24225 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proted Idemiflu lon PWU9TNO
Build AddO _ , 24225
oau rc • ares: one:
P TCITY OF CUPERTIN4BUILDING DIVISION ��
c fired« N.me: APPLICATION I PERMIT
BUfIDINGW.ECIRICAI PLUMBINGMECHANICAL CATEGORY CONTROL I
A En
ELECTRICPERMIT FEE BUILDING PERMIT INFO
Ad �� PEtMITISSUANCE ❑ ❑
LICENSED CONTRACTORS ECIARATI
I hereby affirm that l am lkm.ad under provlslora of Chapter 9(mmmm AFPLIANCESRESDENDAL Ipg
Ingwith SaYlon700D)o(DlNdon3edth Bualrcu an ofesmon.Code,and
Ikmse la In fu rte and feel T PANELS 1 ,
Lis _.la _��k.♦ v
Date -e��{oMaC I-� UP TO 2DO AM
ARCI IIm ECIA j 1 701-1f100AMPS
q�v�2 IundermnrW my PlanaelaRbe used c • OVER IOW AMTS SQ.FI.FLOOR AREA S/SQ.FT.
Fi Ll o dProfesbral SIGNSELECIRICAL
G 61 OWNER-BUILDER DECLARATION SPELIALCIRCUIT/MlSC
I.., 7. Iherebyafflrmthatlare eumpt frornthe Comctb l.
raorl¢selaw lar the
po following reason.(Suction 70315,Bualnand Psfesbm Code:Any dtyr
o
2 F. (Suction ® TEMP.METER OR POLE INST.
muntywhkA requbes•per Wmrabuctalter,bnpmve,demo h,orrepar
ae soymmdure prlorto lb bsuarm,also requie.the apperant for such permh to POWER DEVICES
a file.signed enm
teent that b t he Themed pursuant to the praMlas of the
O
ConuadorS Lkese Law(Chapmr9(mmmendab
ng with Sen 70W)of DM. SWIMMING N01-ELECTRIC 1..,3T sbn3ofthe Buelnm.nd Prdenbs Code)arthat helseumpt therebomard VALUATION
Q,� the bash for the alkged ezenWtbn. Any Wdatbn ed a 1..7(315 by any
rk?i appllant fora permit aubjxtathe appBcuntoa dull penahy of nat more than OUTLETS-SWITCHESFLCCURFS
fieundred dollaa 0555.
�n 1,as o of the property,or my employees with wages n their reit NEW RESIDENTIAL E.ECIR 9QFI'. STORIES TYPE CONSTRUCTK)N
t mmpewHan,wBldothe wrk.nd the structure is rmt NteNed or offered for
ole(Sec.70N,Bu.lnese ab Prdesbru Code:The C.olactoe.Lleerue Lw
$ dm not apply to an owner of property who builds or lmpreves lherzon.and
whodowchworkbim Vmthroughhisownernplcyen,prwldedthatwch ,- a\ \' OCC.GROUP RES.UNITS
Improvements are not Intended or.ffered faoade.If,however,thebuiWing or
bTOTAL,
\
impsvemeld sold withinoneyecmn
arofpldbn,the wvner-buBd.rwW have \~1
tIgjZardenofprovingthat hedid esbuild orlmprovefee purpose ofsak.). QfY. PLUMBIN PERf`T'IIT . FEE..
"L as owner of the property,sentucbodmly contracting wtib tlased _ E.OD 70NE AI'N
contactso to mmtmd the project(Sec.7014,Ruslne®and Professions Code:
The Comred.e.License Lw don our apply to an owner of property who
build.or improves thertan, and who contram for such p'Fm wah a ALTER-DRAIN4VFNT'WATER(pA) Q
FEE SUMMARY
sdar(a)I ernMpurwant to thSC®tnd«.I.Icese Law. BACKFLOW T.DEVICE
Lf I ire exempt uude,5.� a/n B 4 P C for thio rescanQ-USIDE FEES
Owner' /�-/T7�/I2 "pals RECEIPT
DRAINS FIDOR ROOF, LOND. SANITARY _ N
. Wrm OR"AN COMPENSATION DECLARATION FIXTURES-PER SCHOOL TAX Y N_
01 hereby affithat I have.certUkate ed em.nt to self-Wam
u , a
aa
nlBot.ofworke 'Cmnpere aRm a
insunee ar.a certified copy thereof(Sec. RFLEPT.
3803,LbC. CAS EA.SYSTEM-1 INC.{0[JILEIS PARK ITB Y_ N_
RECEIPT I
Pdky I GAS FA.SYSTEM-OVER 4(FA)
Co. nvif/ Rd - BUILDING DIVISION FOES
`" "d opy 'm CREASE/INDUSIRL WASTE INTERCE'7DR PLANCHECK FEE
Certified copy b filed with the city ivpedbn division.
CERTIFICATE OFEKMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION
prR NCE SEWER-SANTEARYS[ORM EA 2(]OFT Date Recel t# /S+�
TThbsedbn need.us becornplded Rthehe perMt bforoshundred dollua
(flm)or les.I WATER HFATEt W/VENT/ELECTR ENERGY FEE Y
I anlfythat bthc pedomanm ofthewosk brwhlch Ode pemdtbbued, � N
I alall not employ any person Ina y canner n as to become subject to the
Workero Compensatbn Lova p1 Ia. Dale' WAS ��/ PAH PAID
O Z Appllant �/� NEW RESIDENTIAL PLMB. 9QFT. Date Revel t#
Z O NOTICE TO APPLICANT:H,ahermking t hb CertBkateof Exemption,you
should become subjectto the Wotkeri Compesatitm pmvbbm of the Labor t �� jkw TOTAL:
a. (A Code,you mat forthwith amply with such provisionsorthls pemOt shall he BUILDING rEE
W0 deemed rooked. a�
CL
CONSTRUONLENDINGAGENCY / ( t It 1 1 SEISMIC FEE
Ihembyalflrmtlut CTItherehacoruWctiat kndingagerny for the pedomm TOTAL ELECTRIC FEE
M Z a nsofthe.rkfarwhkhthi pomdlbbR dQee3097,Civ.C)
00 Lende .N.. PLUMBING FEE
F LlMer'e Addresa QTY. MECHANICAL PERMIT FEE
LL t MECHANICAL FEE
O W (meet. tagreetIall vcrnply a pplicttbncl coo t.thmthancear bfonemlan
bmlgI.lulldl.o complywhha0dtyandmuntyize representatives
state laws PERMIT ISSUANCE FEES PAID'.
} fl cit hose enterupon
mstmdlan,aM hereby Pty orlre pe thio tathosemI.
F.,N Im
dtyWenteree to the hose-menti one d.keepertyfor Wpe Cft purposes. ALTER OR ADDTD MECFT.
?
(We)agree to save,lydemntfy.ndkeepmes wh m the CB a of ayaodrtoo
Date ReO t#
V agalrat lLbWtln,jrdgmentn,mel.aM ezperlss which may W.nywayssse AIR HANDLING UNIT(TO t0,W0 CPM) SUBTOTAL:
aga ist said City in coseque.of the grant Ing of this permute -
AIRHANDUNOUNTr(OVER to,mocF.M) CONSTRUCTION TAX
Sigratureaf Appaant/Contrada Date D(HAUBT HOOD(VV/DLkM CONSTRUCTION TAX PAID:
HAlARDOUSMATERIALSDISCIASUREt r10—
W0l the appRont orfutom building oicopant mom or handle havrdcus ]iFATING UMT(TO 103,000 BT1p Dat t#
rsterlalndefined by the, nlrq MuNtlpal Coda Chapter 9.17,and the
Heahhanl Safety, a 1.25532(m)? - HEATING MIT(OVER 100,000 BTU) TOTAL:
❑ Y. o
Will the appllaest tum bulldingosupantuu rcm equlprordevkcs VENTILATK)N PAN(SINGLE RESID) ISSUANCE DATE
whkh errat Faard .osis Me ss dented by the Bay Area Air
. Qua Rty Marugement 7 BOILER-COMP OHPOR 103,000 B'M Y.
requ lit BOBT
have rudlheh oua rs(eriab Iremanb under Chu er 6.95 o1 p�
ILCR.COMP(OVEtIm,00011) P M 9 y
the Cahfonb Health Safety Code,Sedbm 75505,21533 and 75534. I e
understand that lithe Miding does not currently have a tenant,that it Is myNEW RESIDENTIAL MEIN. SQ.Ff
resposlbWty to notify the ceapant of the requirerreents which mat be not OCT 1°"'
ruoto Lame
uaofa Cerci sn
OUaroy. V s9s7C
F
rarauth Date BY:_
' TOTAL IsSTTEDBY:
OFFICE COPY