19773 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pae"em Identification PERMIT NO.
uMin� Adder 19773 bygo
~ ante. Hi111ae0 953 'q`0e:X0 CITY OP CUPERTINO-BUILDINGDIVISION � q
C`pT APPLICATION I PERMIT —�, �3• _ L
`�^�' `T BUIIAINGFlECTRIC PLUMBINC-MECHANICAL CATEGORY CONTROL
V Arehnec/E„Nneen, Etc.Nn:
BUILDING PERMIT INFO
Address 1 n .
1 1 1n i 4 '. Q ELECTRIC PERMIT FEE
t \1\ PERMITISSUANCR ❑ ❑ ❑ ��X
LICENSED CONTRACTOR'S DECLARATION
Ihcrebyaffl thetlamlkmaedurderpr Womof Oh pter9(�c, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sectbr 7000).(Dlv1s1on3ufthe BuaI...d Pmfesn«uCode,and try
lkeoeEst to and
`Meffecf. PANES C� /
Lke Lie.11 ( � 1/�-/� k—
Dat CFIITE( FIV
ARCHITECTS DTION 1-1(10 AMPS
�7 I uMersarid my plan s1uB ad as be ua ppublk blic rcmrda OVER1 9Q.FT.FLOOR AREA. f/SQ.FT.
gypoW+w�O
Licensed Pro(e>ebrul SIGNS ELECTRICAL
<<<< fWk OWNER-BUILDER DECLARATION gr[t1ALCQtMT/MLSC
Ihercby alOrm that I am exempt freen the Cormacmr'a Ll nae,Law fee the
Fpp ❑ fullmving reason.(5eafon 7m 15,Busbrs and Profeaons Code:Any city or
7 ovrtywhlchrequ4 aper Wmvt Maltn,Imprw de to h,ormpalr TEMP.METER CREOLE INST.
yY •nynm=mpri«tolbt,wanm,abarequbestheappBvntf«auchpemdtto POWER DEVICES
a0 a Ilk a.1ped t temant that he Is boensd Neauent to the prowlom of the
��5Contractor's Lkena,law(Chapter 9(commencing with Seerinn 7000)of Owl- VALUATION
ebn3ofthe Buslnesand Pmfe Code)ortt t het,emenEntherebomand SWP'9tUNG POOL ELECTRIC
P Sn the bast,for the alleged exemption. Any ule] .of Seetbn 7EFI5 by any OIIRP.ISSWI.[CIIESFD(ii1RF5
1�5ry '
applicant miWva
ntfor a pert subjects the applleant to a civil pehy dnmore than
five hundred
owner
ofteate pro NEW RESIDENTIAL ELFCTR SQ.FT. STORIES TYPECONSIRUCTION
❑I,ea owner ll the property,or my employees with wages r their door
mmprvatlon,willdoBoubtethe work,and< .Code:
rch w[Intended or offered L for
O role(notapplyc,70K to an
essaMProfabv CadWilda Comnctoes Ljoheeem law
$ day ora such
toanowvr ofaptough who bulm orimprwmthertoRand
who dmuchworkhlmseB«thrwgh his own employem,prvvWedthat such OCC.GROUP RES,UNITS
Improverrcw are not Intended oroffemd fee sale.If,however,theballding or TOTAL
Improvement lesdd wtlhln ovyvrofcompinbRthe ower,bullderwlil have
tl19,�aben of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
"I,..owner or the property,am euwlve y contracting with liceued FLOOD ZONE APN
eontraaars to mvlruet the project(See.7066,Bushes and Praesbv Code: PERMIT ISSUANCE
The Conrad.e.Lkeve Law does not apply to an owner a property who ��-DRAW 4 VENT-WATER(EM -
bu0ds or impmva thereon, and who contracts for weh pivjeota with a FEE SUMMARY
��ll+do,((.)IleevN pursuant to the Contractee.License I W.
L l .on..rmpt under Sec B k P C for this renin I BACK FLOW PROTECT.DEVICE
Owner Dns DRAINS FLOOR,ROOF,AREA,CONTI. SANRARY Y_ N_
WORIGHAN COMPENSATION DECLARATION RBCEIITg
5�f hereby aRlrm that I have a eertlBnw
te,a consent to self-Ire,or. FIXTURES.PER TRM' SCHOOL TAX Y_ N_
mrtlflute of Workrra'Compemuatlon lvuran««a eenlfled copy thereof(Sec. S. _ RECEIPT
38M Lab C) ,1 GAEA.SYSfFM-1 WG60UTLETS PARK FEE Y_ N_
Policy/e P i iy 1� RECEIPT a
WWay _-- A - GAS FA.SYSEFM-0VERd(PA) BUILDING DIVISION FEES
ay
mpyt,hereby furNshed. GREASE/WDUS[RL WASTE W'INCEPTOR PLANHEGK FEE
Cenlfled copy a filed wlth the city Ivpectbn division.
CERTIFICATE OF D(EMPHON FROM WORKERS GREASE TRAP -
crM..enun need
COMPENSATION
M T INSURANCE PAID
nabcorrpinifthepemt,r«e«handraarnmSEWER-SAND'ARYSIORM FA 700PI
Date Reoei t#
(fern)«les) ENERGYFEE Y N
Imrtlfy,that tithe perfomunm.(Thew«k(or which Wspermitkba7Aed, - WATER FffA7W/VEVT/ELFCIR
1 shall not employ any perwn In any manner w as to become ubjnt to the
Womkern Compereatlon laws of California. SIYla. Date WATERSI/TREATING - PAID
O Z Apphant NEWRES ENTI LPLMB. �F. Date Revel t#
Z O NOTICE TO APPLICANT.U,.her making this CertBlnmbn,
te of ExaPtyou
should bemmr subject to the Workeri Comperoatbn provisions of the Labor TOTAL:
~ N Code,you.9Forthwith ournply with such provt,bv or this pernoth"I]be
deemed rooked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirmthat then It a mrWmetlon lending agency for the perform ELECTRIC FEE
= anon ofthe work forwhkhthb pemJt t,tailed bee 3N7,Ctv.C.) TOTAL
LLO lenders NamePLUMBIG
F Leder,Addmas QTY. MECHANICAL PERMIT FEE ME HANICALFEE
O W Ieedlfythnihave readtw appBatlon.rd nate thntheabove Lot rrutlon
t,cornet.Iagrre to complywlth alidtyard muntyordlnanmand smte law. PFAMETISUANCE • J)DFEES PAID:
} N reWingtobrlldlegmvWRion,and herebyauthoU mpm%,rtativesoftbla
F Z Wy to enter upon the.bovo-mentbvd propertyferivprctbnpurpnsd. ALTEAORADDTOMECET.
(We)agree to aaw,IMemelly an d keep harmless the City of Cupertino Date Receipt#
V agaWtBabWtln,jrdgnmNa,awsarW eapeves whkh myln any wayamue AIR HANDLING UNIT CTO 10,00 CFM) SUBTOTAL:
aga Id City Inc n.ryuerc /the granting a tw meet. -
�� AIR HANDLING UNTE(OVER 10,00CFhrI CONSTRUCTION TAX
m of AppBcant/Contras« bite EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WBl the eppBrard«future building avrpent Hare or hand le,havNous ETF1cTWG UNIT(TO IM."BTU) Date RMeI t#
mamrfai.d defircd by the CCCC///u�pertlno MuNdpal Code,Chapter 9.12 and the
Health and Safety Code,5 1.75537(.)? HEATING UNIT(OVER 10,00 BTU)
Ry. LM No
Ill ihrapp0ard«ruwre building oaapant use equlprrent cedrvkcs VENTILATION PAN(SINGLE RESID) ISSdPW DATE
which emit havrdlamina.,as defined by the Bay Area Alr
iia Wy Mavgemcra Dkt__r}e!r BORER-COMP OEfl'OR10,(100 BTU)
4 Ym F�17Nn
have read the ban we materlat,requirement,under Chapter 6.95 or ROTISR{bMP(OVER 100,000 BTI, IIIAK 19SU
the Callfomb health A Safety Code,Sectbv 75505,75533 and 25536. 1
uMerstardthattithebulidingdaawtmrrtntlyhaveatevnt,thatitt,my NEWRESIDENTIALMECH. SQ-FT
—PovthBityw-airythe.paMatherequlrtmentnwhkhmustbemet /slPy Of
r11
p t smiles aaCertlRof of Oec panty. WM
a �- Jn,�
e r authorited agent Date 1 `
TOTAL: ISSUEDBY:-J- �U
OFFICE COPY