSTEa1-0VFR )
Com nv BNLDING DI VISION FEES
CeniBee copy is he funniest. GREASE/NDUSIRL INTERCEPTOR PLANCHECK FEE
CcrtlRed ropy b filed with the city Inspection dlvidon.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID
(TM.se<1bnneed
COMPENSATION INSURANCE
radbe Ia bf«ane hundred dollars SEWER-SANTT YORM E.A.2IwTDate Ri t#
R1Oo)«Is.JENERGYFEE Y N
1¢rtBy that bthe per(omun¢of thew«kforwhlchlw pemwls Wuea, WAr6t w/VENT/ELFiTR
I shalt not employ any pensm to any manner o as to become subject to the i '
w«krr:campensanan law.of California.Date WATERTRunnc PAID
C• = Appliant NEW DENTIAL PIMB._SOFT. Date Recei IN
Z NOTICE TO APPLICANT:If,after rtaking thio CertBlate of Exemmppttion,you
F N .haute hemme subject to the Warken'Compensatlon provbbns afthe Laver TOTAL
Cade,you nose forthwith merpiy with such provisions or th6 permit shall be
Wd¢rrrd revoked. BUILDING FEE
CONSTRUCEONLENDING AGENCY - SEISMIC FTE
tl Ihrnebyafflrm that then ba constudion)ending agency for the perform ELECTRIC FEE
= arm of the workfor which this permit Is Issued Err.3097,Cl,C) NOTAL:
U2 Lender'.NaPLUMBING FEE
ms '
LL F I-ende6Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE, L
O W I cert ify that l have read this appllatbnand Matethd the above lnformatlon
d bmrred.Iagreeto c«nplywtth all tltyard muntyordlnanmand role hew• / PERMIT ISSUANCE sat•(/(a FEESPAID:
F Z_ daregyes to lenter upon
bg mma nrosetrqucucemlroi¢n,oafndth dhegpreranrboyptienrty dfee
in aionpurpo�s eoV(.th
fe
ALTER OR ADD]O MECH..
(WeagrectosaW m iffyand keep harmematheCity ofCuprdW Date Recei t#
agaWbbWtb,Iudgma,msandapeewkmyinany�yau< AIRHANDLINGIMT(LO10,000a ) SUBTOTAL
g
AIR HANDLING UNIT(OVER 10,000CFY0 CONSTRUCf10N TAX
Slgvturear AppBant/Contract« Date EXHAISTHDOD(1V/DUCT - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant«roto¢building occupant them or handle harardou. / HFATVJGUNIT(TO 100,000 BTU) /TZDate Recef [#
naterial as deft I by the Cupertino MuNtlpal Code Chapbr 9.I2,and the
I Iallh and Salrty Code Section ZS532(a)7 - KEATNG UNIT(OVFR IOg0W FM TOTAL:
❑Yes No
WI,,the ePphka.or tvrehuildingottupsntuae equiprnrnt or davlm. VFNIILATION FAN(SINGLE RFSD) ISSUANCE 1 D1ATE, 1
wh)eh endt huardous.ir contaminant,u defined by the Bay Area Air II ,.�a � I,G. f
.
Quality Mawgem -0TU) 4
ent Dentrkti BOrLERDMP PI E'OR 1W,IX9 RV
Yes No
4have ad the h ❑
ard grated WrequlrementsunderChapter695o( BOILEROOMP(OVE2 I DDD00 BTU) —%!a; o
therlhfanUlieahh&Sof Code,Sedbns2550,7a533and2S534. I 1ym�tp
undmt.nd that ifthebuildes bgdonotmn
rntly h.venten•nL that It bury NEW RESIDFN7LAL MECL SQFT 2-7—L
respons@Blty,to notify the oocu ant of the requiremew which Trout be root
Prior to issuanee da Certiriate of Orcupaocy.
Ownerar.whora iagent Dale ISSUED BY. Y'Faa✓Vu-^i�•-11^CJs
TOTAL:
OFFICE COPY