20004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
hultdingt Froldentlfiealon PEKWTNO. A
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23 00 V a'l5 S (� !3
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a U (rZiJUP CITY OF CUPERTINO-BUILDING DIVISION
emn.ao .Name: Lk.No APPLICATION /'PERMIT
BUILDINC-ELECTRKALPLUMBINGMF NKAL CATECARY CONTROL,#
Artrµect Fsr�J C ,� l7
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QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add— �0 �SS PERMITISSUANCE ❑ El
CONTRACTORS DECLARATION
Ili mbyaffU thatlunlben mMerpm Wwsof Chapter9(mmrry APPLIANCESRESIDEMIAL 0 RIPIION
Ingwith Sectton7000)ofal 9.3ofthe Bue� dProfeulonsCoapandmy �}-.�–I. �
e¢mc is In foe for,e and effect. PANELS
Lken�/__W. c3Cn_L1rI An ���
Date F>J_,/__9f1 CoMTECT res RATION Mechanical
ARCHITECTS DECLARATION OVER
ANTI'S
IundentaM'r'Y plans e)uBhused se,public records, OVER 1000 ANTI'S SQ.FT.FLOOR AREA 5/SQ.Ff.
Fi z LI¢nsel Pnimbns] SIGNS ELECTRICAL
<<�t OWNER-BUILDER DECLARATION grFLIAL CIRCUIT/MLSC
p,. I hereby aBhm that I am exempt from the Contrwor's Li eros Law for the
pflt–� foBowing rcaeon.0ioelon 9m15,9usinmand Profealo.Cock Anydtyor TEMP.METFRORPOIE INSI. ;I .i I� I N
muntywhieh mquhea permit tomtutruct,alter,Improve,demolish,ormper I
Yy� wystm amprimtolbbuamgabaregmlretheapphontfa mchpe to POWER DEVICES ,a p �"r
C file a signed autement that he b Ibenaed pursuant to the provlsbns d the U C
�a CootrateUcmLaw(Chapter 9(mmmenelogwith Sectlon7000)ofDlv4 SWA1hENG1OOLFlECRC VALUAON
O abn3dthe Busineasand Pmfmbm Code)orthehebexemptthmrc mand -
the barb far the alleged exemptbn. Ary vlalatbn of Sactbn 70115 by any
I� �� app0antfora pemMt subjMsthe applkwttoa dull pemltydna more than OVD.FISSWITCFHSFlX7LRE5 ISA
F" �^ five hundred do"MM.er e as their TYPE CONSIRUCIION NEWRESDENTIALELI)CTR 9Q.FT.
, M 1,an ownof the property,or my employewith wages their w
C ,1 mmpeneatlon,will do the wor"od the etnscturc b not Wended or offered for
p sok C5 70K Buninns and Profmbns Code:The CoMrad.e.Llcrue�
r dour not apply to an owner of property who builds or Improves tle¢aR and
RIS UNITS
OCC.GROUP whodoesuchwork M1hnseVorthrugh hbeuch
own employe ,prwlded that -
looprwemesds are not Intended oreffered foreale.If,however,thebulHingor TOTAL:
Improvement bsold wXMnomlcarofcompletbn,thw er-b MerwUhave
t rden of pmNng the he did rant buOd or Improve for purpose ofsee.). QTy. PLUMBING PERMIT FEE
Lj 4 as owner of the pmpencontracting y,en exchostwiy ng with licensed FLOOD ZONE AM
oontraetmtoromtrod the pro)ect(See 7094,Buenm and I'm(mloro Code: PERMIT ISSUANCE
The Contractor's Li.+"ne Law doe not apply to u owner d property who ALTER-DRAIN 6 VFM-WATER(EA)
builds or Improve thereon,and who menet f¢such p(ojeets with a
c�AjPachorW erene,d pursuant to the ContractQ.LI¢rae Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
M
LJ I am exempt uar Sec B A P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANTTARY Y N OLISID
Owner Dee RECFR71
'WOReSAT
® ffimnthe ve
COM DECLARATION
1 hereby athe 1 haa¢rtlBote of consent to seRIruFD(�q,PER TRAP SCHOOL TAX Y N_
-
urc,or• RECEIPT R
¢M,Lab ofWorkm'Conperoatlonlrounn¢ora¢rtlffed mpythe¢of 6ec. GAS FA.SYSTEM-1 WG4OUTLEIS PARK FEE Y N
polis Lab C
C.ley._nrl rani nAp T— GAS EA.SYSTEM DVER4(EA) DING Dr
y BUILDING DIVISION FRES
CertlBedropyb Feraby fumW GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy la feed with the aY Iropotbn dMsion.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE
(Bdaaectbn need not be completed if the permit is furore hundred dollars SEWER-S'NTLARY-STORM EA'rigFF' Date Recei t#
f5100)cvy,the WATER HEATER W/VENT/FIFiTR ENERGY FEE Y N
¢or to the b the per(onnsn¢of the for which this permit le bast,
I•hall not employ any person in any manner so as to become subject to the WATER SYS ENI/TREATING
Worker?Compensation Lava d California. Date PAID
PP NEWRISDENTIALPLYS. SQFr.
A Ilam
Z � Nortel:roMl'LICAM:v,,RermaHytwcertu�teofExemptbn,yw Date Recei t#
N should bemme subject to the Workers''Compewtlon provblam ofthe Labor TOTAL
Code,you muss forthwith comply with such po,islons or this permit shall be Q
W > deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that them 0.mratmctlon lending agemy for the perform- ELECTRIC FEE
Z anon of the work for which thbpermit bbeued(Se3097,Cie.C.) TOTS-' a3o
02 Iender'.Name PLUMBING FEE O O
LL f Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FIE
O W I certify the l have read this applletbneA statethat theabove b m
foration
1 son,, Iagr wcm,plywkhalidtyaMmuntyordln andMtelaws Fab,GTLSSUANCE 'FEF$PAID.
} relating to building eostuction,and hereby mathori,oe nepreentam,.of this
F.Z city to enter u Pon the abavo-mentbmd property for iroHo
p n pu rpoees. ALTER OR ADD TO MEC}#. Date RCCCI t#
V _ (We)agree to save,Indemnify an d keep harmless the City of Cu pentbo
against habibties,judgments,mrtnaM expense whkh may many way amue AIR HANDLING UNIT(TO 10,010 CFM) SUBTOTAL
ag.inst.old CRy Noruque�dUageMingdthispe t.
AHC HANDIING UNIT(OVER 1QODDCFt CONSTRUCTION TAX
nstumof Appliant/Cont o< Date EXHAUST HOOD M/DUCD CONSTRUCTION TAX PAID:
HAIARDO SMATERIALSDISCLOSURE -
Wllltheapplkamorfuture building oocupantuo¢or handle hazardous HEATING UNIT(70 100,000 BTU) pate Raei t#
muterlal as defined by the Cupartlw Mu Napal Code,Chapter 9.17,and the
Heahh and Safety Code Section 75532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: 0
❑Yes No
Will the appLk ret or to a building occupant use equipment or civ VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
which eros ha.rd.s air contaminant,ae defined by the Bay Area Ah ►.C'lI1S,0,.
Quality M.osgcmeM Diwiet7 BOILER-COMP 011POR 10gOM BTI))
Yn ❑No
t haw read the hazvdoae nuturibrequirem,ents underChapter G95 of BOILER-COMP(ova IW,OOO B'IU) JUIN n C IVQJ
theC Lf. Heahh6Safety Code,Sabm75505,5533and75534. I
uMem tatifthebulldingdonrwtmr¢ntlyhaveatenanLthatitbnry NEW RESIDENTIAL MECH. SQ.FT. /s
responsibility reality ty the aav pant the rej hem,erve which must be met illi of Cu -
prior tobd
suame .Certlfkateo 0 p.ncy. f nertino 1 1�
mer or authorized agent I Dote TOTAL: ISSUEDOY:� f7 ./vwll
OFFICE COPY