23662 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pro'ed ldemlfkelon - - PERMIT NO.
Building Address:
a --? FF C 23662
Monte: APPLICA]ION SUBMII-TAL DAM
CITY OF CUPERTINO-BUILDING DIVISION
Contndor •",<', 'N. APPLICATION /PERMIT3;7
r
S BU D NGF]ECWCAL LOMB NGMFLHAN GL CATEGORY CONTROLY ,
ArchNM/i glrcm: IX Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSJANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed urderprwhlmaof Chapter9(mmmrn APPLIANCES-RESIDENTIAL JOB DE�RETKIN
Ingwlth5e n]OOD)of DMslm3ofthe Bus and Pmfutl Co e,a d /a I
Ibeve hln(uBJo�anit dfeR. ^� PANELS //1'�{.}I /- 0 w a
Dales'- /r O . ordrado— r'
—LIP TO 200AMRS
ARCHITECPS DECLARATION MI-1000 AMPS
O,QZ IuMenstand my phm,h.0 be used u public mounds. FRAREA OVIODOAMPS SQ.FT.FLOOR AR $/SQ.FT.
Fe E'j Licensed Professional SIGNS ELECTRICAL
1i,Q OWNER-BUILDER DECLARATION SPECIALCIRCUfT/ML9C
71..,�� 1 hereby,flres that I.exempt from the C etratam's License law for the -CVMP a�TER
pO folbwNig rtaeon.(Sectlon 9Q315,Burin®and Profeabv Code:Any tlty or 11�✓IJ frK•
O Z i. TE.(P.MEIFR OR POLE INS'f.
F� angcounry lchpe toiapermittomr requi lttheaprove,demolbh,ornpalr )�
Q any a sucturt statement
he It lkenqubnthe•t to
fvrsuch pe of to IY3WF.R DEVICES /
sK.O�u O4 a signed!Garners w he h Ilrenacd ern g with
the Eon 700M f the
ftil7 Ann 3-fthe Business
lnw(Guptn9(mmmendngwMSeRbnherefof are SWIMMING POOL ELECTRIC
a3� the WAthe the Ale and Prdabn. Any orthat he Isio.of then&omany VALUATION
�^ the bred for the alleged eoctsth sp Any violation of Sen exempt
roftS by any
appBontfor,permit subjuctstheappBantto,doll pealtydnd morttlun OUTLETSSWOCFIES.Fl)(TURES
E n hundred dollars(0B). a
1,as owrcr of the property,or my employees with u with wagtheir wk NEW RESlDENIIAL E11ZTR �3'T' STORIES TYPECONSTRUCTION
�< mmperaatlan,"Idothe wok,and the strueu¢is not Intended or offered for
5 p snit=]OK Suslwe and Prd®Ions Code:The Contractors License Law
does not apply to N ower d property who builds or lmprovn therm,and
C• who does ouch work himself othrough his own emplgm,provided that such OCC.GROUT' RES UNITS
Impr wnrio s art ret intended ooHered for uk.I[however,thebullding or TOTAL
m
improv em beold wkhlnoreyearofc¢npletion,the,owner-hauderwin lave
t1�s.¢�Nen of prwing the he did not bund or Improve for purpose of rIo). QTY. PLUMBING PERMIT IPA�FEE
FLOOD ZONE
APN
LJ L as owner oI the Property,am eschuawly�tracting with limned
urrr,Ion to mated the projed(Sm 90K Busin®and Profesabv Code: PERMIT NUANCE
The Contndarh Luesse Law don not apply to an owner d property who ALTER-DRAIN k VENT-WATER(FA)
builds r Improv thereon,and who mmratla for such p(o)ecv with a
<gp(p,ctnrts)Ammar pure tam to the C¢rcnd¢h LI¢ve Law. FEE SUMMARY
LJ I•m exempt under Sec - B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. NITARY Y_ N_
^• Pvner Date RECEIPT
WORKMAN COMP FNSATION DECLARATION
❑I herby•form that I have• l e r"e d consent tin o"the n,o• FI%'NRE9.PER TRAP TOOL FAX RECEIPT
ortiRcate of Worker Conpevelonlvuru¢oscertBkd ropy thereofpec. GAS EA.SYSTEM-1 WC.4OUMETS
3g W,Lb C) Y_ N_
cow�y Y ar��—�_ GA.sEA.snTlmfovFn4(EA) AECF3IT.
BUILDING DIVISION FEES
Certlfled ropy bheed wtume,city GREASE/WDUSIRL WASTE TNTECEPTOR PLANCHECK FEE
�G/CenNad ropy h filed with the dry Ivpeebn dfvidon.
`P` CERTIFICATE OF EXEMPTION FROM WORKERS' GR'O¢TRAP PAID
COMPENSATIONclotfftINpe bf SEWFRSANITARYSTORM EA 301IFT Date Reeoi NI
(TMs senbn need not be completed Bthe pemJt h(more hundred dollen
Cfi00)oler3 WATIMkTER W/VENT/ 77R ga ENERGYF-EE Y N
]ortuy Nrt blhe per(orrtunce ofthe work fmrwMch(itis pertmth Issued, ER EZE /
I shalt not employ any p<non b any manner sou to bemme subject to the WATER SYSTEM/TREATING
wo<keA compematlnn[awe of c,Br«nL.Date PAID
O Z AppOont
Z O NOTICE TO APPLICANT:U,after making this Certff"m of Exemption,you NEW RESIDEMIAL PLMB. 9]FT. Date Recei t#
should beom,e subra to the Worked Compensation prodslov of the Labor TOTAL
~ _N Cade,you n,rfoMwNh mmplywlth such provhbv rshal
or this l he
LU m`J armed revoked.
LU
CONSTRUCTION LENDING AGENCY SEISMIC FE
UIJILQINQ FEE
a Iherebyaf8rtn that there Inamvtrutllon knaing agency for the perfom-
M Z anceofthework lar whkh this permB bbucd(Sec.3097,CW.C) TOTAL aSD ELECTRIC FEE
LL O Lender•Nam PLUMBING FEE
LL U mil
Lo l Add a 1717. MECHANICAL PERMIT FEE
O tmet that lhave rtedthhappBabonand anMECHANICAL FEE
state thrtthe above Nformnlon
1 UJ hmrrect.Iagrteb<omply wNh an tltyaM muntyordlnanonand nate laws I'EtMIT1S5(IANCE FEES PAID:
} N relatoenter uilont mvtmctloi,and hereby mthurl isrtpnenpurpor ofthis
F Z di(W,fiaeruponthe,boscnialy and keepeheml Wpenbn purpows. ALTER OR ADD'IV MEIN. Date Recei t#
_ (We)ago¢to ave,W emmfy and keep harmiew the City of Cu
ega1vt11abWtks,fudgmema,meaaM npenewhlch rtuyb anywa)a�cmre AIR HANDONc uNrr coo tD,lm a'hf) SUBTOTAL:
agaivt Bald City b conaequeri¢of the graining d this permit.
AIRHANDLING UNIT(ovEc lD,fnocF'hD CONSTRUCTION TAX
Sigatureof Apphant/Cantmctor Date E(I IAl1Tiio0D(W/DIKE CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WOltheappliantofutuce buliding oovpant Ston or handle havrdoua FIFA77N'G I1IsTT(TTJ 100,000 BTU) Date RCCeI t#
noterial u ddivd by the Cupemon Mumdpal Code,Chapter 9.12,and the
Health ant Safety cod( Ire 75532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
Rairy.I No
Ol the appBam tum building o<cupant use equipment or devices VENTILATION PAN(SINGLE RESTD) ISSUANCE DATE
whkh emit haruxl.air romaMvms u deRvd by th<Bay Ana Air
Qualfty Maag<mem rketT BOILER-COMP GHP OR 100,0(0 HM ��
/ Yva No
46rve read the hares smaterlals requ l¢rrcnn TV)under Chapter 6.95 of BOILER-COMP 100,000BD
theCllf.rn Herhhk SafetyCWd ,Smbv25505,]5533,nd25534. i
und"a�tlatlfthebuildingdoenwtmrnntlylaveatenanitlatltbmy NEWRFSIDENTIALMECH. SQFI'. Z'1/ O ��
ropovbnfty to notify the o pant d the rqulrtmemswhich mostbe ent ^/ (7 �
or to Lwuana¢ Ce t of Dec panty. H r s7
S-?A � �
tJr 2
menorah agent Date
TOTAL: ISSUED BY:
OFFICE COPY