20059 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuIldfoR Project Idemlf tion / PERMIT NO.
Building Addrtv: $ �fvldoO —
B-3 d0 UuZTc,, 3 3s rP 20059
TRZMFVM_m: me: APPLICAT[ON SUBMITTAL DATE
�) CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMITcd jZ BUILDINGkLACALPLUMIGMMCAL CATECARY g �SCONTROL 0
a '
Z C� BUILDING PERMITINFO
Q ELECTRIC PERMIT FEE
Addrmc ,�OrS PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I..licensed urder provldon.&Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB isc {LTI0
Ingwith Sectbn7000)of Dlddm3 efthe Businesand Rofesslon.Cedq and /�f"J� /,•�-JJ
license b In to d e fed. s///cy q r� PANELS L rI` E
U FL 01)e
Date
etas Lie e ` �L 7 74
Date CorRTE(7
ARCHITECTS DECLARATION
q�v aO ZpC ]undentaM rtry plaro shall be used s public records OV OVER 1000 AMPS - sQ.Fr.FLOOR ARTA 5/�.FT.
k t(ttuaa/ Licensed Professional SIGNS ELECTRICAL• - A L E D . S
OWNER-BUILDER DECLARATION SpTCIALCRiCUI7 A45C
Z �G Ihembyaflmthatlame.empt fmmthe Cordndorsltceraelawfmthe MPjjU
foVowing maane.SeNm 7m15,Busines and Prefesbro Ce:Any city or 'V'C�jTTj�!'/ v
O TFMP.MbTQt OR POLE AST.
KER
� osunrywhkhre to lapcmdttoar md,altm theapUv tie olbh,orrepto (��El
�[ any atrudare pdmtolte leRrarae,abo requkmtheapp0cant/meuch pemdt to POWER DEVICES '� 'I • ,
K` file a dgned daternent that he b licensed pursuant to the provbbv of the E.
Ou Contractor'sLlceuse Law(Chapter9(conunnctng with Section 7000)of Divi. VALUATION
F,30�n don 3 of the Business and=ra Code)or tW ha L eampt therefrom and SWMIMING POOL ELECTRIC
the Well for the dleged eaemptlon. My dolaticn of Section 70315 by any
G�
applicant fora peredt eubjede the applicant to a ddl perolly of no enonthan OUTLEISSWTTCHFSFD(TURES
flue hundred dollars he Pro NEW RESIDENTIAL ELEM SQFr. -STORIES TYPENNSIRUCTION
esaowrerof theproperty,d the structure
ankhwags rtheresok
offered for
sampewdon,B.inesill do hawork•andlhe,Code:
brut MaldeIntended or.Lw
sale Sec 7041,Buekas.cerci PNsbro Ce:The Conindor.Warne Law
(,}5$ don not apply to an owner,of property who builds or lmprwes thereoq and OCC.GROUP RFS.UNITS -
LL whodooachworkhdmaU mthmugh hiaown enrylaym,provided thatsuh
Improverre ds are not Intended oroffered!sale.If,however,thebullding or TOTAL -
Imp w,re,rt bsold within oneymrofccenpletbd,the owner-0udderwW have
t)q_kurden of proving that he did not build or Improve for purpae ailk.). QTY. PLUMBING PERMIT FEE FLOOD ppNp ApNr
LI L as owner of the Property,am eecLuivety contracting with Ilreed
contradon to corolnud the project(See.7344,Buslnemard Prdeslom Ce: PERMIT ISSUANCE
The Co
terador's Lka Law docs no apply to an owner d property who ALTER-DRAIN A VFM-WATER TA)
or Improves thereon and who contracts for wed plvjeN WIN a
Banned pursuant to the Cmtadds Ltoerae Law. AAO(FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this rt
awn DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Owner Date RECEIPT R
� WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAA Y N
}�}fhereby af(Irm that 1 have a artlfconsentwrc
te of consent to sere-I ,ora —
anl rneof WorFen'Comperodlm lrounnaaaanlfkd copythertof Sec. ATCFTITI
Yb 3 oft0 Q GAS FA.SYSrEM-1 WG40UTLLTS PARK FIE RECEIITN
GAS FA.SYSTEM-0VER g(EA).
y '1 a(f , BUILDING DIVISION FEES
Cenlfled copy L hereby furnished. / GREASE/INOUSIRL WASTE wTERCErmR PLANCHECK FEE
ert13ed copy L filed with the cityIropedbn dlv on.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASE98AP- PAID
COMPENSATIONINSURANCE SEWEt-SANTTARYSNRM EA.20lFr Date Recei t#
(ITL eedbnneed sat beconpleted tithe pemdl b(mamhundrtd doBan
Il alm)nify that
WATER COATER w/VENT/ElFmt ENERGYFEE Y N
Ianor thatbthe peron,anany he rrawale for tohco pemrkc Wiled,
laha0notemploy
rrany perwa of
manneratuto bttome subject to the WATER SYSTIM/TRFA"ING
hackers'Comperwtbn haws of UllfomL.Date PAID
PP NEW RESIDENTIAL"B. SQFr.
n leant
Z 2 NOTICE TOn,subp ANT:I/, .rk..'fter k.vnpeong this Ction proof Ens f the ,you Date TA 1#
aholdbecomeforth to thenply wiComprwtlons or thbpeofthe Mbar TOTAL:
LU N Cnedi mndtathwilh comply with wch provisions or thL pemdt shdl be
`> dnmed rooked. BUILDING FEE
W O CONSTRIK.TION LeMiNG AGENCY SEISMICFEE
CLIherebyafllrtnthattherchacornierdimlcedingageeryfOTt pedor TOTAL ELECTRIC FEE
Z anceoflheworkforwhlchthbpermkbie dSec3 ,CW.CJ
U O leodcra Nam PLUMBING FEE
LL Iender.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE Q
O W Iartltythatl Wvr rtdthbappliotbnaM aatethrtthe above Lfornratlm
bconeer.lagree Wo plywkhakckyaMd ntyordinanmanddate Lws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authodv mprexntadvn ofthk -
1— Z ctty,to enter upon the abov .ttcned property for Inspection purpose. ALTERORADDTOMECFL Date Recei (#
_ (We)agree to emd(y barrel.the fty of Cupertino P
agdrot WblBtln d nxa,cots roe which Lany way accrue AIR FANDONC[UNIT(IY313,000 CFM) SUBTOTAL:
agalrot aid b e ting h melt.
`^ 'n eAIR HANDLING UNIT(OVER IR"CFW CONSTRUCTION TAX
SIg1U App��dor Date EXHIAus'rmm(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBant or future bullding aavpant atone or handle haTardaw HFATING UNIT GO 100,000 BTU) Date Rccci t#
rratedd as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hakhand Safety C cr$mim 25532G)I HEATING UNIT(OVER 100,000 BTU) TOTAL: 870;;?)
Yee
3l the applicant allCfdl obuilding occupant uae equiprrcnt or devlss VENTILATION FAN SINGLE RESID) ISSUANCE DATE
which emit hamrdou•dr curuun mni..a dcfirad by the Bay Ara Nr
Qualky Mawge"en' t 7 BOILER-NMP OFR'OR ID0,0W BTU)
4 Yn No
have read the haw oil.rnutedala reyuU<menLunder Chapter A95 of BOILER-NMP(OVIR IW,D00 BTU) SIL 31 199
the California ff.hhh sty Cade,Sectloru 25505,25S33 and 25534.1 O
uode nd that If th I Ingdon ntly ha atenant,thatltLmy NEW RESIDENTIAL MECHL SQFI' 1,
resporolbllhyton copa oft recJ Na which�at W met Cly,/ n[ n,
prior to taus rt13at pa ' r^nPFirr.I
Owner thodudagen Date ISSUED BYJ I.Q/
rornL
OFFICE COPY