22123 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.'ed Idendfkad.a PERMIT NO.
Building Addrt : 22123
50 a T.
re ams: me. A�CAIIONSUIIMITTAL DATE
CITY OFCUPERTINO-BUILDING DIVISION
Lie.No: APPLICATION / PERMIT lh� II
BUR.DINGELECTRICALPLUMBINGMFCHI CAL CA'IK,OAY CONTROL I
Atehaet/Engloeer. Lle.Nn
- (' QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address41X W, J` PFRMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
]hereby aHlrm tF tleml:ceve erpmvleloruof Chapter9(a APPLIANCI RFSIDF.MIALBDESCRIPTION
ingwith SectionAe())of DivlNm3 olthe Buslrmasand PmfedmuCodeand ^' ,.p'�
license loin fin def(ea. /Jr PANELS
LlcennUP TO 200AMPS v� C-2,Date C.rarasor /HA/ t\,
AACHITECPS TION OVER00AMIa5
rcO 2: I undereta rd my plam.haB ire cad as public nada. OVEI(]000 AMPB - SQ.FC.FLOOR AREA f/ .F7.
U
Licensed professional 9GNSm FC'IVK-ar.
� � OWN¢R-BUILDER DECLARATION� SI'FLIALCIRCUIT/MLSC E D I N
zl.,f 4 (hereby affirtntkeI am eaempt from the ContradoJs Lleenae Law forthe
p following rear en.(Sesame 7m15,Business and t,Imps e, Code:Any city or
OZF-� TEbfP.MEIERORPOLEINST. E R
F� musty which requbesapermkromruwrt,ilter,lmprwe.dennlbh,or repair
any.aptrc prbnnentr to its h®urcgilnrtdpursuettot het(awApemdtte I'O{VEIe DEVICES
C a U file a tlgned tlatement that he b Ilrenxd pursuant to the provisions d the
3w Contras./sLk.Lw(Chapbr9(o.cingwith Section 70(10).!Divi- TUTU
F,�OS elon3oftheButlnessand Profssbmc.de)orthathebesempn thertfromaM SWIMMING PO OL ELECTRIC
Qap brant for the ilbged eaemtheap li vldatbn of Section rot tr bj any IXJTLEISS}VIICHESIIXIl1R6
�U?c appllwtfora pemJt aubjese Neappllcanttoadvll perultydnd moretlun
five hundred ddhn(f50O. NEW RESIDENTIAL ELBCTR 5Q.FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages u their sole
eompwatle ,wW do the work,and the structure brat Intended or offered for
Otole(See.7004,Business and Prdesebm Code:The Contratlofe Lame Law
$� docs not apply to an owner d property who builds or imprwm thereon,and - OCG GROUP R6.UNH5
who does such work hur eelfathrough his ow.employees,provided theuch
improvemede are not Intended oroffered!weak.ff,h.wever,thebulltlu g a TOTAL: '
Impmve ntbwWwtl oneyearofcompletlorttFe erb aderwlllluve
tl)9-t(urdenofpmvingt],khedW notbulldorlmpmveforpurposeofule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE AI.Nr
LLJI L as owner.!the property,am erchrsivety mntrasing with 11¢nad pQ(MRIS;IIANCE
-mains to rorrctrut the pmjes(Sec 7014,Business and Pmfesslotn Code:
The Contrasore License Law does not apply to an owner.of property who
Wild. or irnpra'e tbereun, and who insists for such plows with • ALTER-DRAIN&VENT-WATER( _
+sale)karard pur.uant<o she Cmtrete•Laatue lw. FEE SUMMARY
LJ I am a mpt under Sec B &P C for thla recon - BACK FLAW PROTECT.DEVICE
Owner Dm DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N_ .
• RFOElI'C Y
WORKMAN COMPENSATION DECLARATION
❑I hereby aflUm that l love•mrtlRute of consent to self-]sore,or• FDCTURESPER 1RAP SCFIOOL TAX Y_ N_
aetlfirate of Workers Cmnpevatlmlssu1w.certified u pytheeof(Sec. REL�PI Y
(sof{ GAS EA.SYSTEM-1 INCA OUTLETS PARKFFE RECE�I'I
PdkyY L/ y CJTZ GAS EA.SYSTEM-OVER4(FA)
CCCCCC9y���y���ppaaaaaany BUILDING DI VISION FEES
Certified ropy is hereby furnished. GRFAS'EANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CutNed ropy b filed with the dty Ivpe tion divltlm.
CERTIFICATE OF E3(EMPTION FROM WORKERS'. GREASE TRAP. PAID
COMPENSATION INSURANCE SElyF]e SANITARY STORM EA. Date RCCCI t#
(rhb s,dion need not be completed Bthe paint[b fa om hundred dollar
(f10 rtless') WATER IEATERW/VENT/E7.ELTR ENERGYFEE ' Y N
IceceNfy that Nthe performance of Newak(orwMde Wepemdtbb+ued,
I shall res employ any penin In any manner an as to became asbfeet to the W,A�gy�pM/TREATING
Workere'ComperwRonlawed CGllfornh. Date PAID
"O = Applicant
NOTICE NEWRFSIDFNTALPLMB. SQTT. Date Re i t#
Z O NOT/CETOAPPLICAM:ll,akar ns'Curthle Ceslflceteofo.oftteLyou
Cod!shoe,ld bemme forth ithto co Worten'C ehprawlmns orW3 perout s Labor TOTAL:
LU N Codeym trust forthwith mmply with uch provnrlom or W3 pemnit ehilihe
LU > m
deeed revoked. _BUILDING FEE
CONSTRUCTION LENDING AGENCY SE1241C FEE
IL .•I herebyefirtn that thea baromotion lending agency for the perforiry TOTAL ELECTRIC FEE
M Z anceof the work for which this pemJt b bsted(Sec.3097,Civ.CJ
Lender's NaPLUMBING FEE
LL me F Lender's Addrea. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE (3
OW ]roma!ythatlhavereadthbapp"tbnandmatethattheabovelnf.mmtlm
C bmrreC.lagreet.mmplywhhaldtyandmuntyordinanmandtlatelaw. PERMIT ISSUANCE )1�L..CD FEES PAID:
relating to building romuctim,and hereby autheiikoe repro tuatNe of this
F. U) efty to enter u Pon the above-mentbrcd property fee lnspetlon purpose. ALTERORADDTOMEC}L
Z_ Date Recei t#
(We).grarouve,indeennify dkeep which the in a o(Cuperthio
V agai5 bcfty;indgmenb,��tt.end eapenseswhkh mayloany way accrue AIR]iANDLINC UNIT(p010,000 CFM) SUBTOTAL:
.gal Id Cty In inn �'ss((ce¢ !the nding•d tM.pemdt
nue FfwNDUNG Lim(ovER3o,000cFl.) CONSTRUCTION TAX
Sighawre,of Appliant/Cmtrader Date EXILAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
FIAZA RDOU9 MATERIALS DISCLOSURE
Will tithe efimdb the upertirbuilding oavpant store hhand9.1
.le h and
HEATING UMT(IO1W,aoBeM Date Recei t#
material as defined by the C ion
hfunidpal Code,Chapter 9.17,and lha X)
Ikahhand Sally CodydMion 2S532(a)7 HEATING UNIT(OVER 100,000BM TOTAL: a(JJ
❑ Yet, a17C1 No
Will the appB®nt tore building oavpant use yulpmertadevices VENRIATTON FAN(BINGLE RES]D) ISSUANCE DATE
which rout harardwsaUc undrunb u defined by the Bay Arca Air
�myhUrugementlJhe 7 BOILER-COMP PHP OR100,0(DAfIJ) PA
� L Yea No
I Ihavemadtf hoz materials requirements under Chapter 6.95 of BOILER-COMP(OVFR 100,0000717) �,��
the GlVomla Heakh&Sa(etyC.dq Set1.v 25505,]S.i)3 and 2S53d. 1 „ p p
understand that lithe building does nor eurrently have a tenant,that It Is y NEWRESIDENMALMECH. SQTT
pore ftytotlatify the oat d vpetherequ menbm
whieh trust be et
�at carte daCctlRo of panty' '�W�� C.AYaVT a(,'b (yIe{wljAfg .
sera authorbad ag t Date v� a� ISSUED
rornL: ,QCT
OFFICE COPY