22307 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldl Proe"Idendfiratlon PF3t.WTNO.
Building Add nv:�I QEvA DiLwc 22307
IY1r c .Pa _1 o e:
/ CITY OF CUPERTINO-BUILDWG DIVISION / �l
C • ' nr'D a APPLICATION / PERMIT
V BUILAINGFI.ECTRKALPLUMBINGMLCHANICAL CATEGORY - CONTROL# .
Arehlte /Engineer. I.fr. o
QTY ELECTRICPERMIT FEE, BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby&(floin that l am LceruM under provWona or Chapter 9(oermm APPUANCESREsiDEM]AL 109 D RIPI1 N
Ingwlth-qedwn70W)of Div k.3ofthe Bu ..dPmfn .Code,and
Ikxtne bIn fuUf2,zaodffM (/_ PANELSUP TO 200 AMPS
��
Lbemc Ck. Lie 1 VR��J I
Date Contractor
ARCHITECTS DECIARA- AMPS
0O 7 IuMernaM my plain shaBh used as public
re=dremela OVER 1000 AMPS - SQ.Ff.FLOOR AREA 5/SQ.FT.
() LlcarrsM Pnfuloul 9GNSEISIRIGAL E D
I'n ILUUUy OWNER-BUILDER DECIARATION SPECIALCIRCUll Mi9C
IN
Z I"' z+ (herebyaffirmthatlame.empt franlhe Covtractor'.Lken.e Lwlm the /
pp q�y following re..(Section 70315,B..iness aM Profesbru CMr.Any city m C R
OZ 7 repair
lII✓3.METQt ORIOLE INST. CCmf G
�� _` aaunty, ,tumwl,ieh riot toia perMttomrwrou tres the
applicant
for
ch,ermitt
file
auciurclatemolra Wu he b also to the fmaud permit tho �ypg DEVICES y / /
0 tIb•elgned,mtement that h b Ibeved puruant to the proal bnu of the
Contraori Lkerue Law f0uiptu 9(commencing with Se oo 700D)of DWI- SWIMMING POOL ELECTRIC
P, elan3 ofthe Busimasand PctMesioruCMe)orthat belaemmpt therefromaM ALUATION
5]] the Gala for the alleged e.emplbn. Any Aclatbn of Section 70315 b/any
applicant fora permit subject,the appBcant to a dvil penalty of not euetho OUTLEISSWITCHES-FIXTURES
c Me�undted dolhn%W,
I,a owner of the property,or my employee with wage,a,the r, k NEW RESIDENTIAL ELECIR SQFT, STORIES TYPE ODNSIRUCDON
mmpcneaUon,wBldothewmkand th<atrVcturcbrwt LueMed or offered for
Ouk Sec.701/,Bualneu and Pra(®btu Cade:The Centimeter.License Law
s$ doe not apply to an nwner of property who build,or impwe thereat,and OCC.GROUP RES.UMTS.
who doe aehwvrk hlme elf orthrough M•own employe.,prwldeel that ouch
Improvements are not intended oroffered for uk.It however,the building or TOTAL:
Improvement b•dd within oneyearofcmrydetbRthe wvnerS Uerwdl haw
t rden of pmving that he did not baud or improve for purpose urine.). QTY. PLUMBING PERMIT FEE
Lj 4 u owner of the property,am exclusively coctin
ntrag with Items,, — FLOOD TONE APN
PERMIT ISSUANCEcoxd m to mmtu"the pm)ect(See,7044,Boo int and Pro(mioe Code: I �C ,
The Cmuradm.Lice.Law dm out apply to an owner d property who ,Q.(�DRAIN 6 VENTWATER<F.1)
bell"or Improsea thereee, and who mntram for such p,)cva with a
etiactorW ikxnsed pursuant ro the Contractor'.License Law. BACK FLOW PROTECT.DEVICE - FEE SUMMARY
[JI am exempt under Sec B A,P C for tw reason
Owner Date DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION _ RECF]I'1'#
01 hereby affirm that I have a mnlll ate of oonarm to aeB-InureFIXTURES PER or• FIXPFR TRAP 00 SCI TOOL AX Y_ N
caniflete of Warkere CompenuHon Imurann m a eniflM ropy thenar(See RFCmT#
3800 I<b C) GAS FA.SYSITM-I lNC.40UTLETS PARK FEE Y_ N_
IbIIryI _ GASEA.SYS'1"F]N-0VER4(EA) R
Cra�mparev BUILDING DIVISION FEESECEIPT#
111 Centro, p b 1y rn GREASE/INDUSIRL WASIE IMFKEPTOR PLANCHECK FEE
Cenl/ied ropy b filed with the dty Inpcetlon dlvl,bn.
CERTIFICATE OF E][EMPTION FROM WORKERS GRElSCTHAP PAID
COMPENSATION INSURANCE SEWFR.3ANffARYSURMTA10FT Date Recd tit
(fid,,eetbn need red h completed 0th permit b for oK hundred dollars
1510 tamlWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I enityylhth rt loth perlormane olthe work forwhlchtw pemdtb Loved,
1,hall not employ any per.on In any manner so as t rk b' u the WATER S1SIEM/TREATING
Worked Compenutlonlyw.of CWfamIaAD a PAID
Z Z NOUCE]O iri e g lot Iptl gyou NEW RESIDENTIAL PLMB. SQFf. Date Rcocl t# -
•bald become.ubject to the Worken'Compeuatbn pmvfabro of the Labor TOTAL:
F•• fn Code,yau vf«hw hmmplyw huchpre mortwpemd l]be
W > deemed revoked. IN
cONSfRUCITION LENDING AGENCY SEISMIC FEE
4 3herebyarflrm that therebammM1uetlonbMingagemy forth,perform rorAl_ ELECTRIC FEE
Z an oftheworkforwhkhtwpcmJtbLw (&ee30Y/,CIv.C) 1
V O I<Mer'a Name PLUMBING FEE �C --
LL Lenler'.Addreu QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W InnifythatIGv core twappB Wnardtntethx theabw,lnfonr J.
lxcr ct.lagnetocomplywkhaBdtyaMmuntyord mand,tatelaws PERMIT ISSUANCE FEES PAID:
} S relating to building mmtroetion,and hereby autho rcpreaentative orthis
Z &y to enter Pon th.bete-mentbried property for Wpe"lon purpoaea. ALTERORADDIOMECH. Date Recei t#
— (We)agree to tae,Wmem
eeify an d keep harmlthe City of Cupertino AIR HANDLING UNIT CID IO,000 CFhU
aga1 ties,Wt11eb �udg..0 acetaaM..pent.,whk .yinanywvy..e SUBTOTAL:
a Wt ui hY of the granam,of this permit.
�( � AIR HANDLING UNIT(OVER 10,070 CIM) CONSTRUCTION TAX
g Apphent/Contractor Data 'r-- EXHAUST HOOD(W/DUCT) ' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WBl the applfott m futon budding occupant tore or GMk havrdous HEATING UNIT CIO I(A,000 Irrul Date Recei t#
material a,de0red by the Cupertino MuNtlpal Cade,Chapter 9.12,and the
qui
Safety CodeJL—�SMion 75533(.)i HEATING UNIT(OVER 100,000 BTI!) TOTAL:
WYe u�
Wmit ha,ardmm tun Wlidingonvpantuse the Bay
mdevim VENTILATION PAN(SINGLE RESID) uIS56NCE DATE
whicheMahagemnt airrixt? ntsandeRrud by the Bay Area Air rk,}7
Qu❑silly Management D Yex ❑Mr4t7 BOEERLOMP 01-D'OR l00,IXU RTIn at
No
IIui Bread the M1 m.a materials requinmennunde,CGpter49iof BOILER-0D11P(OVER 100,000 BTU)
the Glf.UHeahh&S fetyCMe,SMbv Ti`. 5,255t3and2 .1
uMmret tMtlfthebuildingdoeanMt mntlyh.veatenanl,thatitbmy NEWRESIDFNTIALMECH. SQ.FT
repombBity to notify the occupant of the requirements which mint be met
prlar to tsuann of a Certifirate of ocapaky.
Owner or aulhariud agmt Date ISSUED BY
TOTAL:
OFFICE COPY