20531 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN'ONLY
Building Project Identification E30I LIQ INEj: 5s 2e-LAAO PERMIT O.0531
Build leg Add rosa: I�'G r/V
103C0 - L-
rcreamane: APPLICATION suBmiT I ALL DA IF
0eM ' s ' CITY OG CUPERTINO-BUILEHNG DIVISION
cHIS`
n�r/�� n [�Lk.Na APPLICATION /PERMIT
Lz es i"I BIIDINGFLBCTWCALPLUMBING-MMHAMCAL CATFLORY CONTROL,1) O`ILle No: C7 MIN QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. 4eQ5PERhUTISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prwbions of Chapw9(commenc APPLIANCFSRESIDENHAL x7B DF
Ing with Seebn 7000)of DhAxun 3 of the B"nessand ProfesaioruCude,,nd my
PANELS
Ikawe bin fail and dfeR _�
Lkcnx1�LICY L/
Date Cor4neor L
Awshall euseda pu OI XVER l0 AMPS
otOZ ]understand my phro ehaBbe used sspubllcremda OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
�j Lkxrued Professional SIGNSEECTRICAt.
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
IherebyafOrm tlutlunvemptfronthe Contneoe.Lierse LawJaL the
pp following maws.(5eelon 7031.5,Buslnm and l'mfesaloro Code:Awry etyor
TEMP.METER OR POLE IN
F<� cwntywhkh rayulrnapermktomrowe,alter,lmprove,de ,orrtpalr
K ,eystrucutepriertoltsWsa.e alwrequbnlhe,ppianIf auclapeddtto roWEyfqACES
K O file a signed statement that he b lkxnacd pursuant to t kora of the
Contneor'e lJceveLw(Clupter9(mrrvrcncing n7000)of LTM- POOL VALUATION
��5uon3ofthe Btdnmand Prdmioru Code)orthat mamptthert(romand
< 0
the bah for the alleged vcmpt Any dolat of Seabn 70315 by any
,ppilant for,perbdt.ubJMethe appllant to I penalty d namonthan
IWC hundred ddlata(SM. NEW .�
�n I,as owner of the property,or my p oyen wdh wages a their sole STORIES TYPE CONSTRUCTION
mmpewtimt,wlll dothework,nd truevrebrctbdendedorofferedfor
Oab 6ec 7014,Busiws and Prof ro Code:The Cmvtneote I�¢sne law
S$ don nwt apply loan owrcr d p rty wM W lid,or improvn lhereoR and OCC.CROUP RES LINKS
whodoeseuchwork himself rough hl,ownemployen,prwded Uutwch
Improvemew are rot lots ed oro/lered for ale.I(hawevm,the buil
dingor
imprrnmenthsddwH
one yearefcompletlor,the owner-builder wlllluve
tlurden or provin at he dm rax baud or Improve fm purpose of sale.). QTS. PL BIN T FEE
LI 4 u own er a pmper<y,,m e.chuWely rontraclNg with licensed
FLOOD/ONE MN
contractors to m rue the project(Sec 7044,Buslnm and I'rofmbm Code: PFRFIIT LSSTI CE
The Cordneo License Lw don not apply to an owner of property who .ALIFR DRARJ A VENT-WA (FN
buidn or I n thceon, and who mmnm for,uch p(ojem whh a FEE SUMMARY
ryp( d •)hart. d pursuant to the Cmtnemb Lkenx Law.
LI m exempt order Sec. B&P C for this mason BACK FLAW PROTECT.DEVICE
OUTSI OF FEES
DRAINS FLOOR,ROOF,AREA,CON I. SANITARY Y N0
r Due
RECEIPT
WORK MAN COMPENSATION DECLARATION FO(7URFS PER TRAP SCOOLTAX Y_ N_
❑I hereby,/firm that I have•¢rtlflate xrt
of connt to eel/-Inm ,or
oerd/lat•of Workers'Compensation lrour,nce or,¢ Bl
rted ropy thertof(see. RF-Cm'1
3800,Lab CJ �)/� /� GAS EA.SYSTEM-1 INC40UTLETS PARK FEB Y N_
Polley I Pc C 4I_131 0 eep ,p� RECID'I'I
Com CAS EA.SYSTEM.OVFR 4(EA)
y a.M.. w . BUILDING DIVISION FEES
CertlOed mpy6hereby fumhhed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE 3
CertNM ropy b tied with the cfty Inupection dW Won.
CERTIFICATE OF EXEMPTION FROM W RS, GREASE TRAP PAID
COMPENSATION WSUR SEWER-SANITARY-STORM EA MOFT Date Reuel I9l
(Thheectionresit not be completed If N he a th(morchundred dollam
ISH"')or
Ica) WATIAIiFA1FR w/VEYr/F]FGTR ENERGY FEE Y N
Ior-Bythu tithe perfamun the work(orwMch tAh pemdthhaned,
l shai nm employ any pend any manner..u to become.,bJea to the WATER SYSTIM/TR[ATLNG
Workcra'comperwtion wat alu¢w.Dau - PAID
PP Date Recei tM
Applicant Z O NOTICE TO 1GANr:if,,Her ma id It Certlf{ate of Exemption,you NEW RESIDFNTIAI,PIMB. SQFT.
should aubFctto the Workerd Comperoubn provbioro of the Labor TOTAL
N Cale must fort lb Hh mply with such provbloru or this pemdt shall be Z u
WILDING FEE
W cc G d revoked. _ .
CL
CONSTRUCTION LENDING AGENCY SEISMIC FEE •.Z
I hereby a/firm that there b a mvtruelon kind mg agency for the perform TOTAL: ELECTRIC FEE
7 Z an¢of the work!or which thh permit b bmnd(Sm 30 Y/,Civ.C.)
00 Lender.Na�rc�'A y� �^ PLUMBING FEE
F Lander'.Addness_ I/'��AJ� -lam QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O IU 1¢niythulluv,-read[hb,ppBationard Wtethat eebo m
1 bmingt Tagrn to complywdh anety,nd manly ox,reprm mdetatebw. PERMIT ISSUANCE FEES PAID.
} N relating enobuponge abow,an,,ndhereby dpropetyorle mprmntathv olthb
F. = dtyWeagwtnthe,bovo-Indemnify
an d keep
the Cit of Cups ALTER OR ADDTO MECH. Date Recel til
(We),gr¢to ave,Indemvlfy an d keep harmlm the City of Cupertire
V aga:lhbWt a w,ms[n,rad e.perun whkh may lninywayacvue ATR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalrot old ByI aecprenoe ofthe granting of this peroral
AIR HANDLING UNIT(OVER IQ"CFM) CONSTRUCTION TAX
Signeureof ont/Cwtraeor (O to E)CHAUST HOOD(W/DUOD CONSTRUCTION TAX PAID:
HA]ARDOUI hBA 1 L UISC SURE
Wil the a ppllant orfutum building o¢vNnt uon or ha M le haeNou, HEATING UNIT(TO 1 OIL"BTU) Date RL'cei tp
makrlal e%defined by the Cupertino Mudepxl Code,Chapter 9.17,and the
Health and Safety Cade Seelan 75537 W7 HEATING UNIT(OVER Iffy"BTU) TOTAL:
Fly. No
Will the applicant Jr7utum building oavpet use equipment or devlm VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkh emit haacdou ab contambunb as defined by the Bay Area Air
Q.alftyhlanagementtde7 BOILER-COMP OHPOR IW,=BTU)
4haereadtheh osmaeab gremnbunderChaper6.95o! BO LER-COMP(OVR100,000BM PAJO
the California health h Serty Code,Scotiro 75505,75533 and 75534.I
understand that if the building does not mnendy have a tenant,that it bmy NEW RESIDFNUAL MECH. SQFr.
napommiily to notify the oeeupant of the requirements whkh must be met t
Owaer¢authorired,gent / Elate ISSUED BY�U _T� '
TOTAL:
OFFICE COPY