20054APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY �(
Build BuildingPromldrntllkalm Lf?� l0c1ii�
PERMIT NO.
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20054
MY. 11
nen. me ouP
CITY OF CUPERTINaBUILDING DIVISION
APPLICATION / PERMIT'9
BUfIAINGFl,ECMCA4nL BINGMEC}UMCAL
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CATEGORY
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QTY ELECTRICPERMTT FEE
BUILDING PERMIT INFO
Address:GO
PERMITISSUANCP
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l amllcrosed under provbionsof Chapter9(reentran
Ingwith Sedbn70W)a(Dlvlelon 3 ofthe Busleassand Pen/nsonsCode,and my
Items b In (uB p and eff,ct ! Z R.IVS��
Lloer�Qyyy o O Lie I 1
CHIT
APPLIANCES -RESIDENTIAL
�.
rn `y
PANEL
PS
ARCIEC HTTECTSDECEARATLON201-1900
OVER 1000 AMPS
SQ. FT. FLOOR AREA 5/SQ. FT.
Iurdent.nd my plan akBk usedupub0cremd>
SKINS Ei ECTIUCAl
Llnxnmd Prdmlonal
9'FCIALCI(CUIT/MISC.
FMU�TEMP
OWNER -BUILDER DECLARATION wlv
Iherebyaffirmthat Iamexemptteenthe Cordndor'aL Law fathe
foilog rtaaon. (Section 7[015, Buelnm and l'mleWov Code:cMydtyor
county requbnspemdt to mmw.1matr,
LED I N
METER OR POLE INST.
apmvgdeemlbh.ormitto
whim,
any smdum prlatoilsbsn beeequ krathettothe t f«achpemdte
Rk . dgned statement that la b Ilceved puromt to provbbv of the
POWER DEVICES QW
P T E R
bWI,U9NGM)OLE ECIRIC
Con3ofthaLkeveLaw d Prof ter9(m e)ortheheomencing k =mpt 7000)of Diel-
S,
Non and
Busnmand PenptoroCode)iolatin
V TION
�lle fo of Seempetkrtfmm
tk haab for the alleged exemptbn. Any violation of Sedbn not m by than
for. the appBcanttoaddl Penalty dna more than
OUME-I`SSWITCEIISH)(TURES
.
NEW RESIDENTLV. FIECTItSQFT.
five hunt
dred do" W.
Me hundred ddWn (e pm
�1, as owner of the property, or my employee with wages as their sok
SIOWES
TYPE CONSTRUCTION
mmpewtlon,wW dock work, mdtheaW cture b rnd Intended or o/(erect (or
salt LSae- 7 lnea� and of np re Llame law
don rot.pply to m owner d property who wilds or improves tkrton, and
ply to f p.pmy ho Wilk.
whodoeuciiwvrkhlmml«through Maownenrylo/seal pewldedthat meci
,OCC. CROUP
RFS. UNITS
Improvemcnb art not Intended orof/ered forests. If, however, the building or
Improvement bsaldwlthln avyearofcompldbn,tkowner-wllde have
TOTAL
t ben of proving that he did not wild or Improve for purpose ofsale.).
L u owner of the property, am euh choly eentr.dK
ing with need
contract. to romteud the pmjrd bee 70K Business and Prduiav Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
,
APN
The Contractor'. Lbeeve Law dm not apply to an owner d property who
wilda or Impmve thereon, and who conn. fm ouch p,)oeta with •
c%gaetwW hawed pursuant to the Contndors License Law.
LJI am exempt under Sec B k P C for this renin
ALTER -DRAIN & VENT -WATER (EM
FEE SUMMARY
BACKFLOW PRO=. DEVICE
DRAINS FLOOR A, NND. ROOF, ARE
SANITARY Y N
gpCmep 0
Owner Date
WORKMAN COMPENSATION DECLARATION
bII hereby a/firm that I love a nmRate d consent to eel(-iwn, m a
cffrt oifteof Worken'compeatllr
FD(ilIRES PER TR"
SCHOOLTAX Y_ N_
REMIPTI
GAS EI. SYSTEM -1 INC4OTILEIS
PARK FM Y_ NLe,_
vmrau asp certNedeaPyth mof(sec.
'MOO, Lab
Q'ORo _,/
II -{ 04
RECEIPT
GAS FA. SYSTEM-0vER 4(EV)
CumI ny IP
Certlfled copy b heeebyfuewhe
ertmed ropy, b feedyfa t d. ivpecuI dhialan.
BUILDING DIVISION FEES
GREASE/INDUSIRL WASTEINTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF IXEMPTION FROM WORKERS
PAID
COMPENSATION INSURANCE
(Thle aectbn need nd k canpided Btk pembt b f« anehundred dollar
SElVFR-SANITARY SIORM EA 2oDF-r
Date Reoel t#
WATER HEATER w/vFxr/o.FrrR
ENERGY FEE Y N
(s1m)onlm.)
I certify that In the pedomann of the work forwhieh Permit b
tibia Pedt ored,
WATER SYSTEM/TRFAUNG
I shall not employ any Peron N any nanner o as to become ubjtta to the
Worken'Compenutbn lawn o(GII(omb. Date
PAID
Appli.
NOTICE TO APPLICANT:B,afler making flue Certlflote of Exemptio,you
Date Recc1 t#
NEW RESIDENTIAL PLMB. SQ.ET.
TOTAL:
should become sub)ect to the Worker' Curepenat lon provbbv of the Labor
Code, you most forthwith comply with sueh peowblov or this peemlt dull be
deemed revoked.
11UILDING
SEISMIC FEE
CONSTRI/CI'ION LENDING AGENCY
I hereby./firentkt tkne ba consrodion lendingagercy brtk perform
ance of the work for which thb permit b bused (Sec 3097, CW. C.)
TOTAL'
ELECTRIC ELECTRIC FEE
QTY. MECHANICAL PERMIT 'FEE
PLUMBING FEE
Landers Name-
Lander. Addrm
I certi(ythat I have rtadthbappllatbn and satethdthe above Infomatlon
Iemrmct.iagree to comply with all city and county ordivnces and sate lawn
MECHANICAL FEE
t�
PERMIT ISSUANCE U0
FEES PAID:
relating to but ldleg mrotmGim, and kreby authortre npresentath es of this
city to enter upon hove -mentis noPerty f« WpeNon Pu npor..
(We) .gem t v , IMemNty d p harts. the City of Cupertino
ALTERORADDTOMFCEL
Date Recei t#
SUBTOTAL:
egaWtkb l gmew, • .peva nay Nanywayamue
agaWt N con of gnmin pcmdt.
'Date
AIR HANDLING UNIT (TO 10,000 CFW
AIR HANDLING UNIT (OVER IO,000CEV0
CONSTRUCTION TAX
lgApplieamt7contraetor
E%HAUST HOOD(W/DUC)
CONSTRUCTION. TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the.pplad or future wilding oeeupam Memo, huxile, h.rdoua
material u defied by the Cupertino Mudeipal Code, Chapter 9.17, and the
Health and Safetyc Section 25532W7,
Dale Recel t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
cit Q
qYen
fflt1u,.pplI.nr or rcwlldugoavpanttisecqulpneN«devim
VENTILATION FAN (SINGLE RFSM)
ISSUANCE DATE
hkh emit h.M.s air contaMvnts as defined by the Bay Area Air
s Iky Mavgement rfct7
Y.
BDrLFA-COMPHPORI00,OWBIU)
O
BOILER-COMP(OVER100,000 BTU)
have read the I, ous materials requlremenis under Chapter 6.95 of
the Celltornla Ileakh 6 fetyCode, Seabv 75505, 25533 and 2SS34. I
understand that ) wilding a m ntly ve a tenant,th a it t my
nepuvMlky no the pan[ therequ et. which rrwU be met
•1
`! $ -1. 111" �Qtl n n
NEW RESIDENTIAL MECH. - SQ.Fr.
pjlor to I co ec too pa
cit,—(C'` I'll_''art.""
—`r �k�a
authoriud agent Elate
TOTAL:
ISSUED BYJ
OFFICE COPY