22030 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmlect Identifbtlon PERMIT NO.
Banding Addoeas: .E 2 2 0 3 0
l 3o Tal-.4
I ams �t c " � mir.
J FS Ce U r IV ;o,S1CITY OF CUPERTINO-BUILDING DIVISION ��, �
Cmtnctar's Hamer Lk.N¢ APPLICATION / PERMIT
�N BUILDINGELECTRTCALPLUMBING-MFLHAMCAL GTFLORY CONT'ROLI
Archimet/Engioeer. Lie,N.
/�
Q ELECTRICPERMIT FEE BUILDING PERMIT-INFO
Addmeu Z O NcEr PERMIT ISSUANCE y�
LICE.\SED CONTRACTORS DECLAMTION '11
Thercbyaffirenthat lam11mmedurdmpmwb1ovof Cbapur9(ournmere, APPLIANCES-RESIDENTIAL JOB N
IngwlthSe n700fpofOWb4m3ofthe Buslm dProfesdmsCode,and my
license is In full form and effect. PANELS
Lkv
eo Chs Llc./
Date Contndor La!M 2QQ ANTS
ARCHITECTS DECLARATION 201-1000 AMES
0'Z IurdeMard my plaraehall be used as publicreourds OVER IWO AMI, S/SQ.FT.
µWCOC
L`j Lloeraed lrafmbrul SIGNSEISIRICAL
�Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MUSE10 V1 r UT R
'Iherebyell.that(am exempt from the Cordraemri Limes law far the T^
FZ., folbwing reason.C+rctim 70315,Bushes and Profesbv Code Any tlty or O /
O 71MP.MEITR OR POLE WSf.
� countywhkh rtga4esapermBto mmUud,alter,bnpmve,dertnllsh,orrrpair
4 anystroctum prlmto lb bmoame,also requhmetbe applicant for such permit to TOWER DEVICES DK
E5 file a signed statement that he b llansed panuant b the provisions of the
O I1.� Contractor's License lAw(Chapter 9(mrrurcntlngwith Sectlon7O(JO)ofDid-
F�wOJ don3ofthe Basin dProfmWl Code)orthathebemmptther mmand SWIMMING IDOL ELECTRIC VALUATION
Q 0 the bash for the alleged ezempUm. Any dohtbn of Section 70315 by any
OUTLETS-SWITCHES FIXTURFS Zv
�j appdontfora penNt subjectathe•ppllunt less tldl pevhydnot more thin
E RHjndred defies($SM. NEW RESIDENTIAL ELELTR SQFT. STORIES TYPEMNSIRUCTION
cal,as owner of the property,or my employees with wages as their sole
compavatlon,w01 dothe work and thesuutlure b not Intended or offered for
O sale&,70K B.Iness ant Pm fesbv Code The CoNntlors Lbense IAw
s� does rot apply to an owner of property who Wilds or Improves themcm,and OCC-GROUP RLS UNITS
who door such work himself or through his own emplaycce,provided that mch � y �rv-na
improwermus snot blended or.fmmdforsale.If,howeverth
, ebulidinger TOTAL: ,"ll t/
Improvementbraidwlthinomyearofcampletb theowner- Mery Tuve
XMened proving that he did W Wild or improve for purposeo(sale). QTY. PLUMBING IO
PERMIT FEE FODZONE AIN
I,es owner of the Property,am exclusively contracting with lleensed PERMIT ISSUANCE
d t deeatomvtmct the projM(See701q Bualnesamul Prafubm Code
The Contractors I.turn Law don not apply to an owner of property who
Wilds or Improve thereon,and who contracts for ad pPjm with• ALTER-DRAIN&VENT-WATER EEA)
cQWfselmW lfceread pursuant to the Cmtractds License LAw. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am ewmpt under Sec ; B& P C for this renin
DRAINS FLOOR ROOF,AREA,HND. SANITARY Y_ N_
1
Owner Dan RECEIVE a-
WORKMAN COMPENSATION DECLARATION 1 F7XNRES PER TRH' ^Z 5 500—LTA% Y N
�I hereby oHbm that I love• Imu ate of consent to sell-iwrt,x a 1
3rerlifleem SWLabof Worken'Compenaatlm Irreoranaeea artBledcopythereof(Sec. R_ a
1'.Ik IA6 CJ l GAS EA.SYSI'F7.1-I INCA OUTLETS Z��CJ PARK FEE Y_ N
),dam.E RECEIPT a
GAS FA.SYSTEM-0VFR (FA)
Ca ray BUILDING DIVISION FEES
E 1 CertNed ropy b hereby fumbhed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CertNed copy is filed with the dty impenbn division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSUR.M Esu.2OWT Date Rccoi tq
(Ms section need not be completed B the permit b forme hundred dollars
(Slro)orle.) WATER HEATER W/VENT/ELEC]R ENERGYFEE Y N
I certify the In the performance of the week for whirl W permits peJt is Loved, —
I shall not employ any person In any manner an as to
YST
become subjeet to the WATER SEM/TRE ATII�
worker:Compensation Lews of California.alifor . Date PAID
z Z Apph.t - NEW RESIDENTIAL laLMO. SQFT. Date RLroel t!1
Z O NOTICE M APPLICANT:If,after ming this CemBlnte of Exemption,you
should become sub}an to the Workers'Compewtbn provisions of the Labor TOTAL:
~ N_ Code,you moat forthwith comply with such provbbv or Nis permit shall be
desnrd revoked.
d � CONSTRUCTION LFNDWCAGENCYT SEISMIC FEE
Z IherebyaorkMtwhkht bammtnuctlmlendNgageuy(arthe pedarmf TOTAL. r s� ELECTRIC FEE l
7 O ancon;`.Naork forwhkh this pemdtbbsued f$er.309'/,CIv.CJ
cV
I<ndera Nme PLUMBING FEE
LL U 1-- Lenders Admeas Cry I MECHANICAL PERMIT FEE
IU l redifythat l have ad this appllatbnand statethat the above information MECHANICAL FEE
reIsmrmot. greebcanplywBh.R tltyard county ordinanmssnd state law. PERhM L95UANCE 12..cri rcES PAID :
relating to building coramutlimes
,and hereby authoree mprentettvn of fhb
03 elty to enter upon tlr above-rrcntbrad property for impeetbn purposes. A1,MORADDTOMFLH. l y()
Z (We)agree to save,IMemoify an d keep burnt.the City of Cuperthio Date Recci tp
V a aW WbWties,pdgmergs,mrtsandexpen whkhnayl anyway amme AIR HANDLING UNIT(TO 10,0(XCFM) SUBTOTAL:
g said City b mnsequener he tingofthlspemn .
9 AIR HANDuIvc(mTr(DOER lO,000cFM) CONSTRUCTION TAX
tureaf Appllant/Contractee Dat IXHAIIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
t1Al RDOUSM T RIALS DISCLOSURE
Will the apphant orfutum building onapant store or handle ha ardoros HEATING UNIT(TO IM,0003M Date ReCcl tlf x
materhl as defined by the Cupertbio Munttlpe Cade,Chapter 9.17,and the
Iieahh and Suety Code Serum M32(.)? HEATING UNIT(OVFR 103,003 BTT) TOTAL:
yeaN
BoI the.ppBarrtm fumeo building oavpant use equipment erdevkl VENTILATION FAN(SINGLE RESID) ISSUADA
which emit hon Mous ab centamivnt.as deRvd by the Bay Arca Air O
Quality Management DWrkt7 BpBFA-COMP OHPOR10f1,000 B7U1
r-1 Y F-I No
havereadthe th&S�f a CWt ,Sbdq.emenhundn Chapter 6.95 of 1)OII.ER{OMP(OVFR 100,000 BTU) f �QFT
the GBfmnh Health&Safety Code,Stcummtly have a teran2bhatit i `as7,
undensiM thatresponsibility
notify the orgdan oftmnentlylavca tenant that it bony NEW RE9DFNTIAL ME(7-L $QFI. aa,.
rupatobs., onot Cy r1i aecvpett of the f0ceupaney. emenn which moot be met W'YR/s R.y
polar to Lsuana d a Certilkats of Omparcy.
Owner or authorized agent Date TOTAL ISSUED BY:
i
OFFICE COPY
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