23572 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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lx� Buildinglkatl
Palen ldsmlfm PERMIT NO.
Bulu^�aa0 c2k- �� �1`P �S 23572
ams: con:
25- ..9 CITY OF CUPERTINO-BUILDING DIVISION
Contnnor's Naplich Llc.N. APPLICATION / PERMIT
CATEGORY[ LGELECT JCn SINC-MECHANICAL CONTROL
AmhLL /Engineer.
\-j I3c Na
/ a Q ELECTRIC PERMIT FEE HUILDINGPERMITINFO
Add. IUS /� S• y.a- ,Zk, PERMITISSUANCE ❑ PLUMB ml�li
❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l en licensed under Provisions of Chap)er9(commen APPLIANCESRESIDENTIAL JOB N
Ingwlth Section 7(g0)of Divisim3 ofthe Busirca.and Pmm
feasisCan
ade, d
Liomlimm,alain full forte and e.0 PANELS
Date Cos LIC I `
Date Contnmr UP TO
ARCHITECT'S DECLARATION 1-10))A.N
p GZOG(0 I urderateul my plarualall be used es public mooed. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
LbL,, Limned Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION 5[TAALCIXCIIIT/M]50
� I Mrebyafllrmthatlenenempt frmnthe Cordraoor'a Llmnse Lawforthe
qqqqqq following ream (5
. eaim 70715,Buerm and Proltasbns Code:My tltyor
Fr'ry county which requires a permit to constmealoe Improve,demoLLh,
SI orrtpalr TEMP.METIX OR POLE INS]'.
O77 anymmn mprbrt ilt ame,460mry4 theapphuntforwchpem to POWER DMS
Rle a signed atatement the he is Ilmnud pursuant to the prodslom of the
7 uu..� Centrsdor's Liccnu l�w(Cfupter9(mmnrndn6 wLLh Senbn 7000)of Did- SWINIMINGPOOLELECHUC VALUATION
F)y o s Mon ae for the lle e d lRdeabu Code)i lade he h Sump(therefrom and
Q
applicant
Gala fort he silegndeutsthea. Mytto a civil by
� SS aPPllant(ora permit wbJectameappBcanttoativll penshy ofnot morethan OUfLETSSWI70HESEIYNRFS
pSI. fW6nartd dollars 05M. NEW RE�FNIrAL w,ECTR SQFr.
< I,as owner W the property,or my employees with wages as thein sale STORIES TYPE CONSTRUCTION
mmpenedion,wBldothework,andmeavutl mbrent WeMedoroffered for
does$ p sole notap apply
Bu anown rofpropery Co b:The contractor.IJmrue Lew
3� whod apply( rkho if pm ',his bemplym,puilds vest to t,and OCC.CROLIP RES.LMRS
whodoeseuahwor tend toraffe hlfo ince.14hoe,proddedthatarch
improvememaarecot Wendedo rofc ylsole.ILhmveve,thewildingve TOTAL'
improvement V said wLLhboneyarofenripledoR the ownerbutlderwlll love
rdenef proving the he aid rest wild or improve for purpose of sole.). QTY. PLUMBING PERMIT FEE
L u owner of the Property,am eachuively contracting with Ilcenud ET-OOD?ONE APN
contracts to coruo.od the project(Sec.70K Basin®and Professions Cade PERMIT ISSUANCE
The Contnnor's Lbenx Law dm not apply to an owner of property who
wilds or improves thereon and who comnm fm such p(olects with at ALTER-DRAIN&VENT-WATER(EA)
qa1(+cte(Oheena[d pu oust to the Cmtnnm's Limnse law, gAIX FLOW PROTECT.DEVICE FEE SUMMARY
U I am eempt under Sec B k P C for this names
DRAIN F SANITARY Y N_
• QLTTSIQF FEES
Owner Date RECEIPT Y
WORKMAN COMPENSATION am DECLARATION TRAM', SCH LTA% Y_ N_
❑1 hereby orlon that I have•mrtlgote of coeu�ent ci oeythemof(S a
mnNate o(Worken Compensation Insunnm m a mklfled mpymereof(Sec. RECEIPTa
3500,Let,CJ GAS -1 INC50 PARK FEE Y_ N
CopoiY CASA:F-0L V DING DTR
ECeY BUILDING DIVISION FEES
rttfied copy is hereby(urntahM. GGFASE/ RLANCHECK FEE
E]Certifie l ropy le filed with the tlty Inspection division. _
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE PAID-
SANITARY-STORM EA.;?00FT Date Recel tN
' (Tldaeectbn need mat G<ompkted Bthe pemJt bra one hundred OOBan
a1lu) ys3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icony mato an person
unroof manner for tob co pemdtla Weed,
1 shall not employ any penin m any runner at u m became subject to the WATER SYSTEM/TREATING PAID
WaMn'Compensatbn lAws of Glifomla.Date
O Z NOTICEAppfiam( NEW RESIDENTIAL PLMB. SQFr. Date Recel t#
Z Q NOTICE TO APPLICANT:U,a(tar making thbCMBlate of Fiemptbn,you
N should become subFcd to the Wor r%'Compevebn provisions efthe Labor TOTAL:
_ Code,ymmuetfamhwuhcompiywithac provi morthbpemJtahallbe
W ] deemed revoked.
CL O CONSTRUCTION LENDING AGENCY SEISMIC FE
1 hemby affirm that them Is a mrutruction lending ageney for the perforrry
M Z arca of me work for which this permit le Loved(See 30Y7,Civ.G) T L ELECTRIC FEE
(,) O I�Mer',Name PLUMBING FEE _
LL H Lender',Adareaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImmifythAlhavere.dthbappB tW..Ms tethetheabove Wom fon
bonmo,t.lagnetocro plywithaBatyaMm ntyordinanmandq telaws PERMR'ISLIANCE FEES PAID:
>. CL relating tobullding mremedlon,and hembysuthormoepmcntatoesofthb
F N my to enter upon the sbovo-mentbrcd propertyfm Wpxrbnpurpoae. ALTER OR ADDTO MECH.
Z (V✓e)agree to.ave,bderneil an d kee arMne the Clty of Cupert W Date Recei tic
V ag.W bWties, n meaande n which m,ybanywayamue AIRHANDLINGUNITIT0I0,WOCFM) SUBTOTAL:
said enmof gr, gdt permit.
AIRHANDONG UNIT(OVER 10,0(X)CFM) CONSTRUCTION TAX
SI to fAppgon cot Date EKHAUSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
Will the appLLant or future building occupant atone or handle havrdous HFITINGUNTT(10100,000BM Date RCeei t
material as defined by the Cupertim Mu Nep ,al Cod Chapter 9.17,and me
Health and Safey Code Section 75537(7 HEATING UNIT(OVER 10,000 BTU) TO
mYea MN.
WBlthe applicant orfuture building oaupant use equipment ordevlcv VFNITLATTON FAN(SINGLE RESID) ISSUANCE DATE
which emet ha,a don air conta Mruma as deRned by the Gy Art.Air
city Management DLatrint BOILER-COW PHP OR IOQO(D BTU) /' p
a
nave
❑No �� U'i II
have reelthe haaardoun mterlaL+raqulmmenn under Ch.pier 6.95 o! BOILER-COW'(OVER 1,000 BN)
1M Gllfornia Health A Safety CMc,Smlons 25505,75533 and 75534. I Ep
uMcr thutlfthaw0aingdonn cot ntlyhaveatenantthatitgrry NEW RESIDFNIALMECH: SQFr. SEP :
8 199
responsibility to notify the pant of the requirementswhich round ue be meS
t 4
prior to bsuanm ofa Certifiatc of oauparcy.
n.l
Owner or suthorWd agent Date Y UC LUrt).IJryI'
TOTAL: ISSUED BY:
OFFICE COPY