22947 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro" Identification I'F]N9T Nn.
Building Addrt»:
22947
�rwaa3los v'L� 4e
4t� 1f
qq I
a!s} 1110 CITY OF CUPERTINO-BUILDING DIVISION I 1
ntractoraName: x.No: APPLICATION / PERMIT `
ri-Sn Mme. Cor �s4j19 CATEGORY CONTROLS
BUILDINGH.FLTRIGLI'LUh1BING-MC{EIAMGL
M1ttect/Engineer. Lk Nm
M La BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Add. - I'F3tAf1i 155UANCK SLUG =1
❑ ❑ ❑
LIC ENS EDCONTR!under rDECLA RATION
I heh Srcdulrtnthatlam lkemM underprovbiomof Clupter9(ommmc APPfIANCFSAESroENT1AL g
Inrnmetmect1on7000)ofd effat 3ofthe Bu.InmaM PmfeadomCode,and nV
Maine b In foil/or¢and effect. PANELS
Chos LIc 1 –A7 t; l\��5
DA
Drte Contractor
ARCHITECI'S DECLARATION
MO Z I understand my plareshall be used o public reande. OVER 1000 AMPS SQ.F r..FLOOR AREA $/SQ.FT.
dy Lkensed Profmlorul SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPFCIALCIRCUTT/MLSC 1^tl
,F, S Ihenbyaffimthatlameaemptfromthe Comr.ctor.Llar Ue forth, K
Q following reawn.(Section 70715,Busin..nd Prolenlors Code:Any ciyor
ryi..� eves TFMP.ME'ERORPOLEINSr
my which requires a prank to aamwq alter,Improve,demolbh,or reply
anyurowreprfor to lb bsvrce,alw requires U<appilantfm such pemdt to POWER DEVICES /J
5 7 !_
K � file a tlgned statement that h h Brenaed pursuant to the provblom of the
Contractor.License I.w(Ctupter 9(mmnenctng w@h Section 700tH of DIv1- SWIMMING IC)DL ELECTRIC TE
the
fo Buslnmand ProfmlomG Any
is exempt therefrom and VALUATION
y�So the b..b for the dkged jecmtheap My t tolatlon of Section 70H5 by any
.yp5 .ppBant fora permk wbjectatheappilcanttoativll pevkydnet moretFan «TD.EI`'SWIICFOSn)<'FURFS
a B undnd ddbn(550Q. NEW RESIDENTIAL ELECIR
j.. �I,act owner of the pop",.,,.y employee with wages act their sole SQPI'. STORIES TYPE CON'SIRIICTION
compensation,will do the work,and the structure b not Intended or offered for
Oea In(See.70K Buslrese and Pcfmlore Cade:The Contractor.License Law
5$ don not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.11N115
who dooauch work bUreeB«through Ms own empicyrn,prwided that such
improvemeMa are ret Intended oroffered fasak.If,however,the Wilding a TOTAL:
Imp nverrent IssoW wtthlnatnyearofcompletbrh the ownn-0uilderwi0 have
t rden of procdng that he did out Wild or Improve fa purpose ofsale.). QTY. PLUMBING PERMIT FEE
"I,as awnen of the Property,am escWelvely contracting with[Renard FLOOD 7DNE APN
contractors to construct the project(Sec 7051,Buslnm and Prolmioru Code: PERMR�IIANCE \? _
The Contractnh License Law does not appy to an owner of property who
WWfa or lnptovea Neeson,and who mMraat. for such pto)cas with a ALTETLDRA1N A VENT-WATER(EA)
W. FEE SUMMARY
�QNf�ant
ex anad puer See. the Cantnctor.L)a P Cfo BACK FLOW PROTECT.DEVICE
I_J I am exempt order Sec B 6 P C for thio Hawn
OtITSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dale Rpt�rg
WORKMAN COMPENSATION DECIARATION ` E.IX.��$PER.Dour SCHOOL TA% Y_ N_
❑1 thereby a(Mn that I have a certificate of consent to self-[owes,m a 1 �o — RECEYT a
certlflateofWorken'Cornperwtimr lmurana ora certified capythereof Fee. GAS EA.SYSTEM-11NC10UTLETS PARK FEE Y N
3800,Tab C.) AFLFM a
Policy Y GAS FA.SYSTEM-0VFR 4(FA)
Com ray BUILDING DIVISION FEES
CirtNrd copy b hertbyturne efty GREASE/INDUSI'RL WASTE INT'FFCEE'IOR PLANCHECK FEE
CedlBed copy b filed with the catty Invpe tion division.
CERTIEFC EOF ON FROM WORKERS' CREAM TRAP PAID
C ATION SURANCE SEW'FFSANRARY=RM EA 20�r Date Recei Ile
(rhlssectkn need be plmrd0the rtNtbn
foronehundreddolla
a100)al WATER HEATER w/vEVT/Et.ECIR ENERGY FEE Y N
lor tlutin pe o ew forwNch tNs pemm blwed,
1 aha or emplo y y no w n to become snb)rotto the WATER SYSTEM/TREATING w ^c m W Date PAID
PP Date Reaei Ie, -
Z nnnwt APPL :If,a ng tMs kat.of Demptbn,you
NEW RESIDENTIAL PLMIL SQ.FT.
res should me Fcttothr Worken'Compemetlon provblom oft..Labor TOTAL:
Codes lorthwkh mmpy with ouch proWbm orthb pemW shall be BUILDING FEE
W > ores ak<d.consrgurnoN LENDING wcwcY - SEISMIC FEE
a Iherebyaf —thettherebacomwctlan fendingagentyfortheperforrr,
TOTAL ELECTRIC FEE
0 0 anmce.Na.ork(or which this permltbLvaed Fee 309'7,Civ.C.) a.I
LL O L rdremAddPLUMBING FEE
U Lenders Add QTY. MECHANICAL PERMIT FEE•
LL MECHANIUL FEE
O W larttythrtlhave Had thio.ppl7otbnand elate Mattbeabweinforrrutlan
bmrntol ieetocomplyion,allm mby..th o lnp..UdsUtelawa PERMIT ISSUANCE FEES PAID:
} 1 rtlat leer upon t1a,td ctlon,andherebywthaUepeato purpoo of thio
F = cityFWr)aeree to eaeahavcmentkrcd property fee Wpctlon purposes. AL77RORADD TO MFG}i Date Recel tf1
_ (We)agree to judg Ind ,r sand keep why the City of Cuprtlro P
agaWtllaI ftyincemema,mnsatd expernnwhkh m.yN anywayacvue AIR HANDLING I7DITr(r010,000 CFTO SUBTOTAL:
I sky m con : of the 6'^tb'B car tni.le tt.
a 1 �1��(� AIR r7ANDUNG UNrr rovEE)ontcr•M)o CONSTRUCTION TAX
Slgnatuaa AppBnnt/ tn<tan lz' to EKI-uusr HooD(w/Duc'1) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thea pp0nm or future Wilding occupant store or hand k havrdan HEATING UNIT DO 103,000 BTU) Date Recei till
material ore defined by the Cupertino Murdclpl Code,Chapter 9.13,and the
He.Ith.nd Safety Code Section 25533(.)7 HEATING UNIT(OVER 100,000 BTUI TOTAL: a.\
((��
Yn No .,gvq�
R "
illappliama tureWOnv
dingopantuseequlprrem ordevim VFNIATIONFAN FINGLERESD) ISSUANCA1 D
which eMt Hvrdoua a4 contamW Me as deBred by the Bay Arca AIr
• Qa.lity Management Dl❑strict7 BOILER-ODMP PHI'OR 100,0(3 BTU,
Q ye" No TL
fhavemadtheh...,materialsregirerrcnbunder Chapter695of BOER-0DMPOVW100, 00B NOV =81991
the Callfomla Health k Safety Code,Sections 25505,25533 and 25531. 1
undenuandthat lfthe Wlldingdoes rrotmrrenty have atenant,that ltbmy NEW RF51DF1Jl1AL hfE(]-L SQFr
ropomrouly to notify the occupant of the mquirx rueM.whkh twat be,met CITY OF CUP q h ,
pricy to Wuarce of a Cettifkatr of Omnpncy.
Owner or authorind agent Date ISSUED B
TOTAL
OFFICE COPY