22388 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY \
Bum Pm en Iden.Ilatl°n IItitMBT NO.
BuIldingA pffilu'lo .J vn;+f> I. 223.88
ner. ,meI phonn:
CITY OF CUPERTINO-BUILDING DIVISION (]
. ContntloraName: Lk Na APPLICATION If PERMIT ^2` 9'
BUILD! GELFLTRICAL-PLUMBINGMECLIANICAL CATFS-ARY CONTROL,I
Archltetl/Engiver. Lie Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERh9TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby.ffirmthat l am licensed underprovblons of Chapter9(annmen APPLIANCES-RESIDENTIAL 1 1QB F/ R➢7gN
ingwilh Setlioton7000)of Divlsim3ofthe Busi..e dProfe .Code,and ' rl 11e-�
lice.I.In and effom �./ PANES L
Lite
Lie.Y C 1
Dale Cohn or fqL I✓� v y� -
ARCHITECT'S DECLARATION 20- LL a I t
7 I understand my plans,hull be used as public read. OVER 10(10 AMPS SQ.F7.FLOOR AREA VSQ,FT.
IZ Lbeved Profesbal - 9GNS ELECTRICAL / /O�
�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M19C 1�p`�lQ l.,es
71-.,�� IherebyafOrm that]am evempt lmmthe Cortranarb Ll¢rue lAw(mthe I�
pp following rtaion.(Seelon 7015,Bualnes and Pro/mloro Code:Any tlry or '^I/��
r2t-� TFMP.MET ER OR POLE INST. perm),+
/ /I
c yCm hmprt toi pe tmmr mqu]d theaprwe,demoWh,orre to _
Y w"'F,aammem that
M ,,alsoredpursuant t the foreuchpeof t e POWER DEVICES 44 .�_a-. n
a file a aunt'.lee.Lethal he l r9(ourd pursuant it the prov6bv of thes/-+1•�-�J
��ul� Contnaor'.Lkens law(Cha pter9(mmrrcndng with Section 7000))/qW- SWA1MBiJG POOLF].E
O;J a n3 ofthe Bu.inea and Profesbv Code)or that he b exempt therefrom and VALUATION
�y •7] the basis for the alleged esemptbn. Any ululation of SV ion 70315 by any
appB¢nt fora permit subjeeisthe appheant to a tivll pwlty of not mo¢lhan OUTLEISSWITCFTES
E - ftt�uodrtd dollars($.SM. I
I,as mvmr of the pmperty,or my employem with wages a their wk NEW RESIDENTIALTYPE CVNSIRUCIION
compensation,wW dothe work,and thestnscW m b not Intended or offered for
O eak(sec 7D1t,Bushis and Pro(esions Code:The Ccuntedora License Law 9 t
don cot apply to an ower of property who builds or Improves thereon and IJP RES.CC who doesMeh work hi.0 or through Msown employcm,provided that.6
improvements are not Intended oroffcrte forsale.If,however,the building or TOTAL;
Improvement issod withlnoreyearofmmpletbnthe owner4 ilderwBl have
tryc.¢arefer,or proving that h,did not build or improve for purpose ofale.). QTY. PLUMBING PERMIT FEE
LJ L a N
owner of the property,am esclueely contnning with ll¢iadrFLOOD ZONE AI'N
mntntivn to mnslmct the project(Sec 7044 Bushes and Pmfesiov Code PFRMTIISSUANCE .
The Cmurador's Lkeeae Law don net appy to an owner o(property who
bu1Ws or Improve thereon and who mntncts for such pAojeea with a ALTIER-DRAw4VENT-WATTR(EA) ,.
ry�a�tWe)IkePursuantee Pursuant to the Comedur'.Lieeaa Law. BAacFlow PRO=.DEVICE FEE SUMMARY
U I ion e.empt under Sec B It P C for this reason
®
Owner Dee
DRAINS.FLOOR RODE,AREA,OOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT
p�S PER TRAP SCIi00L TAX Y_ N_
1 hereby affirm titre I have a l M r¢ df amr to self-Insure,ora RECEIIT,Y
nl meofWorker'Compesa-09 'ura¢ma¢rt.led copy therto(LSee GAS F.A.SYSI.[•M-1 INC4 OUIUFlS PARKF-EE Y N
leyb
3800,YYC.)�� �� GAS EA.SYSTQrf-0VERI(FA) DING DIVISION
is here rruahed. ,c 1 - BUILDING DI VIgION FTU
CeftNed ropy by
ertined mpybrded with we tltyin.pettbr,atvi�m. enFABE/wousrRL wAsia INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY
nor becompleted If tSIOItM EA 31OT1' - Date Recei I!I
(Title salon need he permit b forone hundred dollar
R100)¢fy that
WATER IlEATEE w/VENT/EIFCR( ENERGYFEE Y N
1¢nor that in the persman¢of the work so as to whirh
pemdt cLasued,
1 shall not employ any Peron Tri any runner e a to become abject to the WATER SYSTEM/TREATING
Workcrs'Comperaatbn laws of Gll/omit.D.rte - PAID
.0 Z App.¢nt NEW l6E9Dlw'I7AL PLMB. SQFT. Date RCcci fIl
Z NOTICE TO APPLICANT:If,after nuldeg/w Certificate of Exemption,you
N ahmld beconr subject to the Worker:Compensation provisions of the labor TOTAL:
Code,you.0 forthwith comply with such pmvtabnsarthla pemdt shall be
W > deemed revoked. I '
CONSTRUCTION LENDING AOENCY SEISMIC FEE
CL Z Thereby ffi.rm.whkht this
ingSee. agencyfor the perform- ELECTRIC FEE
7 Z armof ee.Name wldchthla pemdlVblued(Sec 30Y7,CIv.CI TOTAL:
V O Lender.Name - PLUMBING FEE
IL H endereAdd s QTY. MECHANICAL PERMIT, FEE MECHANICAL FEE
O W Irm,1.lhatlhace plywhakaUonaM my oho eabovelnfomuawe
tamrrea.l:greeto c¢nply whhWtltyaM ctiuntyordlna¢s ane cote law. I'FlU1R ISSUANCE FEES PAID:
} N relatlry to building rorutrusion,and hereby authorize repre,entattvm ofthes 4
F Z city to enter upon the above-rtentbvd Property f¢mepectbn purpcaes. ALTER OR ADD TO MECH. DBLC Reed Ile
_ (We)agree to.ave,ted emity an d keep berrNme the Ctty of Cu pertlw
against Babllltles,0dgments,mtt.and expenses whkA may in any way a. AIR HANDL]NG TWIT(TO 10,0)0 CIN) SUBTOTAL•
ago Inst said City in ro eqt roe egrant Ng oftw permit
//G' AIR IiANDUNc uNrr rovER l),o)ocF�Il CONSTRUCTION TAX
S�P-�Pfa cunlratl¢ %/ yAli' ExliA=HOOD(w/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will the applleant mfutue bulklieg occupant Mom or handle havedous HEATING uhlIT(TO 100,0)08[]]) Date RCLCI IM
rvtcN lasdefinedbythe CupeM.MuNtlpalCode,Chapter9.12,andthe
HeahhandSafetyCad imi25532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑ Yea No
Will the appliord tore building occupant use equipment ordevim VEN71LAUON FAN(SINGLE RE-SID) ISSUANCE DATE
whkh emit hazardous air contaminants as deRred by the Bay Area Ab
• QuaIHy Alavgen.en Wt 7 BOIIFRCOMP(31-0'DR 100,0(U BTN
I Ym ii °ma
love read th<h [erieLe requlrtmenh under Chapter 695 of BOEFRCOMP(OVQt 100,000 Bi1J)
the Glt.rdtat iftth bSafety Code notibv255 ,vee tand25534. I
uMentahillyt .thebullding pm not erequire ent,w kit that It]amy NEW R®DFN77AL N.ECH. SQFT.
rmponslb0lty to natty the pm d the requirements whkh rr=,.,be met
prioZ dJr i to of P. q. r
7h//
Uve mStAorrl ent to - - ISSUED
TOTAL —-
OFFICE COPY