19965 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Addremaldin Proen WentllkaJan Off R CIT PFxwrno.
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teeCITY OF CLIPERTINO-BUILDING DIVISIONtv
Co nRo eName: �a , cNa APPLICATION /PERMIT
IbA..l BUfLDINGELk�f1UCA4I'LUMBINGMCCHANIC.AI. CATEGORY CONTROL/
ArchltM/Fnglnnr. N
60 Z . 6 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreve
` , PERMITISAIAN�
LICENSED CONTRACTORS DECLARATION ® 1:1 ❑ ❑
Ikrby affirm that amsior3 dudes Joeteawof Chapler9(mmnm APPLIANC6RF_STDFNITAL )OB DP N
irwtlice.
Senbn for.andff lon3oftheguJrcsaandl'mfeadauCade,and ,
Visnas a In full for¢and e.# PANELS
LiceDate - clam Lk.♦ pups-e.�e
Dale - GofdndOr UP IQ 2DOAMPS
ARCHITECTS DECLARATION2M-IMO
nez I urderstaM my phm shall be used u public rtmrds OVER IWO AMPS 9Q.FT.FLOOR AREA S/SQ.Fr.
Edo L¢ad Pro mbnal SIGNS>�RICAL D . I N
�� OWNERexempt ER DECLARAEON or
the afflnnl-WNTR-xe from the IARATIOr'a LI¢nm law for the 9eFLIAI.ctI'UIT/MLSC
Z Q� f.low g�rtAsor.Lye .7f l5S,Burn.aM Profembro Code:My dty or
FI"u] eountywhkh requUv a permit tomrutruM etn,Impree,demolbh.Orrepalr TEMP.METERORPOLEWSI'.
r'YE 3 anyatmetum prbrtolta lmame,Alan requ4ntheappBont f¢ach permit to IXYWER DEVICES YA�
K The a ,igred statement that he a ed
li¢nspursuant to the provbloro of the
0u, CmtractoriLIceroe Law(Chapter 9(mmmendng with Sinn 7000)of Divi-
`SOS sum 3 ofthe BJdem
uness and Prlora Code)or that he b exempt therefrom and M SWING POOL ELECTRIC ALUATIOtJ
g0 the ksa for the alleged exemption. Any vlaatbn of Section 7MI5 by any OUTLETSSWHCHIS-F D TURES
°PPBnr'tfor°permit subjects the applkant to a tivll penalty of no,mom than I I t
(y22 0t�undmd dollars%5M. NEW RESIDENTIAL E.TCIR SQFT. STORIES TYPE CONSTRUCTION
GG1l �n 7,as owner of the property,or my empbyma with wages u their sok
comperaation,will do the work,And the stmctum b not lMeMed or offend for �O _�mk T.70"Ruerem and Prdemlura Cod,. r
The Contctors Lim.law
f$ don mt°pply to.owner of property who WU,.r lmpmveitheraorc and
EEE whodoetsuchworkhlnmeB¢through hlsownemplwhech OCC.GROUP RFS ANDS
nym,prldedttm
Impmvemcnb arc not Intended proffered for aa3e.If,however,the building or TOTAL
Imp emend aaoW wHhlnpkyearo!<omplelbri,the wvner-bulldrrwl0luve �3
XFT.0enMproving thatkdld rwt baud orlmprove for purpose of uk.). QTY. PLUMBING PERMIT FEE
u owner of the property,am evclusixely contracting wM 11¢n ed
0D ZDN'E APN
¢•to ceatruct the pmja (Sm 7014,Business and Profmloro Code: PERMITISSUANCE
The Contractors Llmue law does not Apply to an owner a property who ALTER-DRAIN&VENT-WATIIt(Fl0
Wilda or Impress thereon,and who cordraces for aueh ptojete with a
elf�IIt�+ctortURoen°d puruant to the Contractors Llnnae law. FEE SUMMARY
, r(
am exempt ureter Sec B&P G for thy reason BACK FLOW PROTECT'.DEVICE 0tTrqI0F FLUS
rot:
/ /1 !/in DRAINS-FLOOR ROOP,AREA,ODND. SANITARY Y N_
• Owner °OMPA SATI nae RECEIPT0
WORKMAN COMPENSAiIQQ. RATION FTXTURFS PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm thM I have°¢rtificf oruem to self-insure,ce a RECEIPT 0
certlBote,OlWnrker'Comperuadoo lwraum ora omilkd copy thereof L"ec
'00,Iab CJ GAS-FA.SYSIT7.11 INCA OUTLETS PARK FFE Y N
policy
try sI
y GAS EA.SYST1MOVER 4 MA) BUILDING DI
V ISION FEES
Centred copyIt hereby throbbed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy It filed with the my Inspection dIVIJ�.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM I:A.7111FT Date Recti tit
(This stolon need not be completed Rtk permit b f ore hundred dollen
ctlOO)rrtfu anWATIMHATERW/VENT/ELECIR ENERGYFEE Y N
I terrify
lut In the perfo
lerm ¢of thewors for wNchthis permit trod, —.
I shall not employ any p rsem In any manner so u to become subject to the WATER SYSTEM/TREATING
wokers'C mpeneta en[awanf California. Date PAID
O Z Appllont NEW RESIDENIUL PLMB. SO}T. Date ReCCi tit
Z O NOTICE TO APPLICANT.X.fter making this C;,mifateof P empnon,you
shouldbecomesubjediothe Worker'Compew provi mofthe Labor TOTAL:
Q N Code,you rrunfanhwkh mmptywlth ouch pmvbbu orthb pemtlt slallk
W ] deemed revoked. BUILDING FEEr
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihrmby°fgrmthe them I..romentetion lending°ge for the perform, ELECTRIC FEE
Z a n¢oflheworkforwhkhthbpermkbL Qec3097,CIv.CI TOTAL
00 L<Mera Name PLUMBING FEE
LL — LeMOra Addrees QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imeifythatlkwmr thbappllatbnadetatethattheabw f.m on
1 bcomet.Iagreetoc¢nplywlth all eXy°M muntypnlWnmend steel. PERMIT ISSUANCE FEES PAID:
r relating to buimingmvtruction,and hxreby authcrim repruentatly ofthh
I— = dty to enterupon the Abovcrrcntbned property fee Inspection purposes. ALTMORADDTOMECIL
(We)agree to use,IMemrdfy an d keep harm1 m the City of Cupertino Date Recei tN
V agalvt WbWtiea,judgmenb,mesad experon whkh may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ga Wt aid City In c ...quer¢of the gnming of thio pe
ZIW— p,y�j'-�G it 1,L/ /-,� AIR FtANDUNc uNIT rovFR l4oaocFaD CONSTRUCTION TAX
Signature of Appllont/Qwnea[[E' /'late' EXHAUST HOOD(W/DLCD CONSTRUCTION TAX PAID:
HAZA R DOLS MATERWILSDISCLOSU RE
Wit the a ppllea rt or future build log ocnnpam more or ha le hasandwa HEATING UNIT(TO I W,=BTU) Date Recei 1N
material as deBKd by the C4 Perrino MunldpaI Code,Chapter 9.17,and the
Health and Safety Code Seetim 25532(a)? HEATING UNIT(OVER 10400D BTU) TOTAL:
Y.
�I Oltheappikaniter turtbuildingoavpantuseequipmentmdevlm VENTILATION FAN(SINGLE RFSID) 15$UANCE DATE
whb:h eM!havrdoua aU contartdnants as deBrcd q the Bay Arta Alr
QualHy Msiagemerrc Dletrk[7 IiOILFR-ODMP OFB'ORIDO,IXq BTU) lU't�l•
4 Yn ren No JU
have f.4Hthe hara fuyC materials .255nrunder 5533.Ckpter495 of BOILERLUMP(OVER 100,000 BTU)
� the UBlorna Hnhh&SafetyCde,Sr�1bro 75505,75533 and 25534.1
udertand that if the building don not currently ha,tenant,that it Is my NEW RESIDENTIAL MEC]-L SQFT f " it'1,IIBP,I�rl nd
resporo3Blty to notify the ocupard of the mqu Ucmerda whkh mun be met J '
prior to Lmuaocc of a Cortltbte of0exparry. ,((�
Owner or authorized agent Date
TOTAL L5&UED BY:
OFFICE COPY