23745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Addtci:
I o'er W . aqv,-.rt�Plc� ���-o �S �• '.�" 23745
r. sore: odic. �LAIVJN�bmirf'AL DATE
CITY OF CUPERTINO-BUILDI G �N O ^
APPLICATION I P UIT �O l�
Coo�,�Raa���ttca'a Na o
A�p�/y� L� 6 BUfLDINGELECTRICALPL INCA HAMCAL CATEGORY COMM
QTY ELECT IC MTC FEE BUILDING PERMIT INFO
Add. I E -
LICENSEDCBxxr Aunder
dere DECLARATION
Af I herebyillbmthat land d,l.3.fth.Bus1.ion.ofChapter 9rWoe,C de,mrrr ENITAL JOB DESCRIPTION
Ingwlth5ectbn9000)o/delelon3o(the BuelnevmdPrv/ex+lonaCode,and �OU
64
Ikxae b Ina o and e a I O ...`� �••-f(.T,J Pte'
7.Ia�nseC Lb.a
Det A.—Contrador AA45
e�RcxITECT Rieno Ov2d%i000
1 SQ.FT.FLOORARFA $/SQ.F7.
LA
z 2 I uMe rex( my pha shad be used a pub0c rends. N
oC S CANS r•
t 1 Llcensd Prdembrul _
�<rg OWNER-BUILDER DECLARATION gPEC CBt /M1.SC
i.., ewirgrasnm that l amexernptfromthe ComradoriLlarue lawfeethe
bllowing rtason.melon 70115,Bu.ln..rd Profobru Code.Any my,or
6�H 772d OR POLE INST.!
pp an ntywhkh requM.p ancxo conabud,after, a prove,dennlbhZe repair
qqq SOS any atrudurc pale entahat he Is Rcmwd puranures the rd to the for pro,uch pend[a DEVICES O
(Ile a signed statement that he b Ilceneed pursuant to the pmvbbn of the
t❑y3 Contnd1orSIIee IAw(Chapter9(rommeneingwith Sedbn7D0G)of Divi- GPOOL ELECTRIC VALUATION
abn3ofthe BuNnmmd Pmfesbm Code)ortM1x M1eb therctromard
the dab for the alleged e...option. Any violation of Section 70115 by any ZOO
0 appBont bra pemdt wbjM.the appbcmttoadvil pevuy dna more than OIITLE159WITCFISFUCIURFS
nnnareaaala,acssam.
lJ L a.owner of the property,or my employees with wages as their solo NEW RESIDENTIAL E1.ECTR SQFT. STORIES TIFF CONSTRUCTION
7Q compensation,wBl do the work,and the Wudure b not Intended or offered for
D sale(So.70K Bualnea and Profeaeba Code:The Comradoes Llmme Law
$ dm wt apply to an owner of property who builds or improves thereon,and OCC-CROUP RIS UNIT5
c'^ who dueswchworkhlmself orthrough hbownemploycea,provided thatsuch
improveme aims[Intendedorofferectfmsale.If,however,thebulNNg« T
Improvemem hwd within on<ye.rafcompinbn,thewvner-bullderwW M1ave
t"rdenofprovingthathedbnmbuudortmpmvef«p rpw ofeale.). QTY. PLUMBING PERMIT FEE
LI I as owner of the property,am eschulwiy contracting with Ibensad FLOOD ZONE AI'N
contract.to mdamad the project(Sec 7055,Builnew.rd Proferlom Code: PERMIT ISSUANCE
The ComrcdoYs Llanse Law does out apply to m owner d property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improve thereon,and who contracts fee such p1o}eda wuh a
�+darW Bemad purwml to the Cordrarte.Llmnse law. BACK FLOW PROTECT'.DEVICE FEE SUMMARY
Lf I am exempt under Sec B 4 P C for this reasonNITS I DE FEE 5
Owner Dns DRAINS.FLOOR ROOF,ARG,COND. SANITARY Y_ N_
. ROP
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOI.TA% Y_ N
I hereby af(Um thn I have•certlBrate of Conant to self-Wore,«a RECErE a
n IL.bC.Workm'Compemdlonlwar.nm ma certified copy thereof(Sec. GAS G.SYSTEM.1 WC40UTLEIS PARK FTE Y N
3800.Lab CJ 1 a7 RECEPTI
Pdky l� GeCO' $�7� I GAS G.SYS -OVER 4(FA)
v A. (� BUILDING DIVISION FEES
rtII Is 0, furnished. GREASE/WDUSRL WASTE INTERCEPTOR PLANCHECK FEE �`
Certified copy b filed with the euy Wivieim. l
peet..d1CC
CERTIFICATE OF D(EM PFION FROM WOR K ERS GREASE TRAP PAID J.J
COMPENSATION INSURANCE SEWER-SANITARYSTORMG 200FT Date Recei t v "'a
(This section need not be completed B the perm[is fvrorc hundred dollen
(flammle:.) WATER FEEATFR W/VENT/a.ECTR ENERGY FEE Y
I certify that In the Performance of that week for wldch tld.permit b based,
I shall net employ my person In any manner w as to become subjed to the WASYSI7M/TRGTING
W«kers'Comperuatbn laws of California. Dee PAID
O Z ApplicaNDTICnt NEW RESIDENTIAL PLMB. SQF. Date Recei IH
Z O NODCETOnx PsubCAM:B,cher maklomperng this adion n(eofons oft eLLyou
F Nould becomewb)M to the Work.'Compemnbn prvvfebm o(the7abor TOTAL:
Q N Cade,you mustf«tM1wuh comply with wdi provbbm or this permit shall be BUILDING FEE 'ZQ-7
W `> deemed revoked.
consrgucrloN L1Wo1Nc AGENCY SEISMIC FEE I
CL Ihembyaftirmthe thereby coatrudlon lerdingagency for the perform- ELEC'rRJCFEE
D Z anerotthework for whkhthb perdthbwed(Sec 3097, H.C) TOTAL:
V O Loden'.Name PLUMBING FEE
LL ~ Iendrea Addree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r
U I«rtifythn l have read thb.ppBentbnvd statethat thealsmelnforution
O nhcorred.IagreebcontplywhhaD dtyandmuntyoMdl mord Yafela— �h TL6uANCE FEES PAID:
>. relating to Wilding comtructim ami hereby authMae repreintativsa ofthh
F Z dty,to enter upon the abovrmmtbmd property for Inspection purposes. ALTERORADDTOMECLL Date Recel to
_ (We)agree to save,indemrdfy an d keep harre]m the City of Cupertino
ago bet billtln,ydgme ad.ad pence wMch may N anyway.. AIR HANDLING UNIT(TO 10,0)0CFM) SUBTOTAL•
ago Wt In mingathbpermB.
AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTION TAX
Slgnatureaf puont/ca e « /Dare D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
US MATERIALS DISCLOSURE
Will the app"ra or forum budding o pant store or hurdle hanrdous HFATWGUMT(FDI00,000BTU) Date Recel tit
Buterhl a deRrud by th.Cupertino MuMdp.l Code,Chapter 9.lZ and the
I ieahh and Safety Code Section 25532W? HEATING UNIT(OVER 100,000 BTU) TOTAL
❑Yee N No
Will the applhnt or future building occupant use equipment m devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
hith emit hvardcus air coniamirunn as defin i by the Bay Area Air
Illy Management IXnrlcl7 BO=-COMP QHPOR 1 00,000 BTQ)
Yn ❑Nb
shave read the harurdow nuterlab requirements undcrChapier695 of BOILGR-OOMP(OVERIW,"BM P A r
the CalBomla Health k Safety Code,Seetioa 25505,Sin and 255A. 1
understand that if the building does not arrently have a tenant that It is my NEWRFSDFNTIALMECH. SQFT
respoamBity,to oalfy the oavpard of the requirements whkh most h met JUL 14 a e
prior to issuance of a Certificate of 0eeuparcy.
Ownerorauth.d.d.gem Date T. ISSIIFD CI. Y `� i Illvu
OFFICE COPY