22374 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY V�
Bull ng Pm'ce,Identification a PERMITNO.
Bulldingdddrtae: o G a Q n; fis 2r1: 12s e N 22374
rcn m: ane: APPLICATION SUBMITTAL DAM
CITY OF CUPERTINO-BUILDLNG DIVISION ^ ^ I
® ca oto awm : Lb.No APPLICATION / PERMIT e y
Ile No:
BUILDING-aFCMCAL-PUJMBING-MECHAMCAL CATEGORY CONTROL Y
AmhllM/Englroer. '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE El ❑ ❑
LENSEDCONTRACTOR'SDECLARATION
I herebyICaffU thatlunllcmaedunderpr Wmsof Chapler9(mmmm APPLIANCES-RESIDENTIAL
ILDnagtwe�gth�Syedi.n7000).!D�iWMtn.tl3oorfthe B . .dProf .C{o�dy,wKd.9'
RIPTIO
bt
loenaebbuu ra dedea PANES -Gyr O , unp
PS�ARCHTS
DECLARATION
1Q�0 CZO I understand my pha shall be usM n public records OVER 1000 AMPS SQ.FT.F(1Y�00R ARFA 5/�.F7.
E (0 LieerueaPrd®bnal SIGNS EL RR IQCC'S ye'
Q OWNER-BUILDER DECLARATION 1
7 W Ih rabyafBrmthatlamexemptfmmtheCoMr ore Lime Ul f«the SPF�ALCIRCUIT/MISC 0 ,^
O9t- following reasan.(SMion 7WIS,Buabesand Pro(miaro Code:Mycltyor TEMP.hfEPEROR POLE INST. - 1 C\ mL
Fvi muntywh m'qulrenapemdttommt Maltrr,lmpmve,demolbh,orrepalr �OO��
'rQ� anystruture prbrto Ila bsaarcc,alw requlrntheappllantf«wch permxto �,ER DEVICES .
�a 4 file a signM statement that he b 1te rased pursuant to the provisions of the
O o,rE.
Contractor's Lkersela,w(Chaptcr9(co.ruagwLLh Section 700))of DIW.heSWIMMING POOL ELECTRIC VALUATION
30J sbn3ofthe Budneswd Pr.( br�Codc)orthat be,,empttherefmmard
IS the hash for the alleged emmptbn. Any violation of Section 7MLS by any
applicant fora permit subjects the appllant to a evil penalty,d not rmrethan _
five hundred dollars($W. . TA
❑1,as owner of the property,or rev employee with wagn as their sok 'U' � STORIES TYPE CON'SIkl1ClION
mmu
pendne,wllldo the work,and the structure b not Intended or offered for
O role(Sec.7014,Bualnes and Pro(eNorc Cade:Tlu CoMrators Wmrue Law .
dwa not applyban owrcrdpmperty who builds orlmprwnthertoR and
ate-' who daewch wohhlmaeB«through hisownemployees,prvvldedthateuch OCC.CROIIP RES IATIS
Imprew,mew are not Intended oroffered for sale.If,hwvever thebuliding or DATE
improvement lawldwtthln°neyearofcompinbRthe owner-1auiderwi0 have
t nese ofpNngthat hedM Wild d orimw
pr •r« w purpoof sale.). QTY, PLUMBING PERMIT FEE
� m
T,as owner of the property,am.xcwlvely FLOOD ZOKE APN
mntratm to omatrut the pmFt(Se,70K Bushes and Pro(eebro Code: PERMIT ISSUANCE
The Comeatar'e Lkens Law dm out apply to an owner of property who ALTELDRAIN4 VENT-WATER ffla `
Wilds or improve thereon,and who mntracb f«.wch plo)aab whin .
c-,WLctuaW llatuN pursuant to the Cmtrader.Lice.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L_jI am exempt under Sec B 4 P C for fhb ere '
awn•
OUTSIDFFEES
OwnerDate S ETDRAINS ROOF,AREA,ODND. SANITARY Y_ N_RECE97#
WORK MAN COMPENSATION DECLARATION FIXTURES I"TRAP SCHOOL TAX Y_ N_
I hereby affirm (laro
that I have•wrtite of csnt to self-Insu «re, • RECEIPT,s
arc a o(Worken'Comperiaatlanlw�rjanga amt0led copythereof(Sec. GAS EA.SYSTEM-1 VEC.4 OUTLETS PARKFEE Y N
Co I GAS EA.SYSIFM-0VER4(FA) DING DIVISION Toy �}?y�_X BUILDING DI VISION FEES
.ry `"ice°%b-{reeeb' `d' GREnsE/INDUsrnL WASTE 3NItRCEPTOR PLANCKGCK FEE
CMWed copy b IOed with the city Inpetbn d W Won.
CERTIFICATE OF IXEMPi'ION FROM WORKERS GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER&A ARYSICRMFA2EN)T Date Recd [#
TI'weectbn need eat he complied 0 the permit b f«aro hundred doBue
($1OOJ Of Ie®J WATER EIEATERW/VFNT/ELECrR ENERGY FEE Y N
Irony thatoan persrninanamew«k forwhichtw pesubjcawes,
1 ori, not employ any Peron f any manner at a to become subject to the WATER SYSTEM/TREATING
w«her:camperuatbn laws a/aluamb. Date PAID
N7EW RE51DFN11AI.PLMB._SOFT.
Applicant
Z Date Remi t#
Z O Nculdb co APPLICANT:If,after melding Workers'
Cetor pro o/Faemptbgyou
F N should become, foriFctto the W«hent Compeaatdepor this ermit labor TOTAL:
_ deemedyou nvss fwthwhh comply with each provisions°Mw perMtat�llhe
W > deemed revoked BUILDING FEE
=ELEC7RIC
t
CONSTRUCTION LENDING AGENCY
CL, !hereby atBrm that thertbamatrutlan leMbg agerrryry for the perform
Z awe of the worktorwhieh this permit b bared IS,3097,CIv,G) TOTAL
02 IerderbName (�U. H IcnaerbAddreas - QTY. .MECHANICAL PERMIT EE MECHANICAL FEE 7—
O W IartOythatlhave readtw appBatbn.rd matethat tLeabovelnfornution _
4 IamrrM.l:grectommplywhhauetyaMm ntyord/ cma dstatelaws PERMIT ISSUANCE FEES PAI D:. I/G
} N relating to building construction,and hereby authoere representative of this
Z city to enter upon the ab m,ntbrod property f«Imsetbn p+ ALTER OR ADDED MECH.MDate Recei t# /
— (We)agree to ave,t demo fy an d keep harmless the City of inaa _ _ P
ago WtllnbWtks,Irdgmew,00LLaard ezperon whkh maybwywayaevue AIRFLSNDLINGUTCIOI0,000CFM) SUBTOTAL:
ago Wt•IECIt In nee hegrantbgdtM.permit AIRHANDLINGUNTTtOVFR10,(100CF.M) CONSTRUCTION TAX
Slpurun of App /Con to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will the appllant or future buiding oroupattsore orhandle huardous HEATING UNIT(TO 100,000 BMJ) - �
material.,defined by the Cupenloo Mu Mcipal Code,Chapter 911 and the Date Recel t#
Eleahh and Safety Cod rm 25537(p)7 FffATING UNIT(OVER 100,000 BTU)
r, yes YNo
WW the applies building occupant use equipment«devim VENTILATION FAN(SINGLE IRFSTD) ISSUANCE DATE
whkh emit haardous air oontam/nards as defined by the Bay Area Air
Qu lhy wrugement 7 HOMER-COMP AOR 100,=RM '
❑ Y. No
(have read the hav materials requirements under Chapter 6.95 of BOILS ODMP(OVER 100,000 BIU)
the California Health k Safety Code,SMbs 25505,ES33 and 2&531.I
undent.mith tifthe Wiidingdocenot.mnllyhaveatenant,tlutlttrmy NEW R} IDFMIALMECFL SQFT
r6pontlbOBy,to notify the wcvpaM of the requirements whkh muthemet
priorto ana to party.
erorauth agent Dae I D
TOTAL 4— &11
OFFICE COPY