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21950 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ButldIo Pru et Identlfkatlon PF]kMITNO. ing �� Tues 21950 Owner e i p CITY OF CUPERTINa BUILDING DIVISION Contra re.N.me LIc.N. APPLICATION I PERMIT BUNOINGELLCTRICALPLUMBINGMECHANICAL CATEGORY CONTROL Y ArchRect Isglneer. Lk.No: _ Q ELECTRIC PERMIT FEE ,,��---A.BUILDING PERMIT INFO Address ` 0 PERM ITLAUANCE l-. � LICENSED CONTRACTOR'S DECLARATION II CC I. IIJ IMrtby affirm that 1 am Beensed under pro salon.of Chapter 9( c APPLIANCES-RESIDENTIAL JOB DESCRIPTION ingwith Section 7000)of DlvWan3ofthelludveseand Rofession.Code,and my Ikense b In full form and effY. PANELS "�-iftJti-tr License Clam LILY Dale Contractor ARCHITECTS DECLARATION 2DI-10DO AMPS _ ZpC Iuod.t."my phm.hall be used as public mord.. OVER10DOAMPS SQ.FT.FLOOR AREA S/SQ.FT. Ft z O Lken.ed Professional SIGNSELECTRICAL <<�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT./ML9C 7f, 5 Ihertbyaffimnthat l am e.empt from the Contractor's Linme law for the P fulle R winre g ason.( cti7011 on 5,Business and mfeason.Code:Any y or O Z SemTEMP.METER OR POLE INST. P4 couvtywhleh requUnapemdtmron.tract,alter,lmprwe,dennlbh,arreryir anygmct mprbrtoitt me,aWrrqubo eappUca tfm.uchpemdttu POWER DEVICES Ne.signed statement that he b Licensed pursuant to the provisions of the �3�fn Contratar'sUcem,Law(Cha Pier 9(mmnrndng wkh Section 7000)of Dov SWIMNUNG POOL ELDC'TRIC X03 .bn3ofthe Buetnessand Profess mCode)orthathebe mpttherefromard VALUATION the bub for the alleged exemption. Any Wdatbn of Setbn 7MI5 by any OUILET-SWT CHESFIXIVR Co o O{) appLint for a permit am bjethe applleant to a civil penalty of not mortthan R five hundred dollare(y5W). NEW RESIDENTIAL ELFtIRFf k?< ❑1,as owner of the property,or n7 employees with wages as their sok ® STORIES TYI'ECONSIRUCTION' compensation wOldotheweck,.ndtheata mbr Wsidedor offered for O le(See.7C 4,Business and l'rdmlona Code The Comosone.LIceme law $ does not apply to an uwou o(propeny,who builds or lmpreVes thereon,.nd a•5^ who d..ochworkhWselforthmugh htownemplayeea,provided that ouch OCC.GROUP RES.UNITS Imptovrment art nIN Intended Proffered!croak.If,howeo,,thebuildinger TOTAL: I Lr lmpnvement bwldwhhlnorieyesrofcompltbn.tk wmer-bulldarwW love ' tlrenofpmWrgthat he did wtbuud or tmproae res purpose orale.). QTY. PLUMBING PERMIT FEE v owner of the property,am excW.Nely mntrecting wdh Licensed FLOOD ZONE APN C=,.rorMrut thapmjM(See 7(144,Buslness.M Pmfessbro Cade PERMIT ISSUANCE 1Z� Cootrator'.L1omm Lw does sat apply to.n owner or property who ALTER-DRAIN k VETT-WATER MA)bu Bdn or improves thereon, and and who mMsoh sh p - lojeets with a FEE SUMMARY �+ta(e)lkensrd pamunt to the Contnci�.Licerue Law. BACK FiOWI'[L7TECT.DEVICE LII am exempt under Sec B A P C for this mason Co Owner Date DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y_ N_ WORT MAN COMPENSATION DECLARATION Y ' FLYR17IffS TRAP TR4C� SCIIWI,TA% Y ❑ . 1 hereby.(firm that 1 hate a certlfiate of consent to.elf-Uwre,or N_RFFCEEPT certificate efWorkere Comperuabon Insurance or.certified espy thereof 6ec. GAS E.A.SYSTEM-I INCL OUTLEIS PARK FEE Y_ N 3800,Lab C.) RECEIPT Go GAS G.SYSTEM-OVER 4 MA) Comm any BUILDING DIVISION FEES 11Centf4d mpybhemby famished. CREASE/INDUSIRLWASTMINTERCEP70R PLANCHECK FEE ®Certified copy Is filed with the eJty trupmtom cih,Won. CERTIFICATE OF EXEMPTION FROM WORKERS' GREA'SE7RAP PAID COMPENSATION WSURANCE SLIVER-SANTfARY SICRM EA.20[IFT Date Reoef t# Rhlsee tion need not be completed Uthe permit Is fee orae hundred dollars (Slro)orleaa) WATER HEATER W/VFNT/FI.ECIR ENERGY FEE Y N I OMifythat lo the performance of thewcek for which this pemdt is loved, I atoll not employ any person in any manner an ae to become abject to the WATER SYSIEM/IRFATRNG - Worl eri Compensation laws of allI mb.Date PAID Pp Date Reoef tk A Liant Z O NOTICE TO APPLICANT.If,slier making thio Certfflate of Faamptlon,you NEW RESIDEN7RAI.1'11.IB. SQFT. ahauld become abject to the Workers'Cononsatlm,provl.bru of the Labor TOTAL: CCN Code,yaum eft hwlthmmplywtha&provbtomorthbpem t.hellbe ' Up LU > deemed revoked. BUILDING E CONSTRUCTION LENDING AGENCY SEISMIC FE L Ll Iherebyarftm,thatthemiaam,uwelonlendmgagen�y forthepedcomm ro'rnt. ELECTRIC FEE Z ance ofthe workforwhlch this permit b baed(Sec.3097,CIv.C.) ` PRW U O Leeder's N.me PLUMBING FEE tolcz LL F Iandre,Addrtm QTY. MECHANICAL PERMIT FEEMECHANICAL FEE O W IoedBythatlluve read thb.ppBcatbnard atatethattheabwe Nforrtullm FEEPAID: t� (1 bcormt.I.greetocomplywtth.Udty.rMcountyordirunm.vdatatetws I PERMIT ISSUANCE 'Z.CO S } N relming to building rom uctlon,and hereby auNorue representatives ofthb F Z city to enter upon the abovtmentbrud protb perty for impen purposes. ( ALTER ORADD]O MCfl-1. (`w Date Recei [q � — (We). to save,indemnify an d keep harmless the City of CapertW P ag.Wt lItle,judgment,mats. experues-th nuyinavy ay cerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: a old City In mnsequee¢ f gnmlrgoflhis mr, AIRITANDLING IUNIT(OVER l0,000CFM) CONSTRUCTION TAX fz S of Appil n/Contrrtm ID(RAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MA IALS UISCLOS E the applicant or future building omupant store or ha Mle harardms HEATING UNIT(TO IW,OD)BTU) Date Recei ted note I as defined by the Cupertino MuNtlpal Cade,Chapter 9AZ and the I kkFaa�hh and Safety Cod,Ie�L+—�SS�etion 25532W7 HEATING UNT[(OVER 1 W,ODO BTU) TOTAL: yesTVNo filtheapplicI mfuturcbvlldbg o¢vpant ore equipmentmdevk'us VINIILATION FAN�rNGLE R]SID) ISSUANCE DATE whieh endt h.ardou�ab eontMrurde.e defined by the Bay Area At, ' Qa Iny Marugemaru Dbtritll BOILER-COMP 0HPOR 100,000 BTU) 4Yee No have read the ha:ap.materials m)ulnements under Chapter 695 of BOILER-COMP(OVER 10,000 BTU) the allfomt I lealth 6 Safety Code,Sections 75505,25533 and 75534.1 understood that lithe build[ng does not currently have a tenant,that it e,my NEW RESIDENTIAL MECH SQ.F7 .paramLiltytova Rythe.paru oftherequm er4swhkh mostbe met prior to], u.oce or a Cetlfkste of Occvp.ruy. .� (N� ,'.,L���p Ownerm amharlud agent Date ISSUED BY:, TOTAL OFFICE COPY _ {'t/�fSf-IEC' -Qey,F I�L�Lc�c{r0 J OE' jf�5` jGOC2 X10 o K klTe NEM FFFi A{{ I L DES � MAR @LDG, INSPECTION:DEPARTMM CLIC DE DIIFFRiI►,10,,� C-t-�.,o � _� _ �' ._ -� ..- IN ACCO pP��O��l^.©M COP`f11T/NO ANCE w1r. u l - - DAT CODQc�;O'rTH@ 0171,600 QTC! - - .. _ . . �Irvarve 8 - owlQ this ser o`� p, l� - - - - - be Ala,vs - kslo pq the a d sPecificsno _ lawful - - p _ s ort maks h n at all times. . ns t4NST _ .the Mme wrthou Y� nBas and itis fhe_ tramp' DgAjr t GSty Pernrulp�r2bOtis ---- - --SHa1C rvat`��InlS pin Cuvertrl2 iror,•t -. _ - - - _ _-�- � _- -_ herd --- �f_a lroatr nit:or - __ Of 1e to�B�'s--- -- --=--�— - ----- - ------ ---- - --- r - - -- --- DI kEz ;- ---/0330 741 =ea ✓o--.