22037APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
building Project IdentlfkaHm
Building Address:
- PEJ.wTN2 2037
I Ulu
con nMine: Lle-No.APPLICATION/PERMIT
CITY OF CUPERTINO-BUILDING DIVISION
BUILDINGE.ECTRICAI PMUMBING-MECHANICAL
CATEGORY
CONTROL 0
Arohhed/Fngln Lie, Na:
Q ELECTRIC PERMIT FEF,
BUILDING PERMIT INFO
I
Add.L1li rD �� — y" •�,•
—/L ,. that ED COrneed uie04R9N•D-W...f.fCh ON
IhthSedereby Hirtnthat lam l:m3ofthe usinm dPmfhapter9de,mdn
limoselShaun 70fX0o1 D1diset. 3ofthe Buanmand Ro(eWonaCde, and
Ikemc b In full ((yyaa and dfee.
qA 11 Corrt¢dor
ARCHITECT'S DECLARATION
I understand my plam.hall he used As public remrd>
Licensed Prdmioml
OWNER -BUILDER DECLARATION
7exempt4mnthe Contractor's Wmme Law f¢the
Thereby afRr (Section
f nting ywhkh requ edxpe7 5,Buanm and,rope eCde:Mycitym
countywhichpe tolapemmtoa mrequ alter, a p h demolisher repair
any amrned prism, itthe rrcgalwreed putheapp the pmmrh peof t e
filCt a signed Ter. Lt ( he h licr9 (co panuant to the provbbro of the
('en3ofths Wcen_Lw(Chapter9(mmmencing with Smlon7000)of and
ehalsas the BuelnmicAexeetcl mbn. Ary orthahebesetkm7Q3refromaM
Iosis for the akgd eaemptlon. My Wolnbn o(Sedbn 70315 by any
appumnt (ora pemdt subjectsthe appll¢nt to a civil pmaky of not mom than
Iq.
0 nA d`doiowne, of
I, u owrcr d the Property, or my employees with wager u their sole
mmpensadon, wal do the work, and the structure Is amt Intended or offered for
.Le (See, 70K Busbm aM Profmlom Code: The Commdor. Eceme Iaw
don and apply to an owner of property who but)" or improves themon. and
who don each work himmlf d
cethrgh his ow nem ployen, provbd thesrch
Improvemenh am dt intended oroffemd fm Cale. It however, thewllding or
improsemembudwlthNomyearofcompletbatMe er- erwWlave
tl(Eknrdeo of pmvmg that he dm not wild or Improve fee purpose of sale.).
LI L as owner of the Property, am e.W.luely coning tractwith liceesed
contractom to dmtmd the project (Sec 70N, Budnu aM Ihofmlem Cde:
The Comnctor. Lke,n_ Law does no apply to an owner of property who
Wad, or Imp. thereon, and who dmncts fix, sueh p y,,tA with e
qWV+etre(.) aoenaed pursuant to the Contndml License Law.
LJ I am e.umpt oder Sec r
B 4 P C for this ream
PFRIATISSUANCE
�j�' ❑ ❑ ❑
I01
APPI]ANCTSFffSIDEM7AL
B N
��11
-
PANELS
M-10DO AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ.FT.
'
SIGNS ELEC RICAL
SPECIALCD(CUIT/MLSC
TEhIP.MEI'FRORPOLEMST.
POWER DEVICES
SWIMMING POOL. ELECTRIC
O(TILE.ISSWIIC}IESFL�f [7Rt5
' VALUATIQN
C)Q` Civ
NEW RESIDENTIAL ELFLTR SQ.FT.
S7ORIIS
TYPECONSIRUCTION
TOTAL
QTY. PLUMBING PERMIT FEE
OCG GROUP
RES.UNITS
PERMIT ISSUANCE
ALTER -DRAM 4 VIM- WA3II2 (EAI
FLOOD ZONE
,1PN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTS] DF Frt �q
DRAINS FLOOR, ROOF, ARE A, CONTI.
FSS PER TRAP
SANITARY Y_ N
RECEIVE
O wvcr Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a mrt111¢b of ronsaWrtornt to self -o, a
MOL La a of Worken'Compematlonlmunn¢ ¢a mrtukd mpythemof (Sec.
Policy# CJ
SCIR TAX Y_ N_
RF�m
GAS EA. SYSI'FM-1MU 0[HLE15
PARK FIB Y_ N
N
RINEPI'I
GAS EA. SYSTEM-0VER 4(FA)
Coma y
BGILDINC DI VISION FF. ES
eertlnd copy b hertbyturtdand.
CeM1Nd ropy b (Tied with the sty Impertbn dlvield.
CERTIFICATE OF EXEMITION FROM WORKERS
COMPENSATION INSURANCE
(Ihbeectbn net nd be completed u the pemtt b fmorc hundrd dollare
(SIM)orlm)
I mrtuy that In the pedoman¢ of the work forwhieh this pemdt b bend,
I.haB n¢ employ any person U any manner w as to become subject to the
Worker: Compen.atlon lawsof California. Date
ApplNOTICE
NOTICE TOAT'PLI,r tto(he orIm'CompbCertukateo(Imo Mayou
Compamatbnprvvbbmofthe Lib or
Codedbecame subtestto the ply with
Code, you moa forthwith comply wl(h sada prwlebm orthb permit Rail be
domed rtvokd.
CONSTRUCTION LENDING AGENCY
IherebyafOrm ttitthem bammlmctlon ledingagemy forthe pedortry
arm of the work for whkh this permit b Issued (Sr 3097, Civ. C)
IeM.r: Name
Lender's Adams.
nertlfythat I have mad lh sappli¢ttemad fme
ate that the above Inforttm
Is no..I.gree, to comply with W city And county odinances and sate law.
relating to wilding mmtauctlon, AM hereby author ax, representatives of this
city to enter u Pon the ab e,onsntbned property fee inspection purpmeii,
(We) agree to save, indemnify an d keep hemi. the City of Cu pertlno
Against liabalties, Pdgmew, refs a M e. per. whkh may In any way..e
agaimtsed City mcon eequenm o(Ihe germing dthb permit. ,
—w- er 4 Date
gtamrtdAp ltARDO ctm Date
lAfture MATERIALS DISCLOSURE
Will iA theappBamorWlupWilding oIdpantmom de,Chaandk ha and
Health la deflrty Coby de dion2ieo MurdcipalCde,Chapter 9.12 and tha
Healtha"Safety Cde Smim 25537(A)7
I—I Ye . No
ill theappilnmen MI. pantuseequipmemmdevfos
which uMt luvdom air mntamW ms a de0md by the Bay Arta Nr
Qaallly Mamgnment Dlstrkt7
QlhaYn No
have mad dsmateaabmq immentsuocerChapte,6.95of
the Califomla Health 4 Safety Cde, Seetbml5505,25S73.nd 2-15M. 1
udmlad that tithe wilding does ret currently have a tenant that It is my
respomibBity to ratify the omnpant of the requimrrenta which mast be met
primtoL uaeed•C2rtffloMof Oceopamy.
CREASE/MDUSIRL WASTE INTEICEPCIR
PLANCHECK FEE
PAID
RecA tit
GREASE TRAP
SElVELSAMI'ARY SIDRM FA 2007r.Date
wwTER rDATE7 w/vE r / TECrR
ENERGYFEE Y N
.
PAID
Date Recei tit
WATER SYSIYM/TRFAnNG
NEW RESID04TIAL PLMB. SQ.FT.
TOTAL:
13UILDING FEE�0
SEISMIC FEE
TOTAL
ELECTRICITE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
AIR HANDU NG UNIT (TO 10,0DO CFM)
Date ReCel fA
SUBTOTAL
A(R HwNDLING UNIT(OVIA I 0,W0 CFS)
CONSTRUCTION TAX _
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 EN)mater
Date Recet tlf
HEATING UNIT (OVER 100,000 BTU)
. . TOTAL:
VENTILATION FAN (SINGLE RFSID)
S CE DATE
�s/
APR15 /
5IN1
of
ISSUED RY:
BOR.FA-NMP PI'IPOR 100,000 BTU)
BOILERCAMp(OVER100'"BM •
NEWRESIDFMIALMECH. 'SQ.FT
Avner or authortred agent DateC
' TOTAL:
OFFICE COPY