19458 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
—Building project identification PERNIITNO.
Buading Mdnes: 19 4 5 8
Z ,
am : one:
CITY OF CUPERTINO-BUILDING DIVISION
e.yera 's Lk.Na: APPLICATION / PERMIT Hn
Archeed/EnBUILOIW—ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL
glneer. Lie.Nce
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I'IRM17755UANCE
LICENSED CONTRACTOR'S DECLARATION
IherdsysfthmthefDWtdmsedue Buss ad sof Chapter9d,an me AIrTrT.IANC6RE9DEN17Al JOB DESCRIPTION
In rase,is mtbn 7003)ofd off n3.fthe Buelmsmd Rofe.elonsCade,wd my
If¢me le In full fora and dfed. PANES
CVs
Date L1,,0
Date Cone or s
ARCHITECTS DECLARATION 271-1000 AM
0 7. I understand my plans auR be used as public teco da OVER 1000 AMPS �.F7:FLOOR AREA 5/SQ.FT.
qq��+ O 9GN5
Fi`�`� Ckenxd Pmfesloml
<<Eu OWNER-BUILDER DECLARATION�a Iherebyaf .thatlameaempt(r� eContradorsLke Uwforthe SI'FGIAL CIRCUIT/
,
pp 0.3 following reser.5ecti.70315,BueinesaM Pmfesab.Code:Arydtyor
O y t- TEMP. OR INST.
�� manly which mryEaapermkbrorutmd,atcr,improve,demolish.orrtpar
q' anm
yamueure pdmto its L.�.n,ce,aleorcqulm thcappllcantfasuch pedtto
CSO !he a dgr d statement the he la Iso m
sed pursut to the provisions of the SER D
H3Ca ter ar'.Lke.Law(CMpter9(mmmendngwkhSeaion7000)dDivi-
pF O.5J7 eian3 ofthe Bushes and Prdesbv Cde)orthat he b exempt therein ' 'DNG E.ECTRI VALUATION
5 <X the hesis for the alleged exrmptkn. Any vlelatbn d Section 70315 by any OUR.ETS 1 x
IS} appBantforapmmkeubkatstheappB .ttoadvilpmltydnannrc MY
g Ifve hundred doll..MM. NEW RESIDENTIAL
O..
F1 1,.owner of the property,or my employees with wages as their sole '�'�' STORIES TYPE CONSTRUCTION
t mmperw0on,will do the werkand theetrum m is not Wended or offered for `
5�o role 6ec 7014,Bu.ineu and Pmfmbm Code:red Contradur.same I�iv
S$ does rot apply to m owner d property who builds or bssp..thereon,and - OCC.GROUP RIS.UNITS
whodoessuch wade himself orthraagh hlsownemployce,provided that such w
immpvme
ew arcrot intended red mothefmsale.If,hwvever,thebullding or TOTAL
impmvxmaniiewdwlthinomyearofcompletbn,tMowner flderw have
t"rdenofprovingthathedid n.t baud or Improve for purpose of axle.). QTy. PLUMBING PERMIT FEE
ZONE APN
L-i L as owner of the property,am exclusively contrading with licensed FLOOD
rontndms to ronstmd the project(Sm 7014,Busims and Profnabm Code: PERMIT ISSUANCE
The Contractor's Luras Taw den not apply to w owner of property who
builds m Improve thereon,and who contracts for such Ptojem with a ALTER-DRAIN&VENT-WATER ff�V
rytBla"tems)bated pursuant to the Contradoes License Law. FEE SUMMARY
IJ 1 am exempt under Sec B As P C br,thh recon BAO FLOW PROTECT.DEVICE �SIDF RES
i DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_
. Owner Dae 1 RELEPII
WORKMAN COMPENSATION DECLARATION E.IX.N�S�. P SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a artHbte of c.t to self-bsurt,or a
artiRose o/Workeri Comperoatim Insunnm ma mnilied ropy thereof 6ec.
RECEIPT a
3B03,Iab ) GAS EA.SYSTEM-1 INCA N_
OUTLETS PARK FEF Y_
P.Iky a RECEIPT a
Com y GAS EI.SYSTEM-0VER4(FA) BUILDING DIVISION FEES
. CedlOedropybherelyfundshed. / GRFA.SE/Ir USMWASTEINTERCErroR PLANCHECK FEE
❑Crrtified ropy Is filed with the city inspection divlston.
CERTIFLCATEOF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE / SEW'E-SANUARY-STORM EA 2arT Date Rcrocl I#
O'hL eedlon need not he completed Bthe perout is,ferone hundred dollen
($100)mleaed ' WATER HEATER W/vFNT/ELFCM ENERGY FEE Y N
ImorThatbthe pedormana of theworkforwNch WspermRlsbsucd,
I shall not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING
workeri Corperoatlor laws.f Ghfmnia. Data PAID
PP NEW RESIDENTIAL PLMB. SQRr. Date Reaei t#
Z 0 Applicant NOTICE TO APPLICANT:11,after rrvking thio Certificate of Exemption,you
N e should becomsubed b dit m
the WooCompextor probns
vbof the labor TOTAL:
Code,you rosea forthwith romply with such pmvisbm orthls permR shall he
deemed revoked.
LU > CONSTRUCTION LENDING AGENCY BUILDING FEE
SEISMIC FE
CL 0 Ihereby of nnothat there ba oomtmdion leMingage for the pedornv ELECTRIC FEE= Z anmofthework forwhkhthis permR d O
h issued CIv.Q TOTAL
U O Larder'.Name PLUMBING FEE
LL e Lender.Addmea QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certify thal have reed this application and stauthatthe shove information
(1 J,00, Y.I agree to comply with all city and county ondbunom and state laws PFRMTT ISSUANCE ' FEES PAID:
>- N relaingtobuildingmmtruetion,and hambyauthw mprtxntatNndthb
He
Z dry to enter upon the abovcmntbmd property foe Impeetbn ER purposes. ALTOR ADD TO METH.
(We)agree to save,indemnity an d keep harmless the City of G,pertiw Date Recei t#
V against lusbWtlm,pdgment,%onaned!e.pemn whieh may lney, y.mue AIR HANDLING UNIT CFO 10,034)CFM) SUBTOTAL:
against sad City in consequence of the granting of thts permit, -
' - AIR I-rANDutNc uNrr covlR tD,aaD CFM) CONSTRUCTION TAX
Sigmtureof Appliant/Cm adm Date IXHAU517 HOOD(W/DUCq CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcanu or borne building aaapsnt store.,laMle hazardous HEATINGUNIT(TOl00,ODOBTTn Date Re i t#
material as de0md by the Cupertino MuNclpal Code,Chapter 9.17,and the
EkahhedSafety C.de,Sp'a1Jon2S5M(.)r HEATING UNIT(OVER 100,000 BTT) TOTAL: t(Z
LgYes
illtheappilaMa tune dbgoceupanruseequipmentmdevkm VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkheMt havndm,e atr edeas deRmd bytM Bay Arta Alr ppppQ
Q4.My Management Dist 7 BOLER-COMPOHPORi(1Q000BTU) ICIARId]
Yes me
• 1F.0 u'Wmla Iealth& Cis
ad the �e, 75505,25Si3 and75746.'S of BOaGR-cUMP roVFR il10,000 erI!) ��no
)i S i L J
understand thlt if th dldlnR7laemo ,neatly have a tenant,the it is my NEW RESIDFNHALMECII. �.i7.
sees roma t eo dddldrd mrm.te whkh must be met
ma
prlortolsuaanc� ceki (e'of ter Fancy. of "r1 b110
Owner or auth - Date - ISSUEDB I,esN
TOTAL:
OFFICE COPY
I 1