22366 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Nuldbg A-/AreBuildin Proect Identification �r^� c iy PEIA9T NO.
Z330 Q 1614 E��y xPL (/N,n57co 22366
rcre ante: one: I -
CITY OF CUPERTINO-BUILDING DIVISION
•. cannda ."ante: U .N. APPLICATION / PERMIT
Archtted/Engineer. Lb.Na BNLDINGELECfM CALPLUMBINGM ILAMCAL CATEGORY CONTROL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addresa: PFRMITISSUANCE ❑ ❑ _ ❑
LICENSED Iam Hc.
dorder mvW.,RATION
I hereby
r Sectio M00)olamllcmaeduderprww«umChacrxCodn,ard AI'PWANCFSiRESIDEM7AL ]pBD�R➢�IgN
Ingwlm Se follI )ar d effecn3oftheBuYneaeand Pm(eaalonaCade,and my
B¢rue la In toll fora d ic.# PANELS ✓ 4ie•4�/
Contractor
Azcllz
RCHITECTS DECLAIETION
M '
2014CCOASIPS V ID tic
X Iundentad mypbroshallbeuacdaspubhcremrda OVER100AMPS SQ.FT.FLOOR AREA S .ET.
o Ti LbensN Prefesbml SIGNS ELECTRICAL
«< L4y7 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/hiLSC
71.,�i IhembyafBrmthatlamexemplfmmtlm Contr°nor'aLbem wf«the Ter
//yy��'
Ir
(olbwing maven.(Section 7015,BusNm and Profesebm Code:My city or GTR 'S-
F� county whichrequiea a permit tomnnootd,alter,Improve,dermLLshormpalr TEMP.METER OR POLE INSE. ygl 7S
q � anyatroctumprl¢mlb lsauarc<,aleo rcquBntheapplfant!«ach p<mdtto 205
f69 O a SNe a signed statement the he b Bccru pursuant to the pmvL icm of the n DEVICES
Co-tractor's Licerue Law(Chapter 9(me
mnndng with Section 9(100)of) Divi-
3 elon3oftheilu - and ProfembroCode)mthat hebexempttherefromard SWIMMING R70L ELECTRIC VALUATION
y-' the baale for the alleged exemption. Any violation of Section 9015 by any '
applicant fora permit abjooutheapplfcant toa civil peruhy dd nmore t han IRTIl"DTS
W Mv6undrea dollars MM.
�n u I,u owner of the property,or my employes with wages u their soleNTwqjptpSIDMl6 TYPE CONSIRLCTION
c«npawtlon,wllldoth wak+nd me drudum brctlmeMedor offered for
�ap cak bee 9044,Rusb¢sad Profeeloro Code:The ContnctofaLmrue Law /�a
prF doesnwapplytoano mrdpmpenywMbulldaorlmpmvmthereo d OAT V
w whoda® &wohhimself¢thraughhLsawnemploye ,pro WN thatwch .GROLIP RES,UNI S
lmpmve amrctlntendedoroffemdf«mk.If,hwvever,tho WtUingm - TOT
Improvementbeddwflhlnomyurofcompletbn, owner-0 Merw love
t)p.pardenofpmvingthat h did mtbuua orlmprow furprposoofsak.). QTY. PLUMBING PERMIT FEE
"L a•owner,of the property,am ettb �
.Wely tractleg with licensed FLOOD IDNE APN
contr°cton to comtruct the project(Sm 9014,Rushers and PM<sbm Code: PERMIT ISSUANCE
The Contractor's Llcerue Law dm not apply to an owner of property who ALTER-DRAIN VENT-WATER Solids or Improve Nemmda
Nemo-,and who mnf«ouch pko)ects whit
q➢tr.ctar(s)Ifmnaed punuam to the Contnctae.Lime Law. BACK ET.ow I'Florecr.DEVICE FEE SUMMARY
LJ I am exempt under Sec B 4 P C for this reason
OUTSIDE FEES
DRAINSA,ETDOK ROOF,AREGOND. SANITARY Y_ N_
Dde
® Owner
WORKMAN COMPENSATION DECLARATION I RECEIPT#
FD(TVRF_S PER TRAP SCHOOI.TAX Y_ N
I herby alflrm the I love•¢rtlBcam of content to self-iwrt,or• ��T
NI ate of Workm'Compematlan irarranm«a¢rtl(led oopythereo(6ec.
3800,1a6 C) GAS F.A.SYSTEM-1 INCL OUTLETS PARK FY ' N
,,,,,, kyaa.
If
�������pppppprtBled o A e� y f'�9h GAS EA.SYSTEM-0VFR4(EA) BUILDINGDIVISIONFEES
rlBied copy haloed with the dry bIN'
upectlon division. GREAS:T/ DUSIItI•WASTE EVITRCEP'OR PLANCHECK FEE
CERTDTCATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR-SANTTARYSTORM FA 310T DRte RL i t#
UMsaectbn need not be completed lfthe pemdt b(ororc hundred aoBan
(910)«ferJ WATER HFATTR w/VENT/ELECTR ENERGYFEE Y N
I¢reifymatNanypthe fo In mm any
a,It become
eemdtisbored, —
_, I shall rad employ any person in any nunn<r at n to become ubjM to the WATEIR SYSt.EM/.TREATING
w«rmri cornpenwbn L.wa af6womb. one PAID
NEW RESIDENTIAL PLMB. SQ I.
A licant
Z TO Date Recei T#
_Z 0 [WUCEemor sujct to
doer mkingthbarion Certificate
provt Exemthe Labor
_
ahauldou noo sforth it me Workers'Comp euvininprovbloroofthe Lab or TOTAL:
~ N Code,you rt.ced.forthwith comply withwch provhbro orthb permit shalt be BUILDING
deemed mroked.
W G CONSTRUCTION LENDING AGENCY SEI IC FEE
a IherebyafBrm thatthmbamrolwctlan krding agenry forth per(omm
Z an¢of the workfor which this permit et iaved(Sec 3097,CW.C) TOTAL ELECTRIC FEE 0`1 < u
(� O Lerdela Name PLUMBING FEE fo plowJ
LLF Ldela Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certlfythatl have mad thhappllatbn and°ntethat the abovelnfom m �A M
1 ix-ore.Iagrceto comply wtthaBcityad county oniWnm and sten lawn PFRMITI9VANCE FEES PAID. ------ ■ice
} N relati-gtobuildingmroaroctlon,ad hrmbyaumarire"..tativesofthb `
r,z city to enter upon the above-menBored property for Wpedbn purpora. ALTERORADDTOMECH. Date Recti T#
V — (We)agree to save,idemd fy an d keep harndess me City of arpertW
agalWha,/udgrnenh,m s dna expenses which may In any w.y,caue AIR IiANDllNC[JERT(T010,000 CFM) SUBTOTAL:
agave lad be . e art tbgdml.permit. AIRHANDUNGUNUT(OVER I0,000CEAD CONSTRUCTION TAX
hTh,fiorrofApplicant ntmcter Date/ 011AISTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
FLA�RDOUS MATERIALS DISCLOSURE
WBlthcapplIant or fummbuadingoavpantdom orbar le havrdwa HEATING UNIT OD 10,000 BLV) Date Recti t#
material as deRned by the Cupertino Municipal Code,Chapter 9.17,and the
Ekahh and Safety Code Scatlm 25532 W7 BEATING UNIT(OVER 10,"#LEU) TOTAL:
I—I Yrs N`� . .
Illthemt applhara rrt occupant um equipmentaAir VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whish emit havrdous air�y^tamW me as defined by the Bay Area Ah
Quality Merognmerd D�eFLLt7 BOILFR�N1'ONP OR10�0(10 BTU)
F-1 Yeor.
have madthehav mrtedalsrequimmennunder Chapter6.95of BOILER-COMP(OVER 10p0O BTU)
the California health La Safety Code,Sexnlom 75505,255D and 75534.I
uderetand that lfthe bulldrng dm rut camo0y have a tenant,that It is my NEW RESIDENTIAL MEIN. SQFT.
responsibility to notify the occupant of the requirements which must be met
prior to Lwua t paruy.
O(hdr or at orl gent pa'F—
TOTAL: IssuEDeY:
OFFICE COPY