24228 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Buildln Pro ed Idenllfkatian Address:
NQ,
Building Addr : \\ Z
4228
APPLECA FION SUBMITTAL DATE
CITY OF CUPERTINO-BUILDING DIVISION
can do N. APPLICATION /PERMIT
BUR.DING-ELMCATEGORY CONTRcLe
Iced gid r.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A
PERMITISiUANCE ❑ ❑ 1:1LICENSED CONTRACT RS DECLARATIONS
I hereby aHlmn that l am licensed under provWmts of Chapla4 c APPLIANC6RE (DENTAL ` P5U N
ing with Section7OD0)of Divi ofthe Buslnesa and Profeazi.0 de,and
Loose b in full f a and dreg. .a1 r/ - rANPT6 2-1-3
f \ �
Date C ® Lk I Al Y
Date Camnct
ARCH r1E - ECIA 'I AI-
µQ�pC7O I urderstard try plan shag sedn creeds OVFRIODOAMPS SQ.FT.FLOOR AREA F/SQ,Fr.
E u Licensed Ptalesbnal SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION,
LI affirm that from the Contractor's Lice. loathe CIRCUIT/RISC
L
7$J
following recon.Semon 7(815,Buslnm and Pmfmbns Ccdc My dty or
071/.. TEMP.M=OR POLE ASF.
Fy cvunywhldi rcqubnaSmdemmrmtruct,alter,bnprove,demoWh,orrcpdr
anyatmu mprlmtolbbauar ,ahoreq theapph=tf«auchpemdttn POWER DEVICES
�a file a signed statement that he Is,llmnsed pursuant to the provisions of the
Contradori Lt.Law(Chapter 9(curnmendng with Section 7DW)of Divi- SWIMMING POOL ELECTRIC
SOS son 3ofthe Buelnneand Profeslo.Code)arthat he In exemptdrom
therand VALUATION
•.1 the bub for the alleged exemption. My violation of SMbn 7m15 by any OUTLEISSWETCHFSFlXfIIRFS
applicant fora pemat subjects the applicant too dvll penalty of not more than
By undred dollan(y500). SQFr.1,as owner of tho property,«my employer with wages as their sole NGW R®ENTUL ELFGTR SIORI6 TYPE CONSTRUCTION
oxnpewtion,will do the work and the structure brat intended or offered for
Dsale 5ac 7061,Businessacid Profmlon Code:The Contrador.License Law
don not apply to an owner of property who bulls or improves t hereon,and OCC.GROIRa RFS.[(NITS
aE who does such work hUruelf orthrough h1sown raild yen,provided that such
Impmvemanb ace rot Intendedoroffered fm ilk.IL however themilding or TOTAL:
Impiovementbaolwhishomyurofcompldbgtheownerb aderwWlove
1119 Men of proving that he dl not baud or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LLJJ 4 as own.of the property,am aachuHely contracting with licenid
.tractors to corutrud the pro)ect(Sec.7044,Businmard Professions Code: PERMIT ISSUANCE
The Contractor's Lice.Lw don not apply to an owner of propny who ALTER-DRAIN kVENTWATER
mild.or Improvea thereory d who coturam for.&, p4o)em - - IEA)with . FEE SUMMARY
cgp or(s)Bmnsdparty/t to the Contractor's License Law. BACK FLOW PROTCCC.DEVICE _
LI I am nempt u er [rr. g 4 P C for this m OUTSIDEF1 US
Lon DRAINS FLOOR,ROOF,AREA,COND.� I SANITARY Y_ N_
• Owner Date Y R�F97I
WO COMPENSATION DECLARATION r'^
❑1 hereby affirm tis 1 Fave a artlflote of consent to self-Toone,or a FE(TIIRFS PERiIRAI'� ! I• SCHOOL TM RECEIPT I
certlRateofWorkens Comperuationl unnomacertllled ropy thereof(Sec GAS E.A.SYSf'FM-1 PARK FEE Y N
3100,Lab C
Pollry/ RFGFFIPCC 1
Com ny BUILDING DIVISION FEES
"iGAFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CedWed ropy b filed with the city,inspection dlvWm.
CERTIFICATE OF EXEMPT ION FROM WORKERS' CREASE TRAP PAID /yam
COMPENSATION INSURANCE SEWT1RbSANIT"Y-STORME.\ 7DOFT Date RCO21 t# d�✓'�
(Thlasedbn need not be completed Rthe SURA b!«one hundred dollar
(s100)«Im3 WATER I-IEA'DRw/vENT/ET,ez-rR ENERGY FEE Y N
I certify that In the performance of the work for which this pertrd is Issued,
I shall not employ any person In any manner o as to became subject to the
Wcrkcra Compensation Law@ W��pate. WATTRSYSEM/TREATING PAID
O Z Applicant LU/ NEW RMDEN11AL PLMB. F7: Date Re I t#
Z O NOTICE TO APPLICANT:If, Aer this Cert if lateof Eaemptbn,you C1
should become•ubrd m the Worker'Compmatlmr provision of the Labor /, �C .� TOTAL:
CC N Code,ymmutf«thw hmmplywltheuchpovmorthl•perm allbe C
R j deemed revoked. BUILDIN
G FEE
W — CONSTRUCTION LENDING AGENCY EIS IC FEE
d Inereby.fnrmihal there b.mmemdlon kMingagency forthe Sdarm TorAI_ ELECTRIC FEE
= anceofthe workforwhkh0ds` t Is issued Loc 3097,CN.C.)
(-) 0
L<mera Name_ PLUMBING FEE
I- lends/e Addrns QTY. . MECHANICAL PERMIT FEE
O LL
w art0y haH u . p t nandatatethattheabovelnformrtlm MECHANICAL FEE
IL isrorrec.Iagreemcomplywu auckyaMcountyordinarmandstatelawn PERMIT ISSUANCE FEES PAID:
N relaing to builing mruvudion,aad hereby authortu reprnentathves olthts '
dtym
.to enter upon the abovcentbned property for lnnb
pen purposes. ALTER OR ADD TO MECH.
U) g Date Recei [#
— (We),gee to save,Indemrdly an d keep harmm lthe City of Cu Sdim -
agairut llabWtln,Odgmew,coeteard ex pe.which rruy lnanywayamue AIR HANDING UNTIE DO 10,000 CFTC) SUBTOTAL:
against said City In consequence of the granting of this pentut.
AIR HANDLING UNIT tOV6t 10,000 CFM( CONSTRUCTION TAX
Signature of Appuant/Contndor Date DCHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appuont ce future building a pant store or handle h—rdous HEATING UNIT(TO 10,000 BT1p Date Revel t#
outcrblas doBmd theC dine Munidpl Code,Chapter 9.17,and the 7,
Tkalthend Safety Ion 2537097 a HEATING UNTT(OVER 10,000 BTI) TOTAL:
❑
yesHEATING
(utvre building-ocmpntum equipmeN«devim VFNITIATIONFANISAGLERESmI ISSUANCFLDATE
which emit hs>ardous U tambunte n de0nd by lire Bay Area Air ir M L
QualNy hlanugemen�i7 BOdER-NMP 011P OR 100,ON BTIn
Tit Yn a'� �r(]Q�
hsveread the ous materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,OW BTU) OCT ' / IJx
s the Calffmnb Health Sifdy Code,Sections 75505,r533 and 75SM. I
understand!that if thebuOdingdoes not mirently have atenanL that It Is my NEW RESIDENTIAL MEQ,. SQFr
rnporuibllltytonatifythe.c p.ntdthemqulrementa which nwrt be met Cin OF GUrtHI INU
prior to Issuance of a Ceniflof nry.-
ZZ2 �s 25Ow a odred ret Date TOTAL: ISSUED BY:
OFFICE COPY