22000 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Suilding
Bui033(�-7T� Amar rEwwTNo.
22000
one: -
NiF'/vl • LTO t5icm 4ry �Z.Ljc 7CITY OF CUPERTINO-BUILDING DIVISION
Conies Named:,Ate• Lk.No:
APPLICATION /'PERMIT
C NIJC�Z BUILDINGII,ECTRICAL-PLUMBINGIC
MFLHANAL CATD50RY CONTRO
Archttetl
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add. ,
ISSUANCE ��.
LICENSED CONTRACTORS DECLARATION PERMIT
I hereby affirm that l•m Beenaed under provbions of Chapter 9(recoment, APPLIANCES-RESIDENTIAL JOB DESCRIPTI
ingwith Setlbn 7000)ofaAMun3dthe BuMneu dPmfml Code,and my ON
Ike.b In full furor and e/fetl. PANELS j7
Llnme Clea IL1cI
Date Contractor
ARCHITECTS DECLARATION M-I(FKElAMPS
0Z I understand my pbmehaB be used as public recada -
OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.Ff.
0 Llansed I'nmfmloml SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
fn a Bl SPECIALCIXCIIIT/ML9C
yI' IhcrebyaWn fSenttIt lam11'5,B from ln.. dmf.umaCod,:raIctor's License, rydtycr
q❑ ..tyve for the
grtaaeq l$eelm to.Bu andrrufmbru Cade:Any tltya
� I'u( oasntywhlch requlrnapemdi to corutrue,often improve,demolbh,orrcpalr TEMP.METER OR POLE INST.
qqq`'� ^J anystrunure prbrbils bauance,•Ieo mryLetheappllant(orwch permit to
p5 We a slgiud statement that he is flamed punuant to the provisions or the POWER DEVICES
Contractors Lee.law IM apter 9(comme ,ing whb Seebn 7000)of DivF SWIMMING FK)OL ELECTRIC
�Ua Mon3ofthe BuMn .dPra(eabru CMe)ort Ahebe mpttherehomandVALUATIOV
y.'•.1 the basis for the alleged exemption. My violation of SrYbn 7DriS by any ^ / Q L/
appllant for a permit subjMe the applleant to evil penalty d no more than DUTI.ETSSSVITCHESFlXRIRES u V l/
n�u ownerdredl of the property,or my employees with wages as their sole NEW RESIDENTIAL ELFL]R SQ.FT. STOWES TYPE CONSTRUCTION
o
oempereatim,"I d o the work,and the structure Is not Wended or offered for
psale(Scc.7044,Buabam and Podeabro Code:The Comneors Lt.taw
c$g docs not,apply to an owner of property who W lids or improves t hereon,and OCC.GROUP RFSUNUS
who dm such work hlmeeE«through his own employees,provided that such
lopmeemama•n at Intended or offered for sale.If,however,the building or TOTAL 'go
Improvement bsdd within one yearofcomplebn,the ownerbuWrr will have
tpc�men of proving that he did not wild or bnprove roe purpose of rale.). QTY. PLUMBING PERMIT FEE
PCO L a owner d the property,am ecWslvely amtracting.with Il rued FIAOD ZDNE AI'N
T eaatocoruttutltheprojed(Se.7Dd4,Businman]PrdeabnsCode. PERMIT ISSUANCE . OU
The
Comneors Llccnae Law doe not apply to an owner of property who ALTER-DRAIN k VENT. WATER(EA)
bu Ids or improve thereon,and who contracts fa such p(ojee.with, "OFEE SUMMARY
0�juvctw.)nonmed pursuant to the ContnctaYLlonmelave. BACK}TAW PROTECT.DEVK;E
1_J I a empt under Sec_ B da P C /or this reason
• Owns I/{LL Due a DRAINS FLOOR,ROOP,AREA.ODND. SANITARY RECEIPT
1 O 1 IMS1 COMPEN ION DECW TIO
❑1 h aftbm that I have a flute of concent to seff-Irwn,or FOCTURFB'PER TRA SCF[OOL TAX Y N
aeniBole ofWorked Canpeossdm Imuran¢ora certi/led ropy thereof(Sec. / R5CEPII
3800,Lab GAS EA.SYSTEM-1 IJC401JTLLRS • 0� PARK FIE Y_ N_
Polley/ - RECEIPT'
ray GAS EA.SYSI'EM-0VER4(EA) BUILDING DIVISION FEES
RcertWed copy la hereq with
thea. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CeniBed ropy b filed with the dty WpMbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA•SETRAP PAID J,
COMPENSATION INSURANCE SE'WPRSANfIARY STORM EA 2l1IFT DRIC RCOCI IM
(fblsaectbn need rad becompletedff the PermK b forom hundred doffan
fslamalm) WATER EffAItR w/vEx/E ETR ENERGY FEE Y N
I aertBy that N the performance of the work for which this permit b issued,
I shallan
not employ any person in y mn anner as to become subject to the
kan
Wor 'Compsresmo. awaor Gll/omWATER SYSTEM/
b.Date TRGTING (l PAID '
Pp SQ Date Reuel tk
A ¢ant
Z 0 NOTICE TO APPLICANT:If,after rtaking lite Ceulflu/e of Ezc Xh,ioR,you NEY.'RE9DFNTIAL 7'I.MB. FT.
F y should become wbjeet to the woeter:Compemattenprowbmm oftne labor TOTAL:
c _ Code,you at forthwith n rrply with such provisions or this permit shall be J Q
9deemed evoked. BUILDING FEE
ISMIC FEE
CL O Iherebyaffithat then ba comtrutlinn lendingagency for the perfomm _ep ELECTRIC FEE
Z ance of the work(or which this permit b Issued Sec.3097,Cie.G) TOTAL
U O lender.N.me PLUMBING FEE
H tenders Addrms QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE a
O W a nret. thgneeto redly withphratbnand MatethdtnancesebftairI. n
1 bcoinglobgnetomrsomwtth andtyand auntyoralmnmand Matelawe PERMIT ISSUANCE FEES PAID:
} N rclatl enterupontheabo mcmton,and d reby property
or in npre:na rpurs,his
Z dty,to Wr)aree to sae,Indemnify
pro etyma inspection purpose. ALTER OR ADD TO MECFL ()
(We)agree to ave,Indemnify an a keep hamdm the City o/Cu raw Date Recei ted
V ago BabWlin,pdgmems,coMnand¢perm whkh nay Nany- • AIR HANDLING UNIT((010,000 CPA) SUBTOTAL•
ag d City in coneeque�d min fthtapemd.e7/
6 ATRHANDITNGUNIT(OVER10,mOCFM) CONSTRUCTION TAX
Aj 51 not ppant ai Date EXRAUSf HOOD(w/DUCT) CONSTRUCTION TAX PAID:
HAlARDOUS MA pa DISCLOSURE
Wtheapp0untafutun dill Monip.IC.dn hrptMr .h .dour HFATB�G IIMT(IO 100,000 BTU) Date Recd ted
material n Safetyd odthe Cupertino MuNdpal Code,Chapter 9.17,and thea
Efeatt Yes Safety code Section 25533(x)7 HEATING UNIT(OVER 100,00)8'[71) TOTAL: a I�
❑
Yes No
WWthemt appBanta tun w0ding uapmt use equ ipment or devices VENTILATION FAN(SINGLE I(ESIJ) ISSUANCE DATE
whichemita ren? as defined by the Bay Area Air Pan
•
Quality Management DbtrN7 BOILER pEIr DR 100,IX0 BTU)
Yes ❑❑No
haff.Ldl,.Ith&rdfety C.erlabnqulremenbunderChapte4. I of MOILER-NMP(OVW21 W,000 Bi1)
the CGlBomb Hellh k building
Code,Sor ism75505,ve a undt,that I
undarstand thetif the wading does not cvrnmly have atemnL that ltEmy NEW RI5IDIN'UAL MECH. SQFf.
mp-to lesuitonotifytheo to of ortherequlrtmemawhichHurlherend-
priortolguarladaCert1/fate o/Oavpanry.
OVUM�\�C r
Owners authod>ed agent Date ISSUED OY:
'TOTAL .O
OFFICE COPY
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