20001 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Pro' Ids dli¢Uoo PERMIT NO.
BuP1ding Addrtv: levy d ev Y o o o 1
_ o 0(si S -31
�l9 t_JP me. CITY OF CUPERTINO0.BUILDINC DIVISION QQ
. Contnna(sName: Lc.N. APPLICATION If PERMIT
Annb fFnglraer: B.=ING-ET•ECTI{ICAI.PLUMBINGMFLHAMCAL CATEGORY CO L I
it
2BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Addreu: `p j} `S'S S - PERMITISSUANCE ❑ Ll LICENSED CONTRACTORS DECLARATION -
IFe,ebyeffbmthrn
t Iamllcied underpry,WoaafChaomm
ptcr9(oornAPPUANES
CRF_EDENT1M,
Ingwlth Section 7(X0)ofDlvWon3 olthe BusinessedProfrsdom Code,and my
Inoerue is In full to.and effr PANE7S
Lkn.9e eb. Lk.R_22,7.562-1
Dee oar B(a tan n Mcrh j Hj6a1 UP TO 2DO AMPS
ARCHITECT'S DECLARATION —M-10001IMPS
07. lundentandmyptaas Rbeuwdapubeclnam OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
c
Q61 OWNER-BUILDER DECLARATION SP[CIALC T/A45C
ZE• Z' Thereby alRnn that l amexempt fr�the Condretorb Llm�lAwf¢the
09-0 lolbwing rtuon.6eailon 7m15,Buslnm and Profubns Cade.My tlty or TEMP METER OR IDLE INST.
F� county,which requ be a permit to outrun,shn,Improve,demolish,or repair
qqq any munure prfo,to Its bsua me,also requires the appBant for such permit to POWER DEVICES
f5 I. fib•signed statement the he h Bsunt
¢nsed purato the proWlom of the
3u, C-rhadne.Lkense latw(Chpter 9(co.ocing w Section 7000)of DNI- SSVID{MINGPOOL ELECTRIC
�0 sion3ofthe Rusin.and ProfessbmCode)mthehe6exempttherefromit" VALUATION
yl the bub for the alleged exemption. My WoIeJon of SeRbn 7Q3LS by any OUTLETSSW[TCHFS-FIXNRFS
6i appB¢ntforapem bier eappllcmttoad ipeuhyofnatmmt¢ n
five hundred dot"( AQ.
n1.as owner of the Property,or my employee with wages as their ante NEW RESmENTIAL EI.F.CTR 9Q17. SIDRIES TYPECONSTRUCTION
comper saflon,will do the um],and the stmomm Is"Intended or offered for
��A o6(San,7041,Easiness and Ptdesbna Cude:The Cormadoe.U¢nse Lsw
�$ don not apply to an—of property who builds or Imp.t hereon,end OCC.CROfllr RIS.UNITS
e
who dosucow
hwvrk himself or through his n employee,provkicd that suds
Improvnnenb are not Intended orofferad for cele.IL however,the building or , TOTAL:
Improvement beald within one yesrofcumpinbn,she wvnerbullder will have .
U)Sjsnrden of pmvlhg that he dkinot Wud or impeove for purpose ofu6.). QTYI PLUMBING PERMIT FEE
LI I,as owner of the property,am euluslvety osn a g with Tissued FLOOD ZONE AM
costr+noe to rowrun Ua pmjM 6ea.7044,Bwloess and Professions Code. . PERMIT ISSUANCE
the Cormador's License Law does fiat apply to sm owner of property who
Wild.or Imp. thereon, and who ardnm for such projects wish a ALS-DRAW&VINT-WATER ffA)
rrus,(e)B mad pursuant to the Contractor's License,Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
am exempt undo Sec B&P C for this¢aeon
DRAINS FLOOR,ROOF,ARRA,GOND. SANITARY ,Y_ N
OUTSI DF,FEES
O.vKr Dee RECEIPT 4
WORIC.{AN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOL TAX Y_ N_
®f hereby,/infix the I have a¢rtlB¢te M ronaeM to ulf-Lorre,¢a RECEIPT R
3800,UeofWorken'Canp<nsatlon lruurm¢¢a¢nl/kd copy thertolf$ec. GAS E.A.SYSTEM-1 INC4 OIIITFB PARKF'FE Y N
Paltry
Lib C)
Com s—pI1b1�Q��.�]7Q (:AS EA.SYSTFM�OVER 4(FA) DING DIVISION y_1YtlLLS sill IE)5_ BUILD W C DI VISION FF.Eg
®CCertified copy b hereby furnished.
mifln]copy b filed with the,fty lrapenlon divWon. GREASE/INDUSDU.WASTE WTERCFPMR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
Cant earn lel ift epeR t CE SEWERSANTTARYSTORM EA 200FT Date Recei t#
(fhbe tion need fiat be cornpinN if the perrtJt bf¢ov hundred dollen
mLn)¢Iw3 WATER HEATER W/VENT/ELFCTR FNERGYFEE Y N
I¢notffy cop In the pe,r.In ofthe weak fors to
Wseemdtb band,
I hallork not employ any person N any manner at u m become subject to the WATO{SYSTFbf/TREATING .
worker;campenadan l�waor�uram6.-oxer PAID
ZOZ ND]ICE TO APPLICANT:If,slier making this Crniflate of Exemption,you NEWRFSIDENTIALPLMS. 9Q.FT. Date Recei to
F y should becorr¢sub}at to the Worker Campame1un prov6Lebo,
bns of the TOTAL:
code you twat frethuMh comply with such provisions or this permit shall be
> deemedt.10 i.
W �IJII DING FEE
— CONSTRUCTION LENDING AGENCY ISMIC FEE
1 I hemby affirm that them is a construction lending agency for the perform- ELECTRIC FEE
� z an¢oftheworkforwhkhth6pemdt66sued&c.3097,CN.C.) TOTAL
U Q lender.Nanne PLUMBING FEE O
LL 1- L<nder's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lsend!y NdlhvemadtM appllotbnaMWtethetheabw foo lon _
b armi.Iagr¢to comply wRhallntyand county ordlrunmandpate laws PERMTISSUANCE FEES PAID:
} N mlatingtobuldingwnsma n,aMhembyautho mpresentatM ofthb ,
F Z sty to enter upon the above-mentbnned property for impeNon purposes. ALT}]{OR ADD 7O MEICH. Date RCCci to
_ (We)agnc to save,iMe.Mty an d keep harmiew the CNy of Cupeniro SUBTOTAL•
,gaWt habNtka,WdgnrMa,cmte and expean which mayb anywayamve AIR FONDLING UNIT(TO 10,000 CFM)
,gabat aid City Inconsequen¢or th<granting sur Wape,mlU AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
4.1ure of Apph.rt7C.ff41or Date^ EXHAUST HOOD(W/DDCD - - CONSTRUCTION TAX PAID:
HAPARDO S MATERIALS DISCLOSURE
Will the applloM or future building occupant store or handle haredous HEATING UNIT('M 100,000 BT" Date RCCCI IN
material as defined by the Cupenim Mu Mnpal Code,Chapter93Z and the
Ekethewl Safety Code Senim75532(a)7 HEATING UNIT(OVER 100,00 RT" TOTAL: CL Q
❑Ye Na
Will the a pptio ntorfubui
ture build Ng oavpant use equi poen orci i VENTILATION FAN(SINGLE RESID) ISP DATE
which emit haardoua eai,r mntamW Ms as definwd by the Bay Area Ab
Q.alalty Management Dt❑tr{G7 ROILMCOMP PHP OR lWDN
RM
• Iha'e mad the haLmaterlab rayum,ments underChapter 6,95 of BOILER-COMP(OVER 100,000 BTU) JUN-2'6,199U
the California Health&SafetyCnde,Sections 25505,ZS33 and 2_634.1
understand that lfUm Wildingdm outarrently haveatenant,thatltbmy NEW RESIDENTIALWCH SQFT
neponsmBbytomxifytheoaopeu&the mqubentemawhich nwnbe met Rs, ,{M.aaa.a+aasaR
prlortoivuam,no6CenlriateofOmnpanty. YY1I W 411VWa".
G 11?- 40 'S�
orauthorlud a gent Date ISSUEDBY: ��✓ /lkilX-lJ-�(
TOTAL
OFFICE COPY