21662 APPLICANT TO FILL INJNFORMATION WITHIN RED LINES — USE^) BAL�L/P}OINT PEN ONLY
Build]"Pr.ea Id fkatlmt - /'}l./D—/y/ I. PkBh4T 21662
Buildln Addrea: r J (, ��{
ATTLICAT
m. CITYOF CUPERTINO-BUILDING DIVISION �� l l p
o APPLICATION I PERMIT l
I BURAINGELOCR CALP UMBINGMECHAMCAL CATEGORY CONTROL Y
ArchR /Engieeer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PEIU9i] ❑ ❑
LICENSED CONTRACTORS DECL4RATION
T hereby iffirtnmatlam Bcevedunderpu W« of Chapter9(oa a ANC L )OR DES(M- N
Ingwith Sedl.o 7000).!Dlvbim3o1ine d orardt,and crty
lions.b in d d(M.
Lfnve�Lk.I / RF
Date Contractor
ARCHITECTED T OVER
utOZ IuMentand my plants slug be used upubecremds OVER 1000 IPS SQ.FT.FLOOR AREA $/9Q.FT.
oIj Llmmad Pmfeabvl CAL
tLRi1 OWNER-BUILDER DECLARATION IAL CIRC /A11S -
Zi., 3 Ihtrby aMrm that l am exempt from the Cordrae 'OLl« («m
Fpo following reason.(Sedlon 7MIS,Buelnmana Pmfewbv Cad ydty.
ZI"' muntywhfchrequiteapemdttow� d,atter,lmprove,de crrepafr RPOLEINST,
SmY anystructure,prlorto lb luuance,abo requires theapplIant fm Pemdtto CES
K Rk a signed statement that be,b!Ixensed pursuant to the p b of she
3m Contradm's License I..(Chapter 9(commencing with Section of DIv4 GPOOL ELECIWC VALUATION
mos tlon3ofthe Buslnmad ProfesbvCode)arGut hebe.oTHhp mmand _
O_
the boob for the alleged eumplon. My Nolatlon of Sedbn 7fD1 by any
S�>cf appllantfora pemdt aubjedathe appllcanttoadWl pevlty dndT than O
By,£h,undred dollars(SSM.
"1,a owner of the pmpedy,or my employee with wage as tt le RF D �'�. STORIES TYPE CONSIRl1CTTON
amipevaOm,wW dothe warK aMmestrudurtbroHrrtendM or offe r /
OBale(Sec 7004,Balnm aM Pmfmbm Code:The Contadots Umme❑
$ don netapply too owner ofpmperty who builds orlmprwnthereoR� an
mv^ who doessuchwork hleB«through Mnownemployes,provided thatau, OCGGROUP RFS.UNITS
bnpmvemensamnMl tendedoroffendfwuk.ILhowever,the Wlldingor - TOTAL ,
Impmverrcnt b sold wRh b one yvr ofcomplcUOM the vvner-0ullderwlfl Fay.
t rden of proving the he did cot build or Improve f«purpose of aIle.). Qry-1 PLUMBING PERMIT FEE
Lf L u uhe
owner of the property,am exchly contacting with licensedFLOOD ZONE APN
.mtacton to mmtmd the project(Sm 7N4,Binns and Profmbm Code: PERMIT ISSUANCE
11s C.rdnd.e,Limve Law does out apply to a owner of property who
Wild.or lmprosv thereon, and who contras for such Miteb with a ALTER-DRAM&VENT-WATFR
ilcerued punvnt W the Cmtad«'a License Law. BACK FLOW PROIECf.D FEE SUMMARY
LJ I am exempt under Sec 8 6 P C for this reason
DRAINS FI K g D. SANITARY Y_ N
• Owner Date - RECEII74
WORKMAN COMPENSATION DECLARATION[:]I herby affirm that I have a mdiflute of consent to self-Inure,«a FE(TURES PER SCHOOI.TAX Y - N
RECEIPT I
artiBab olid tion issuers«ma copy cone.! OAS EA.gyS-fFM-1 1 PARK FEE Y N
• 3800,his CJ
Policy I RECEUr a
CAS FA.SYSTFM-0 )
Com ny BUILDING DIVISION FEES
�CedBbd copy b herebyth tN,cit. I GREASE/INDUSTRLW INTERCEYIDR PLANCHECK FEE
�CedNed mpyb(OM with tFe city! d _ '
.CERTIFICATEOFIX PDON FROMW RKERS OREA_Q'TRAP a PAID
COMPENSATION INSURANCE g}yFTFSANUARY STORM Dale RCceI [#
(1-hla section need nut W completed lf the pemdt b f«one hundred dollen
(slap)«lm) WATER HEATERW/VENT/ ENERGY FEE Y N
I«dlfythe loth.perforwn«.fthew«kfanwMdthi,pe i.H ed, -
I shall n«employ any pesos in any manner e as to become subject to the WATQiSYS��M/TREATING
W«kcrs'Compewtlon laws of CaWounia. Dec PAID
-
0 Z AppRant NEW RESIDENTIAL I'LMB. SOFT. Dale Recel 1#
ZQ NOTICETOAMUCANT.UahermakingtwCedlflateofaemptbn,yw
should become suby tto the W.rkni Corepersatbn puvisbv ofth.Labor TOTAL:
N Code,you mustforthwith mnply with such provisions orthls permit gull be
W deemed revoked.
a BUILDING FEE
o CONSTRUCTION LENDINGAGEICY ISMIC FEE
Iherebyafflrm that then b a covtructlon landing agency for the perform- - ELECTRIC FEE
7 Z an«of the w.rkfor whkh this pemdt is�ed(Sec.3D97,Cl,C.) TOTAL
U O Lender.Name PLUMBING FEE
U. r I<ber.Addrea. QTY. MECHANICAL PERMIT FEE MECHANICALFL-E
I¢dlfythatlFave .dills ppLvtbn.Me tethatthe.F.; womutlm
O W
IL b .I.gree to comply wfth.R cityud county ordbunms and elate law•. PERMIT ISSUANCE - rj C)a FEES PAID:
N rel tl g WlLiing mvtruherebm
yauthorcoamprentathe.fthb
Z" t rupon the abo mentis property f«Impedbn purposes. ALTERORADDTOMECH.
V — gree to neve, e a d keep armless the City of Caped
Date Recel t#
elm bill ijr�g ape whh "�tayw ya a AIRHOL•
ANDUNOUNTTO10,000CFM) SUBTOTA
��� y AIRHANDUNGUNTT(OVFRIQ000CFM) CONSTRUCTION TAX
grstunof Appumm/con Date E(HAUSTHoDD(w/DUCD CONSTRUCTION TAX PAID:
HA7ARDOUSMATERIALSD41 A E.—
WllltheappDontor or rdie havrdous HFATINOl1NTf(N 100,000 BT1J) Date Recei t#
material a deBisd by the Cupertlw Municipal Ch er9.12?ndthe
Hcahh.M Safety Code Sccf.o 75532(.)7 HIATING UMT(OwR ilio,000 gTD) OTAL:
❑Ye No
WBlthe applhN« tum Wildinfloavpantuseequlpmemmdev4 VENTILATION FAN(SINGLE RESID) 05E ATE
w thuvrdousalrcontandrunbade0nedbytheBay Are.Air• gd1 Qualfl a vgemoin Dfnrict7 BOILER-0DMPIJ}RtDR 100,0(9 BTU) Ji 1
❑ +�
nee ams havrd mdeda Iremente un 3 and 25511..9sM BOILER-CVMP(OVER IW.000 BTU)
t IU }IeaBh k Sou( C by ,E833 and 25534. 1
u that i/rhe bull ng cot ,_IM
n y haveanvnithatitlsmy NEWRESDENTIALMECA. SQ.FT. tg-}I67.-Ma �^JL'pJCJ'�
o nutlfyt o the mew Mch.9 be met
I t of
Owner«authodred agent
Date ISSUED BY:
TOTAL OFFICE COPY