20088 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ea Id—tifbtlmr
Building Address: PER.WTNO.
���� s ✓e,✓s�,��,� s -FAeK� 20988
n ne LIJWCk, one:
�!Y OF U 2 CITY OF CUPERTINOLBUILDING DIVISION /1O
centnmr N.rn� Lk.N¢ APPLICATION / PERMIT ']
L ✓f e ��4?C��( BUILDINGS.ECTRICALR.UMBINGMECHAMCAL CATEGORY t�
ArcARe t/Engineer. 11 Lk.No
QTY ELECTRICPERMIT FEE-' BUILDINGRMIT INFO
Add. PERNUTISSUANCE El El ❑
LICENSED CONTRACTORS DECLARATION
thereby affirm that l amunder provWovof Chrmc APPLIANCES RESIDENML
Ingwlth5e1bn900o(DWIsfoaMtheBusi.ssand Pro(essionsCode,and
y 10 D RIPIION
lice..b In full force and effect PANES (�� //�J - 1
Llcenyllaae__ Lk.I / /aLL S �y"SIO
Date Comncvr
AA shad] R E 00 PS
AM
00 IuMcratsrd rrry plans shad]be as
a OVER 1000 AM75 SQ.Fr.FLOOR AREA 5/SQ.FT.
` OO
m E 5`j
Licensed Profenbvl SIGNS ELECTRICAL
�= OWNER-BUILDER DECLARATION SI'CCIALCIRCIIIT/MLSC
f., Ihernbyafflrmthallameemptfmmthe Contrs et Lice lAwfmthe
>S) folbwing readn.(Sector 78115,Buainm and Prolesslons Code:My dty m
6LI q❑ TEM .M
PETE[OR POLE INSr.
r5� countywhlch r¢rylrypermit
t ,aker,Improve,demolish,orrepalr
0anysivcturt prbrto k.l.darcc,aleortquirnthoappBant fmwch permxto
O POW
file a signed statement that he b Licensed pursuant to the provWero of the me DEVICES '
7 Comncor'e LkenseLaw(Cluper9(mmmendng with Section 7000)d D1v1-
d ' SWIMMING R70L E.ECIRIC
F�O< alon3ofth.Bu Mr.and Preasbv Code) he Is mpt therefrom and VALUATION
•..tt the bisb for the a11egM exemption. My Wdatlon o(Secbn 7m15 by any
�Gi appllant(ora perrNtdbjca[slheapplkanttoa ctvllpwltydnot monthan OU7i'E'[SSW17LFiES1IKf URFS D D
p... Ilvc ndrtddollars0kW.
�- dI aaownrraftheproperty,or ,yempleyetswithwagnutheirsole NEWRESBJENi1ALELECTR SQFr. STOMES _ TYPE CONMUCfON
compensation,willdo thewmkandthestruchimisuatbendedor offered for
D sale(Sec7014,Ra.beas arch Professions Code:The Contractors Lcerue law
�$ don not apply to an owner ofproperty who Wlidsor fmprovn thereon,and OCC.GROUP RFS UNITS
who docs such work Nmself m through Ida own employer,provided that dch,
irprove Msartnot Intendedearofccdfmu4.If,hosvev-r fldbuildingve AL
ImprovcrrcM beold withinovyurofcanpletbgtheowrier-W I1dmwW have
tlXkurdenofprovingthathedanotbuudorimprovermpurp. ofsale.). QTY. PLUMBING PERMIT FEE
"L as wvnet of the property,am exchWvely contracting with Ikxnsed FLOOD ZONE APN
mnlracters to construct the project(Sec 7014,Basis.arch Prduro bCade: PEUl1T ISSUANCE
The Contractor's License Law does not apply to an owner d property who ALTER-DRAIN 4 VENT-WATER(EA)
builds or improves thereon, and who contracts for such, pAojuxa with a
c7W7'actorW Basch pursuant to the Contractors License Law. gAa:FLOW PROTECT.DEVICE FEE SUMMARY
U p 1 am eaemunder Sec B k P C for this rcnon
QE�%I DE RES
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_
Owner Date RECEIPT#
r WORIP.tA :MPFNSATIONDECLARATION
❑1 heer�ecbbyy.«irtn Nat I have• cf'0I d consent to self-hist re,a a PIX'NRF_S PER TRAP IOOI•TAX Y N
ceclEate o(Wohers'CompenuHonlwnnce cera certified mpythemuf(Sec. RECEO'r
39W,Lab CJ GAS EA.SYSTEM-1 INC-4 OUTLETS PARK FTE Y_ N
Porky1 GAS EA.SYS Ek(-OVER 4(EA) DING I
Com nY BUILDING DI VISION FEES
I�ceriiea copy b hest with
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CludL
odified ropyb(Iled'with the city lvpecbndMtlon. �¢ �l
CERTIFICATE OF EXF]NPTION FROM WORKERS' CREASETRAP PAID Ur,�
COMPENSATION INSURANCE SEVER-SANITARYE.A.700FT Date Reoel t#
(Thla.ecbn need red be completed B the SURA[b(more hundred dollen
M OB)us I..) ENERGYFEE Y N
Icerdlythat in the performance of the work for which Ws permit i•tided, WATER IIFATEt W/VFM/dFS:TR
I sha0 net employ any pram,b any manner,-.to become db)ei1 to the
wm
WATER SYSTEA(IRFAUNG liccmrghen.atbn LwadalBnmb. Date PAID
O ZApplicant
. ZNOU
p onceronrrucANT:v,.fier mamng rob CertulaterrEa.mpbn,you NEW RF3DEN'l1ALP[MB. br1Fr. ' DateRecei t#
shmid bemry sub}ct to the worker,Compevatbn provhbv of the Lalmor TOTAL
~ N wna,al/mthweh comply wllh dch provisions orthh perMt.hall be
> «red rrkea. BUILDING
W deemniw
— CONSTRUCTION LENDING AGENCY SEISMI E
CL Ihemby affirm that then b a conmetion lending agency for the perform ELECTRIC FEE
n Z ante of the work(or whkh thio pemAtbbded(Sec.3Y197,CW.C.) TOTAL:
U O Lenders Name PLUMBING FEE
LL ]ender.Addrma QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W lo,difythatl havenadthbappliatbnaM satethat the above Information
Ismrree.1agrestocomplywkh all ctyam muntyordUunm and state laws PERMIT ISSUANCE FEES PAID:
} N relating to Wilding mnstnctlon,and hereby aithMr representatives of lhb
Z city to enter upon the above-mendoned property for Wponhm purposes. ALTER OR ADD TO MICH. Date RI t#
— (We)agree to save,indemdty an d k p harMes,the City of Cu pert luso CCCP
ag.1mtliabilities,0figments,mstsard eepe.which may In any way... AIRHANDLINGUNITU010,000CFhU SUBTOTAL:
t agaWt said City In mnseVeroe of the grardk,g of this permit.
AIR HANDLING I1Mf(OVFR 10,0)0 CFMI CONSTRUCTION TAX
Signature of Applicant/Contractor Dale Da-IAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HA] RDOUS MATER IALS DISCLOSURE
Will the app0o of or future building occupant store or ha sir Is h.rdws HEATING UNIT CIO 100,000 BTT1) - Date RCCCI t#
material as dell ned by the Cupertino MuniI Code,Chapter 9.17,and the _
liFa2�Y.
fth and SidetyCode Section 75537(a)t HEATING UNIT(OVER 100,000 BTU)NO TOTAL:
YY
dlthe app0aatm tun building oavpant use equiprrcrd mdMm VENTILATION FAN(SINGLE RF9D) ISSUANCE DATE
hkheMtnagemet akrict7 vnD as de0rcd by the Ray Arta AU
Quality Mavgemerd Dblrb7 BOIIFRLOMP PI-D'DR IW,IXD BTU)
O1L�—�� Yn ❑No
Ihave read the h avNw.moterials trnpurerrcnb under Chapter 49S of M0ILER-NNP(OVLRI00,0WI3TU)
the CaWmnla Health k Safety Code,Sections 75505,75533 and 75534. 1 • . ..
urdmuMthatl(the WBdingdm=o mntlyluve.levnt,tlutltbmy NEW RESIDENTIAL MECH. SQ1T. 990
rvpo.mORy to notify the occupant of the requirement which rust b,mel
P rior to soerfi tc of n'�r
_ ,��0 f
r"'!•(Vs . 00 1
r thorleed agent to ISSUEDB
TOTAL
OFFICE COPY