23945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building I'mied ldmefleatlan Iti TNO.
Building Add. 2 3 9 4 5
ore:
Kra a� CITY OF CUPERTINO-BUILDING DIVISION
onmder'a Name: Ge No: APPLICATION / PERMIT
Bl11LDINGELECTRICA MLT.BINGMECH LAICAL CATEGORY CONTROL
A. ed/ glneer. Lk.No:
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PFRMIIISSUANCE / ❑ ❑ ❑
LICENSED CONTRA Merp DECLARATION -
Ihereby a .70ttatlam .3.fth,Bu,i vblamof(7apter9(mrrvravm APPLIANCESRESmENTIAL JOB DFgCRErT10N
Ingw•Iel Sin full 0mea DIefftet (ahegudrmessand PmlevlmuCade,and PANELS
Breo s 6 E hnB/once and of@d.
Date Clan C–/ Lk:I r/744y ,)
I
Date GOM¢dOr —UP TO 2DQ ANTS
ARCHITECTS DECLARATION .201-1000 AMPS
XZ I understand my plans shall be used u public records, OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
0.
Lbensed Prlesbml SIGNS ELECTRICAL
QOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Ihertbys(Orm that]unexemptfrenthe Contranor'aLbnas law furthr
z oo following re seam.(5MImr 901],5,Business and Profesum Code:My dty or
O Z•" 1T2.U'.M=OR POLE INST.
r muntywhich rcqulroapermktomnNrvd,altu,lmpmve,derml6harrtpalr
anyatructurt prbrto 166suarce,alsorequlm theappBant farsuch pemdt to POWER DEVICES
�y file a signed statement that he 6 Bomsed p rsuant to the provision,of the
Contractor's Lkerae Law(Chapter 9(mmmendng with Section 7000)of Dtvl-
dBusiness SWIMMING POOL ELECTRIC
F, OJ on 3 of the Buness and Professions Code)or that he6 exmpt therefrom and VALUATION
Q F5 Sn...333 the basis for the alleged exemption. My violation of Sealon 70115 by any OU1I=-SWITCHESFLCNRES
applIant for a permit subje theipplieant to s dvll penalty of n¢more than
E M hundred dtlW¢($500). NEW RESIDENTIAL ELFCTR
�I,uowner of the Property,or my employees with wages as their sole SQ.FT. STORIES M'ECONSIRUCITON
C is compensurtor,wllldotherrak and the structure 6 not blended or offered for
$ p sle(5ee 7061,Bonham and Prdeslom Code:The Cormusor's LImrae]aw
I $� does not apply to an owner of property who builds or lrnproves thereon and - OCC.GROIII' RES.IIIJDS
who dm such work hlmseB¢thwgh his own employees,provided that such
Improvements art rot Intended oroffer<d for ale.If,however,thebuilding or T
Imp avermm hawki whhlnancyraro(completbrr,the owner-bullderwW have
t n of proving that M did not buOd mr Improve f¢purpose of sale.). QTY, PLUMBING PERMIT FEE
j[u uwnu of the property,am esshahrly contracting with licensed FLOOD ZONE AM
mntractm to mnstmproject�d the proje7O44,Boudner su
and Profens Code: PERMITI%UANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(FA)
burlImproves thereon,or Improthereon, and who contracts m for such pip)ewith• FEE SUMMARY
1pursCommerce'senscd pursuant to the Commerce's Llarue Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec B 4 P C for this reawn
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• re ¢a RECEIPT
WORIONAN COMPENSATION DECLARATION
❑I hereby oHbm that I have• Insu ate of consent to ap (her FLYNRES I'FR TRAP SCIdOOI-TAX Y_ N
axrtiliate of Workers'Comperaatlm Insuan¢ws certlf6dropy thereof(Sec. R�EII'f 1
3500. GAS FA.SYSf[•M-1 WC,10U1LE[B PARK FEE RECEEPTg
Pdky1- }— GAS FA.SYSfQA-0OVER Com nv aL q n wd. !per BUILDING DIVISION FEES
�CertWed ropy 6 fled with
the cid. CREASE/INDUSIRL WASTE INTFRCWTOR PLANCHECK FEE
�CedlBed ropy 6(Ilea wish lit my Inspectlon division.
CERTIFICATE OF II(EMPTION FROM WORKERS• CRFAH.TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 20f4T Date Rent tN
(Hu.nedbn need not be completed B the permit 6 forum,hundred delta.
[�xJNR(;Y FL•G Y N
(A00)orler.) WATER HEATER W/V /EIE(TR II e "
IceMty that N the perfomun¢ofthe work for which this permit is 6ened, ., .1
1,hal]n¢employ any person In any rraon,,o u to beoomc Subject to the WATFIt SYSIFM/ TTk' r
Wnrken'Compereatlon Lawsof GWornia.Date - — -PA;D)
0 Z Applicant NEW RFSIDINITAL PLMB.� SQFI'.� ll T1 DatC RCmi IN
Z O W'DCETOAPPLICANT:If,aBermildngth6Cuufiateot Pa .ptmgyou
should berme mbFat to the Workers'Competaatian prov6uro of the labor 421 TOTAL:
LA Code,yeumofforthwftho ply Mthwc pro north pemdc Shallbe _
iNQIrEE
W deemed _
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby afnrenthn them 6armtrudlon lending agency for the perform- __ ` ELECTRIC FEE
:) = aneeofthewukf.rwhkhthisperMtb tssred(See3097,Ctv.CJ TOTAL:
L) O Lender.Name PLUMBING FEE
LL lender's Add. QTY. MECHANICAL PERMIT FEE MECIiANICAL FEE
O ve mad thbappliestlonand fate that the above Information1 6mrred.lig¢etoromply whhaB dlyand muntyordloanaroand sate laws PERMIT ISSUANCE FEES PAID:
�. relating to building mnstrootio%and krtbyauthor6 erpresentativesofthis
F N city to enter upon the abo ,mentioned property for Wpedun purposes. ALTERORADDTOMECH.
? (We)agree to save,bd emnlfy an d keep hamdem the City of Cu pert ma Date Re ei tN
() aga bmf DabWtles,ydgr2w,mss and experan which may In any way acesur AIR HANDLING UMT(DO 10,000 CFM) SUBTOTAL:
.S.L oft rain 1 It. AIR HANDLING UNIT(OVER 10,000CM. CONSTRUCTION TAX
7�-g Z CONSTRUCTION TAX PAID:
Ggreaure of Appllant/Odor Date EXHAUST HOOD
HAZARDOUS MATERIALS DISCLOSURE
Will theappliam or future buBding occupant sore or handleh.rdoa HEATING UNIT(TO 100,00)BTU) Date Recei4materlai as defined by the Cupertino Municipal Cadc,Chapter 912,and the
Healthard Safety Code–S 1.25532(..)7 HEATING UNIT(OVER 100,000 BTU) TO
I Ya IJ No V N11LAT10N FAN(SINGLE REND)
Wthemit applicant or tune nnua ng oaopant use eche Bay Area
Air inn ISSUANCE DATE
whicheMahardest,ebri,t? rdSa de(Ined bytM Bey Arca AU
FI
Quality Management Dlatrk[7 BOILER-COMP(3tIl'OR 104000 BIT!)
4Ya ❑❑No
havercadiheha&ufvt matee,a6 .ZSSOS, uD3 4255 695 of gOR.ER-CDMP(OV6I l00,IXA BN)
the er Worts Heigh&Sudety Code,Sedum 2550$,have
a t and 25534.I JUL urdmtsndttitlithe building does not currently haveatenant ttitlt6nry NEW RESIDENTIAL h1ECH. SQFf
resperedbility,to really the eocuparit of the regWremew which rtes be met " 1992
pd.to 6mrance of a Certificate&Omrpancy. `a,J�
crrr of
Owner orauthory]agent Date TOTAL: ISSUED 8Y: r
OFFICE COPY