20123 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Mixer Identification 7 MP,14TNO.
Building Address:
/ /0o �7-w h- 20123
ane: A
CITY OF CUPERTINO-BUILDING DIVISION L+,_.•�-�C
nom• QBBQ, x. APPLICATION I PERMIT '
49BUILDING-ELE{IRICALPLUMBINGMECHANICAL CATEGORY CONTROLN
Architect/Englraer: Lk.N. -
�J, QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre,asaf3 PFRMITISSUANCE 2f„a..s ❑ ❑ ❑
LICENSED CONT'RACTOR-4DECLAIIIAIDON
I hereby affirm that l am licensed under provblos of Chapter 9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRETION
Ing with Sedlem 7000).(Dividon3.fthe Bust and ProfesdoroCode,and
Ibeae b In full( dfeR PANELS .
mn� —J,
Dale
Conrad ict UP TO 2DOAH�
ARCHITECT'S DECLA TION201-1000AMPS
aZ I urderatard my pUmshall be used as publicremda OVER1"AN" SQ.FT.FLOOR AREA $/SQ.FT.
k O Limnced Professional SIGNS EfECIRICAL
<L
�< OWNERx ptfirm
DECLARATION SL'CCALCIRCIRT/"LSC '
Z rt
Ihcbyaflirm that lam exempt nlhe Contractor's License,Law la the
following ream,.(Section 70315,Buslnm and Pru/mbru Code:My dty or
O 1- TEMP.METER OR POLE INST.
X54 CantymM1 � to ift meattorequim thempUantfmo 6prrtp o
,7 ay,trocNrepMtoiabsuarcgalwrtqulrnruant to the (.nacos of the ]OWEADEVICES
y+y D� Ole a signed satemenl that k b lfren"punuanl to the pnoWloro d the
�w Contractors LicemeLaw(Chapter9(mmmentlng with Sedion 700D)of Divi- SWINMNG POOL ELECTRIC
OJ don3 of the Businm and ProfmloroCode)or that he la exempt therefrom and AI]ON
a E5 Q...5777 tLe baafa for the alleged exemption. Any Wdatbn of Section 70015 by any
appU.t fora permit tobjeca the appl4ant to a dvil penalty of not more than OUR'E7SSYI7CHESFD(T`URES
c. ft hundred ddlara( M.
"1,u owner of the property,or my employees with wage a their wk NEW RI51DFNi1AI,F7.ECTR SQ.FT. TYPE CONSTRIATION
rvmpenntlm,willdo the work and the stmehim b not intended or offered for
Ci ssk(Sec.7DK Bu,hsm and Po fmbro Code:The Contradur,Lltenne Law
does not apply to to owrer of property who build,or Imprrnxn thereon,and CGROIILs RES UNITS
who don such wura himself m through wown employeea,provided that such b
Improvements are not Intended oroffe"fee sale.If,however,the building or TOTAL
Imprwertent b sett whhIn oreyeardcomplelbR the owner-builder will love
tryc.¢arden of proving that he did not build or improve for purpose of of aak.). QTY, PLUMBING PERMIT FEE -
IJ L all owner of the property,am exelusi ey�terting with Iionsed BLOOD ZONE APN
extruders to mrolruct the projM(Sec 7074,Busbm and Prdmba Code: PERMIT ISSUANCE
The Contredor'•Lie-nee Law dm net apply to an owner of property who ALTER-DRAIN 6 YFNTWATER(FA)
build.or improvesremntrm
thereon, and who arforch supnyjeN -
with a FEE SUMMARY
rQn1pol.d.)li¢nxd pursuant to the Contractor'.License Law. BACK FLAW PROTECT.DEVICE
L j I am exempt under See. B k P C for this runt.
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT 4
WORKMAN COMPE2NSATION DECLARATION it SQiOOI,TA% Y_ N_❑I hereby affirm that I hate a mrt Rete of consent to aelf-Insure,a a FDn`U tES TRAP TR '
""flute of WorlorYCompentait lvuran¢ara¢Nfw mpyt reoffsec. R E7�N
13800,ab C) Lt�_Ml/s O GAS PA.SYSTEM-1 wC4 OU1LEI5 PARK FEE Y_ N_
V N/�+ '� GAS F.A.SYSTEM-OVER 4(EA) RECEIPT M
Calm any BUILDING DIVISION FEES
1 I CenlOedoopylsh bylurnbabed' CREASE/wouslRl.wnsLl:INTERCEPTOR
PLANCHECK FEE
LTJi CenNed ropy bf with the cy Wpeebn dlWsion.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 700Fr. Date Recd t#
(TNasedlon need nct be c.mplcted lf the per"[b fmore Fund"dollars
ased ENERGY FEE Y_ N_
W)or lWAT1REN
F1EATERW/VT/EECIR
I rI.st Inthe prdomren¢of the wmk forwMchtw pemdtbissued.
1 shall not employ any perwn In any manner seeito become subjectto the WATER SY577M/TREATING
Workonf Compensation lawn d GBfomla.Date PAID
O = Appliant NEW RESIDENTIALPLMB. SQ.Ff. Date Reeef ted
Z O NOTICE TO APPLICMTT:If,after makig tw Cenlfiale of Exempbn,you
Fahold become subject to the WorFae''Compewbro L:
tion provbof the Labor TOTA
Q N Code,you nuafcothwbM1 comply with such provisions orthb penNt shall be
W > deemed rewked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il Ihembyafffrmttutdnre bamrutruGlm ledingagercyforth perfomt TOTAL ELECTRIC FEE
0 aox.fthxwu&f.,whichtwpermlt bivued(Sec.3097,CW.C.)
V ]ender.Name PLUMBING FEE
H ]ander',Add rm QTY. MECHANICAL PERMIT FEE
O W Imniythatlhatremedtwappliatmnad satelhattheabota Information MECHANICAL FEE
fl bmrrou.lagreebcomplywiNaB ctlyand oontyordbamad sate law• PIRMITISSUANCE FEES PAID:
} relating to building mrotroctice,and hereby authMze representative of this
f.. N
city to enter upon the abov nxentbred property for hopection pu rposea. ALTERORADDTOMECH.
? (We)agree to save,IMemrdy an d keep harrolm the Cly of Cu penal Date Receipt#
V g.trot WhIltk,,judgmente,na,and operon which may In any wsyamue AIR HANDLI NG UNIT(TO 10.000 CPM) SUBTOTAL:
agoLM old City In cvnaequer�e of the granting d ehla pemdt.
AIR HANIXl NG UNIT(OVER 10,000 CFM" CONSTRUCTION TAX
Slgwture of Appeent/Cotrxtu Date EXHAUST HOOD(W/DINGO CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllont mfuture Wading oavp..t atm,or bauxite h--,d. HEATINGUNIT(T0100,0DOBM Date RCCCI t#
outerial e,defined by ted Cupentw MuMdpol Code,Chapter 9.17,and the
1lulthand SdetyC e IIon2S532(a)7 HEATTNGMT(OVER100,000BM TOTAL: a
❑Ye No
Will the appllutu re Wilding oerupat use equipment or VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardos air mntarol unts a de0red by the Bay Arta Air
Quality Mawgerent t - BOILER-ODMP CIROR 100,000 BTU)
4n Y
havoread the
eabl matorizili Secequlmnona undoChapter 25534..93 of BOILER-mNP(OVER IW,OW BTU)
.nenoarmla HeabM1 Safety Code,Sectba 7S505,ve 33 atend,t],it I /a�q
underwndthat o ut Wlldingdm of wrreMy have•tenant that l[brtry NEWR®DENHAL ME(71. SQFT - `^a/
repo blifty ion the paMdlhe nequbemenb whicM1 rtust be met tlpet
p t Cert to of aEpanry. / ryr((
Omwth agent �Oate TOTAL: ISSUE
OFFICE COPY