22948 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-:- USE BALL POINT PEN ONLY
—suildin,Project Identification 7 POWT NO.
B INIAS Address:
22948
n,` an.. tMi,1 1r c CITY OF CUPERTINO-BUILDING DIVISION A
• er .NZ (�,, •��pLk�Na: APPLICATION /PERMIT
baa }5 ,• "'� �`%S BUILMINGPLBC=ALPLUMBINCMECHANIGL CATEGORY CONTROL
/ gl•� Lk.No:
tT� C-53 Iolp Q.IY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addams: PERWTL$UANCE ❑ ❑ Tyl ❑
LIm that I DCONTRACTORB DECLARATION YSJ
IMmby IRkmt0)ofDMAm kn3citheBusiensed under W«udfead rC PANELS APPLIANCES-RESIDENTIAL JOB N
licame s1.lollformanDMfect. he ButlmsandPmfmY«uCodgmd
nW IkonLicess bInn mrceande#ee. PANNE 3
Dale_ Cscacier
ps ARCHITECTS DECLARATION 1'1000 AMPS
OZQ I understand my plaes sWgbe used m publicn,vdI OVERIWIDAMPS SQ.Fr.PLOOR AREA B/SQ.FT.
Tic Licensed Prde.doml S)GNSmarmu•Ar
g OEBRf1++ OWNER-BUILDER DECLARATION7p 3 Iherebyaflirm that lamtexmpt rromtha Camrseterl License Lawfartha SPECIALCIXIR
CT/M6C
OZHr� following reasm.l5ea1m7031$Bu,bmA, nd Pmfewmru Codr.Anytltyor TEMP.METERORPOLBINSr.
Py) F^Ja mu ntywhkhraquimapemdtmmutmckalWr-Imran ciemdlsh,ormpalr
anywuGumpd«mlYiman«,abomqukmtheappumntf«Wdrpemdtm
file Biped Returned:that M Is licensed pursuant t the provision,of the POWER DEVICES
Contneors LkemelaA,(Chapter 9(commencing with Section 70=of DWI-
E, d
SWIMWNC POOL FLECDUC
t„ ebn3ofineBualnmsm )hofmsmmCode)wthdhebemmpt&erohomard VALUATION
g < the hash for the alleged Asterisks. Any violation of Section 70315 by my OUILETSSWDGIESFD(TURFR
o
applicant for.permit subjects the applicant to a civil penalty of not more than
EE flue❑Ip.ndmd ddlus(SSOBI. NEWRESmENDAL ELECTRSQ.FT. SIOW[S TYPECONSDtUCIION
� � L as owner of the property,or my employees with wags,m their sole
mmpeRead wdldothaworkarmtheNm mismt WendedwoBmtdfor
cele=70M Butlmm and Ptdmlons Cade:TM Com acwe&Lk..L w
�$ don,mtapply mn aownerd propertywho builds or lmpn,w,thereon,and
whodorsmcicwmkhlmseuorthwghhismnenVdoy ,prwidedmatmcb C•�O' jS
Impmvem team MinWndedmoffamdfwsale.lLhowever,thebulMmgm TOTAL.•
Impmvem dbwWwithin myurofcomplmmRthe v t4mldmwlBhave ,
t Nendprodng the be did But bund or improve r«purpose ofWea QN. PLUMBING PERMIT. FEE
L as owner d the property,am exclusively contracting with licensed FTAOD SNE APN
mntm:lmamconstruct the projea(See70M s
Businand Profession,Code:
PFRhIIT I56UANCE
The Contndoh Llms Law dean mat apply to an owner of property who
builds or Improvs,theory and who mmnds for such pwjem with a ALTER-DRAW k VENT-WATFRgW
u«nad pun,rontmtbeCscacuh Lkas Law. SCK FLOW PROTECT DEVICEFEE SUMMARY
I am asempt under Sec B k P C for thin mann
DRAINSFI.00R ROOF,AREA,COND. SANITARY Y_ N_
®
Owner Dee r
WORm due COMPENSATION DECLARATION RECEU7 a
❑1 hereby aHbm the I haw i mM m of cement m s6thm.a «a ` PDI'Illl@9'PER TR11P �O SCHOOL TAX Y N
caedOsed W«kmYCempen,aHminwrmmmaoedlfkd copythemd 61e. RBGF7Pr g
3800,Iib CJ CAS EA.SYSIYI(-I BJC{OUTLEB PARK FFE Y_ N_
PoT I
licy P GAS EA.SYSTEM-OOVER (EA) RIND[
ny BUILDING DIVISION FEES
CatlOed copy b hereby mredbed. GRPA.9i/WDUSI7tL WASTE WiFRCFFIOR PLANCIiECK FEE
CMNed ropy b Ned with lM city In,pMbn divitlon.
CERTIFICATE OF EXEMPTION FROM WORKERS I GSR TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-S ORMEA 300Ff Date Recei t#
OTlseectbnn dM le mdtbf«kmhundreddollam 'ENERGY FEE Y N
4100)arlem WAT}R FffATkR W/VEM/F].FrrR
Icertif clothe d work whichMspemdHSYmed, —
I ehaU employ an an nn as to became subject to the WATER SYSTENI/TRFATINC
w« Compo fk Ise. PAID
Z O A� one •u,a r thbCertslcam dEmmptbn,yon NEW RESIDENTIAL PLMR, SO.Fr. Date Rece1 t#
ehmld m mthe WorkeWCompeslhm provbmn,aflha Labor TOTAL
F N_ Cad4yo hwith comply wimmN provbbnsorth6 permit shtllM
� � d«coed revoked. BUILDING FEE
ILG CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihemby.Mmthatlhebakon,tmcumlendmgagem7f«tlw Pr(mm• ELECTRIC FEE
m
7 Z andthe work forwhkhNIs pemm Is lm097
red(Sec.3 ,CIv.C3 TOTAL: , _
O Landers Name ��.
LL I- lander.Adarees QPLUMBING FEE
TY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cartitythat l have mad thbapplicellmand tlatethetha a Iafo sloe
Q. bavrrec.Iagmmmmplywith lU dlyand muntyoedinancasand eatelas PPRMITISAUANCB FEES PAID:
W rebsng mbuiWing tmwsuelan,and hebyauthadm mproentathms of"
H Z etymenteruponthrabmwmntkmed pmpertyforjm eR npurpos. ALTERORADDTOM CK Date RLrei t#
(We)agree b sense,Indemnify an d kanp hands the City d Cupad W
.gals lbbWtleeJdgmeme,mdsand npemnwhkh my In anywayacmre AIR HANDLING UMI'rro IO,000CFAO SUBTOTAL:
itym eMgam dsdepemn.
AIR HANDUNGUNIT(OVFR)QOWCFM) CONSTRUCTIONTAX
N q
Slgnsmm Applicant/ tracutr Dow E)D(AUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplimnt mfummbuiWingk p..te whandlehaaerdkus HFATINGUMT(TO I(DW0BTU) Date ReceI t#
mat«lal es de0rud bytheCupodim Munidpal Codk Chaptm9.17,and the
Flealth andSafetyCodea_Sedmn T553ZW7 IiFATWG UMT(OVER IODAMSM TOTAL: IL%
Ea
Ym Li No
lllhaapplcanorTummbuilding oecapantuse equipmm«device VENTILATION FAN OWGLEREBID) ISSUAIV(;EPVE
whkhemit harardms air kerlamloacesas defined by 1M Bay Am Air IF,�a AA 1 D
• aiBy Marugemeni District? SOU.BR4MMPOHPOR MUM BTU)
Ys, ink
ve and the ban, onsmletlab rolulremnb underChapter 5.95 of BOELER-ODMP(OVER 100,000 BTU) IFOY ���
lhaC. fomlaHesRhaSafdyCodgSeclons35505,LM3and 75531.
undetand that lithe building does not currently have a tenant that it Is my NEW RESIDENTIAL MECH. SQFr.
.Possibility to malty thecmpard of the require as which me Mmet
paormbmarmol.CertlOormdOcorpamy. CITY OF UUPEF T' IC
Ownerormthorled agent Data ISSUEDBYtlto CIL
TOTAL?
OFFICE COPY