20010 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Peosentltemlfkatl OC - PERMIT NO.
Buuamgaaa) 06 5 2� 3 Z c 20010
�� tee. CITY OF CUPERTINO-BUILDING DIVISION
• ctole "ore: Gc.No: APPLICATION / PERMIT
WFAUTT dd Il
'• /k BW ELECTRICAL PLUMBINGMECHANICAL CATEGORY CONTROL N
A et/ gl —T No:
1 �'r 5 QTY ELECTRIC PERMIT EPEE BUILDING PERMIT INFO
Address (DQ �SSb St. SF. PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dfi.that lam lkenxd under pr W.ra ofChapur 9(ournmere, APPLIANCESRESIDEMTAL tip gg.1.pN
Ingwith Soctun70=ofD(vbim3 ofthe Buslruaeand ProteuloniCode,and try -"N(7 1 (�
ie,cbin fu8 and fff�. PANES l �� f'
Date� Comn�/2rYs (-O
ARCHITECT'S DECLARATION -1 ANTS LLL rt,
0 C
TOC l understand my plane shall be uaod n public mord, OVER 1000 AMPS F � $/SQ.Fr.
od U Lkeneed PmLE
feslonal SIGNSELECTRICAL s... U
t,<N OWNER-BUILDER DECLARATION M P U T E
7 �y Ihemb afflnnthatlamexempifremthe Coeractor'.Lrem Uwfarthe 9PEC AI.CIXC T/MSC
pp =ntywhr rn.P.ccape7 5,Buenecalt Props ,eCade:Mytltyor
0 7�qqq IIIAP.ME7FR OR POLE MIST. W;
Fmly muntywhkhrequb,apemdt to mrotrut,dter,lmprove,demolbharrepalr —J )3/41
CCC171 a arty atru ed staterre W that
he es aboren!puraeart to the faaches of tta POWER DEVICES MA
y'w m� floc a algnM neem eLa Ilan he t Ilmnaed pursuant it the pro7(CO) of the
3u Con3.fthi limes andPreeelr9(mmmenMthethSedbnherefofDIW-
C O�^ elon3 ofthe Buslnmand Profeabro Code)arthe hebexempt Nerefromand SWIMMING POOL ELECTRIC VALUATION
5 fS�g Ne basis for the alleged exemption. Any Nolatlon of SetIon 7m1S by an
�oa app8ant for a permR wbjemthe applicant to a d"I penalty d net mart than OIJD.EISSNOTCFHSHXTURES
ndred ddlan(1500). NEW RESIDENTIAL ELECTRSQ.FT.
as STORIES TYPE CONS7kl-CIIO\'
..p, owner of the property,or my employe,with wag,an their sole
comperuelon,w0l do the work,and the Brume,b not W ended or offered for
C o oale Cit,70K Buerea aM Prdembv Cade:The Coobnu:t .U..Law
Ifisg don wtapply toss owner d property who builds or lmprwes thereon,and OCC.GROUP RES IINTB
GG.. whodaneuch work hlmB«
� thwgh hbown employe provided thatsuch
Improvemew are not Intended or offered for sale.If,hawavcr,the building or TOTAL:
Opmeement bsdd within oneyearofoomplebr,the vomer-buOderwW have
t ed on of proving the k did not build or improve for pu rposa of sale.). QTY. PLUMBING PERMIT FEE FLOOD mNE AI'N
4 as owner of the properly,am exclusively contracting with Ilanxd ppRMpp ISSUANCEcontndns to entered the project(See 7040 Bs
ueneand Pndmbm Code:
Ile Comnctorb Llaroe LAW don net apply to an owner of property who ALIFR-DRAW&VENT-WATER(FA)
Wilda or Impmv,thereon,and who <m contracts for sueh ieo) with a
owlifaeter(O loomed pursuant to the Cmntneor's Linme Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I en nempt under Sec 8 &P C for this reason
DRAINS FIAOK ROOF,AREA,ODND. SANITARY. . Y_ N_
S Owner Dee —
WORIOHAN COMPENSATION DECLARATION RI)$'f Y
hcrtbbyy affirm the I hive a certif to d cornett to self-mere,or �NRFS-PFR TRAP —SCHOOL TAX Y_ N
oe Oare dWorkeni Comperoatlanlrou a Rrtl(ied ropy thereof bee RIrE]PI'Y
aa��II
GAS EA.SYSTEM-1 WCAOUILETS PARK FEE Y_ N_
Pd Yb ) 0 Oft/ 0�/ 'RECI]PI'Y
GAS EA.SYSTEM-OVER 4(EA)
CeY BUILDING DIVISION FEES
tlf copyb
niBsd ropy b fileded with t . GRIASE/WDUS1RL WASTE INTERCEPTOR PLANCHECK FEE
' tthehivy Inspection division. EP
CERTIFICATE OF EXEHMON FROM WOR K ER B' GREASE]RAP PAID
COMPENSATION INR
SUANCE SEWER-SANITARY-STORM FA XIQR Date Recd t#
(ITd,,action need nn be completed lf the pend[b froom hundred dolf.n
W W)o,j.) WATER HEATER w/vEWT/17,ECTR ENERGY FEE Y N
I certify the In the perferouna of the work forwhieb this pemdt is lsened,
1 eha8 nm employ any penin In any manner an as to become sub),cit to the WA.fQt 5Y51P1.f/,IRFA,DI�G
w.lu,.Cmhpen.flon I.Wsaf California.Dare PAID '
O Z Appliam NEW RESIDE T1ALPLMB. SQFI'. Date Recel t#
Z O NOTICE TO APPLICANT;If,a Rer making thla Certificate of Exemption,you
N should become aubjett to the Warken'Compensatlm�provbbm o(th<IAbur TOTAL:
Code,you s[fothwLLh comply with such prvvlsbro or Nla permN shall ha
W > domed revoked. .
CL o CON4TRUCFION LENDING AGENCY SEISMIC FEE
Ihereby.tOrm that there b.mneructlm lending agony for the perform
Z anmoftheworkforwhkhthbpermitblvwcd(SLe3097,CIV.C.) TOTAL' ELECTRIC FEE
V O Larder',Nene PLUMBING FEE
LL ~ Landee.Addr,a QTY. MECHANICAL PERMIT FEE MECHANICALFEE 30
O ION 1 mtifythel have read this eppB ticnedl Bate that the abovebfor m �s
4 bmrnd.lagreetocu plywlthal&yaMcountyordba ..ndnatelawe PERMIT ISSUANCE I 1t�L/ FEES PAID.
N relating to building rorMrudlon,and hereby authonu representatives of this
f" Z dty to enter upon theabuvcmentbred property for inspection purpo�A ALTE4ORADDTOMECH-
V _ (We)agree to.av Indemnify an harmlea t fty of Cupetlm Date RCCei t#
agerot Babwtfn ma cone sea which lnanywayaotue AIR HANDLING UNIT 9010,000 CFM) SUBTOTAL:
galrot said N Barye the els oft mdt
�� ��/moo AIRHANDUNGUNTf(OVER 10,0DDCFSD CONSTRUCTION TAX
Appueant/C dor Date MIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
m oHAZARDOUS MATERIALS DISCLOSURE
Willthrappla in or neturebuading oavpont store or handle havMous HEATING UMT(IO 100,W0 BTll)
mecrhlu dofined Safothe Cupertino MuNtlpal Cade,Chapter 9.17,andthe Date Rmei t#
Health and Suety Codod2S537W7 HEATING UMT(OVFR 100,000 BTI-0 TOTAL: Q O
nn
Yea TOTAL:
m
be Oding oaupant use equi pane or devk, VENTILATION FAN(SINGLE RESID) ISSN URATE
whlcheMthanrdw, kmntaMvsasdeflmdbythcBay Area Mr i Q'U
Ora hty Maregenrnt rkt7 BOB.ER-COMPOEOPOR IW,ODD BTU)
4Yea
huve mad the h oils materials requirements under Chapter 6.95 of BOILER-COMP(OVEt 1W,"BM JUL 31 i9�p
the mn
Callfla Health&SafetyCode,SMbro 25505,75513 and 25534. I
underead that ifilveigelding don rot ntly have.to ant that it is my NEW RESIDENTIAL MECH. - SQFT.
responibilky ton t eeeepad a kement kh mut be raet t ra fs„tet '
prior to baro da rti0ateo O ''' y -
authorlad agent Date ISSUED
TOTAL:19tBY:,,.le
OFFICE COPY