20019 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ap '�u
Building Pru ed Identification PFTthBT NO. 0 019
Baldrew
Building Add :
7,244/7A // dC
rs ase: one.
CITY OF CUPERTINQBU[LDINC DIVISION 0
• c ctm'aN.me: Lie.No: APPLICATION I PERMIT
L r C BUfIAINGELECMCAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Arch Y/Enginnr. IJc No:
j'
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addnec - PERhBTISSUANCE ❑ ❑
LICENSEDCFORS DECLARATION
Nonmed
I hereby affirm that lam lkeaedunder provisions of Chaplar9(conunrn APIrLIANCE5RE5IDEMUL TOR DESCRIPTION
ingwlth Sfctbn700D)of Didalm3 ofthe Bualreaaand ProfesslmuCode,and my
1Ioe.isI.full force and effect- PANELS
DateLfocnxlla5x�f�'nap_Lk.#
' /V CorLLraRor
ARCHITECTS DECLARATION 1'1
µq!1a�yeZ I understand my plana sluibe used as public records. OVERIODOAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
EcL j Lkxaed Professional SIGNSELECTRICAL
<�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
Z I., I hereby affirm that l am exempt from the Comr.tor'.Lkxme Law f¢the
o .. following mon.(Section70315,Busm®and Professbm Cade:Any dty or TEMP.METER OR POLE IN
� ntywhlchatarequl apes tommtmMaker,Impr ,demo l,,orrepalr
P
mu
anywu mprlmtoltalee ,aborequr theappb¢ntfmarhpennkto
POWER
�a
Ile a signed statement that he Is Bmesed pursuant to the provisions of the
Contractor's Lkeose La.(Chapter 9(m.,icing whh Section 7000)of Divi. �'QrU4NG L FIECIRI
OJ Yon3ofthe Buatna dProfexloru Code)orthehebewmpttherefmmand VALUATION
QES 0 the bash for the alleged exemption:Any violation of Section 7¢715 by any OUTLETSSWI7C
•ppB¢ m
rn for a permit subjects.the applicant to a cMI penalty of not ore than
$ flyNwndred dollars(S M. NEWRESID
< use,sa owner of the property,or my employee with wages as their sale STORIES TYPE CONSTRUCTION
�7 mmpenaHon,willdo thew "ndtheabucturebrot Wendedoroffcmdfor
i+.p srb(Ser.70µB..ma and Professions Code The Condnctoes Llcerse Law 1
S$ don not apply to an owner of property who Wilda or Impnovn thereon,and OCC.GROUP RES UNITS
whodoeachwcirkhlmseBothrough IJaownereployees,provided that such
Wpmvem artrotIntendedorofferedfmmte.If,havever,thebullding¢ TAG:
Wprovemem bsald wkhaorcyero(complHbn,tMavner-bullderwRl have
Ul,tfandenofpmvingthathedld not build orimprove for purpose orale.). QTY, PLUMBING PER E
FLC OD
u L as awns of the Property, xc
am ehuWely conUaRing with 11¢nxd
mntractm to comtrod the penjen(Sm 7044,Rusinessand Proferbu Cade: PERMIT ISSUANCE
The Contractor's Llan a Law dm not apply to an owner of property who
lour Hds or Improves thereon, and who common for such pini"with a ALTER-DRAIN&VENT-WATER MAJ
cr)p�ctoa)Bcemed Pursuant to the Contractor's Ll rw Law, FEE SUMMARY
LJ I Mn exempt under Sec B &P C for this reason BAIX FLOW PROTECT*DEVICEOUTSIDE FEES
8 Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECHI'T#
WORKMAN COMPENSATION DECLARATION EIX'[VI&S PER TRAP SC[100L TAX Y N_
�1 hereby affirm that 1 have.¢nlfWm or<amem b aeu-mare,«.
¢rtiBate of Worten'ComperuaHor Iwnn¢a a¢Nfkd copy thereof 0ic. RECEIPT#
]SOOT Lb CJ GAS F.A.SYSTEM-1 BJC40ITILETS PARK FEE Y_ N_
RECEIPT'#
Ib1ky# (1 !/03 G/e r/P S7/ GAS FA.SYSTErDVER 4(EA)
Cam nv CS ATS �dnw BUILDING DIVISION FEES '
^ [BCentNed ropy,is hereby furnished. GREASE/WDUSIRL WASTE IN"ITICEPTOR PLANCI'IECK FEE
1VVVxa��� �CeNRed ropy Is filed
ed Mth the dty,Inspection dlWalon.
CERTIFlGTE OF IXEM PEION FROM WOR KERS - GREASE TRAP PAID
J\ COMPENSATION INSURANCE gyyER.SAN(.I.nxY sroRM FA.y'IOEr Date Rtroel [k
('rMssectmn need not be eompleted Rthe permit b f¢om hundred dollar —
aIW)orI ..) WATER BEATER W/VFN-r/IT.LCTR ENERGY FEE Y N
a Immify that in the perromun¢of the work for which this pemdtb issued,
SIO 1 shag not employ any person In any manner m as to become sebjea to the WATER SYSHTf/TREATING
Wokcre Cmns
npeation Loa of Callfomb.Date PAID
Z Appllant NEWRESIDFNTIALPIMR. BQFI'. Date Recd IN
Z NOTICE ki
TO APPLICANT: mang l his Certlfla
m of Exemption,you
2 N should beemost subject to the Worker:Compan..11an prowlom of the Labor TOTAL:
Code,you must fort hwkh comply with such provisions or this permit shall be
W > deemed revoked. BUILDING FEE
CONSUCTION LENDING AGENCY S FEE
CL TRIherebyaffirmMat there his meatruction lendmgagerny,teethe perform, ELECTRIC FEE
7 Z an¢of the work ror w h this permit b Sec issued( 309'.),Ci,C) TOTAL
(.) 0
� O l<nder'.N.mv, izsxe PLUMBING FEE
LL F f<ndee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FF.E
OW I¢Aifyth.l have read Misapplication and statethatthe ab.Information
1 bcorrtct.IagnectocomplywkhaBtltyandmuntyordinaand statets. I PERMIT ISSUANCE (� � FEES PAID:
N rtlating tobulding comtruRlon,and hereby authorlae¢prantatfvndthb
Z eky to enter upon ted abovcmemtbrid property for inspection purposes. ALTERORADDTOMECH. 2sa� Date ReCCI IR
_ (We)agree to save,mdemNty an d keep harmless the City of Cupertino
sgatrut llabWtks,Judgments,conn."expense whleh may ln.eywayacxxue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against old Cl gnMlege(thlapermlt.
AIR HANDING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
If. /� CONSTRUCTION TAX PAID:
,egranim of AppBont/Contractm - Date IXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
- Will the appllant or fuwre building occupant More or handle hav"ous HEATING UNIT(T 100,000 BTIJ) Date Recel t#
m,bubal as defined by the Cupertino Munidpal Code,Chapter 9.1 7,and the HEATING UNIT(OVER 100,000 BTU)
ITealth and Safety Code Section 2S537W7 TOTAL: ROO
Y. No
WBltheappll¢m¢ mmbuBdmg o¢upant use equlpmem mdevke VENTILATION FAN(SINGLE RESID) ISS CE DATE
which emit hegement amriet? Na.a defined bytM Bay Area Ab
4`Ye Management I—I W BOB ER-COMP PEB OR 100,000 B
have read the by i� .materiae requirements under Chapter&95 of BonxR-COMP(OVER 10."TIM (a;`
the California Health&Safety Code,Soctbm 25505,75533and 75534.I
understand the if the building does not cvrrently have a tenant that it is my NEWRESIDFMIALMECIL SQFT -of
'�iaaA
respomibilitytondilythe panto(the requlrememswhkhrmutbemet
prior to ixuan .Cert at Ocap.n7 .l
I, KhCag 7— D �� r
mer macola
ul ". Date
g<nt ate ISSUED BY
. s 'TOTAL: l
r OFFICE COPY
J