22940 (2) V
APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildina Project Identification -- PFBWT NO.
Building Addres si-v�- 's .cam 6 v cU ' 22940
ounce onc:;
u CITY OF CUPERTINO-BUILDING DIVISION , �G
contradb dName: uc.Na: APPLICATION /PERMIT. L
BUILDING-E.ECTMCAL-PLUMBING-MKHAMCAL CAITMRY CONTROL
Archited/Engineer, - Lm.No: ,
•t BUILDING PERMIT;INF,O-
_ ELECPRICP1ERMIT FEE.1;
Addrc s
'. PERMIT ISSUANCE /" ❑ �} O.
LICFNS CONTRACTORSEDOECLA RATION L�
Thereby affirm that undertlam licensed underprovtalond afChapter9(rommenc- APPLIANCES D L JOB DFSCRIPMON
license
I (.full 7000)of d dleon3o(the Bumneasand PrcteslaneCode,sect my
license le In Tali force and c.# PANELS SPA License Class LIC.M � v /J
Date Contrador
ARCHITECT'S DECLARATION 2011 PS
p�u0b Iundentand my plans ehaB be used epubllcrccorde. V AMS f\ I' �e. _ �R , Y $/SQ.FL
u Licensed Professional NS ELECTRICAL �^a ppp---
<< w OWNER-BUILDER DECLARATION Y LJ �/T g. Q
In� exempt BI'ECIAL CIRCUIT/M15C Y ` , a
71" owing rasormthatlam31.5,Business
Contndoos Wrense Law fort
�zhpp qqq following myon. ices ap 7031.5, omilousand Professions Code:Any city it
p'Iy countywhich requlrcsaperMtroconstrud,altep improve,demolish,or repair T�''MEIFR ORPOLL•INST.
E anystmdurc pdormit.i.arance,eloo rcquirnthe applicant Tor suchperoutto POWER DEVICES saasss
C. file a signed statement that he is(lamed pursuant to the provisions of the
Contradols License l.zw(Cha(Chapter (commencingwith Seduce 7000)of Diel- VALUATION
F t SWPSMINC POOL ELECTRIC
F,�OS
Mon Business Prvfe®bmCode)orthat he Is exempttherefmmand '
SS' the basis for the alleged exemption. Any violation of Sedlon 70312 by any
45 OUTLETS-SWITCHES-FIXTURES - l
appllwntfor aperen($500)d.the applicant too rnil pemlty of not morethan _
'E vn drc-ner (5500). SQFT, STORIES TYPE CONSTRUCTION
NEW RESIDENTIAL ELECTR
s owner of the property,or my employers with wages as thele dole
satlon,Bostonthework,andthes Cods:Th net int.cuo'o License
d for
Iov -
Y p sale(Sec.70Kpply to an
Professions Cods:The Ccutor improves
Lereon Taw
$ don nonsuch torn owner o(property
rough whoWilds nemoympmovided thatand +such OCC.GROUP RES UNITS
who doesucs am n himself or ed orough his owne roffered for .If,hoe, er,theed that or
impmvementsarenotlntenomyearofcomplMW.theo vogthebrwilln ve - TOT t
i pmvement lsdold withinomyearo(compldbRtheowner-bu0derw111 have � ,�)
tm1�,�+rden of proving that he did not build or Improve for purpose of eleJ. QTY. . ;{ ,+' PLUMBING PERMIT I;'_;{,4r {, ,FEE ,'. FLOOD ZONE APN
LJ L as owner of the property,am exclusively rontrading with licensed PERMIT ISSUANCE -
contractors to construct the project(See 7614,Bushes and Profeselom Code:
The Contndora Licenes Taw don nd�/ply to an owner of property who ALTEt-DRAIN k VENT WATER(EA)
builds or Improve he n,and r9 contracts (w such"plopcte with a i
dialfactor(s)llcen nuanyeo ! 'ontradosh License Law. - 'FEE�SUMMARY -
I_J I am axe t der Cc B k P C !ar this renon BAIX FLOW PROTECT.DEVICE OUTSIDE FEES
-
'f DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Own Date ftECF1P1'M
ORKM OMPENSATION DECLARATION pD(TURES PER TRM f,• SCIgOOL TAX Y N
❑ e e affirm I have a artif nate of consent to self-Insure,or
- RECERxf M -
mrtif tend eV
ompenetienlvumnaeramAifledmpythemof(Sec.
&K0,Lab QS GAEA.SYSTEM-1INCA OUTLETS PARK FIT Y N
Policy R RECEPT M
GAS EA.SYSTEM-OVER 6(FA)
Com any" BUILDING DIVISION PI!1:5
ElCertlBcd copy b herebyfurnished.the city - GREASE/NDUSTRL WASTE INTEtCEI'TOR PLANCHECK FEE
❑Cerfifled ropy is filed with the city inspection division. - ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SENT.R-SAMTARY-STORM G.200lT. DatC RCCeI IN
(This section need net be completed if the permit is forons hundred dollars - P
(510(EorI..) WATER HEATER W/VF1JT/ELFOTR ENERGYFEE Y N
I certify that N the performance of the work forwhich this permit is issued,
I shall not employ any person In any manner se as to become subject to the WATER SYSTPM/TREATING -
Workers'Compensation Laws of California. Date PAID
Z Z NOTICE TO APPLICANT:](,after making this Certlftrate of icant Exemption,you N`EW RC DENNALPI.MB. SQ.FT. Date Recei t#
FO should becorrc subject to the Workers''Compensation provision of the Labor TOTAL:
N Code,you reset forthwith amply with such provisions or this parent shall be
Wj deemed revoked. - BUI G FEE
CL . CONSTRUCTION LENDING AGENCY SEISMIC FEE' _/a
IherebyafRrmthattherc biaamtructlon lending agency for the perform TOTAI ELECTRIC FEE
L) Z anceof the workforwhich this Former is Issued(Sec.3097,CIv.C.)
O O lender.Name -- , PLUMBING FEE
H Lender,Add.. QTY. MECHANICAL PERMIT',
O W (certify that I have read this application and date that the above information - MECHANICAL FEE
a is correct.I agree to comply with all city and county ordinances and mate laws PERMITISSUANCE FEES PAID:
>_ relating rebuilding ronswctlon, reby7sentatlen ofthlsN cityrodud.pontheabove-meanpmpatyhou1.npurpme.. ALTERORADDTOMECH. '
Z (We)agree t an d keep harmlem the City of Cupertino Date Receipt#
V agalnstlbb ,judg rat a and expensed which may In anyway accrue AIR ITANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against 'yin d Ing a(thle AIR HANDLING UNIT(OVER I gmOCFM) CONSTRUCTION TAX
nature of Appl nt/ mumdor rData / EXHAUST ITOOD(W/DUCT) CONSTRUCTION TAX PAID:
/HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT HO 100,000 BTU) Date Recei t#
o
ccdal as defined by the Cupertino Municipal Code,Chapmr9.IZ and the
Hnithand SafetyCode Seduon25532(.)7 1. BEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yn No
Willtheappilcanto um building occupant use equipment or devices VENTILATION PAN(SINGLE RESIDE ISSL�Nr.E�
which cult haverdoud air rontaennant.a.dented by the Bay AresAlr, A
Qua lily Ma"gement strid7 BOILER-COMPOHPOR100,0WBTU)
qYea he h No
have read ealth ety Code,Se tions under 6.95 of POILER-CAMP(OVF721fA,000BTU) ` C
the California Health building
Code, otcom25505,ve a tens rt,
it Novry V 1991
undotsland that if the bullding does not avrmntly haveatenanq that it is my NEW RESIDENTIAL MECH. $Q.R.
wmpomubihty to notify the occupant of the requirements which must be end
prior two issuance of Bceteof Occepaniy. CITY LI'',Lx/UCtji I INU
yft
D.v4a/ors agent —'- Date ,• ISS[II-D
rornL:
OFFICE COPY