23281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
building Fooled Identification - FFRMTT NO.
Building Addreas: - 23281
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ne er31 CITY OF CUPERTINO-BUILDING DIVISION A w
Can raar'eName: r APPLICATION I PERMIT
-7 rALCLPS ;BUILD[NGd�TRKALI'LUM9INGMECHAMCAL CATFfARY CONTROL If
0b Fn a`a,��� NP
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— _
PERh4TI$UANCE ❑ ❑ _� ❑
7— ��I PLUMB mkiCii
LICENSED CONTRACTOR'S DECLARATION
[heh S elle Irmthatlamlk 3.fbe uzi.dmeo(Chapt°r9(comment APPI.IANCESREADHM7AL JOB D RII'I'gN
ingwit Is In full ford)alDMeet. olNeBudmaaand PminUonsCade,and toy
Ilmnsebin full farm and died. � PANELS
Luxr.Clan Lk.I LAJ t 4 .
Date m
Coractor l�
ARCHITECTS DECLARATION 221.ImAmps
po
02 .I understand my pluua1ha0 be used u pubhe records. OVER 1000 AMPS 5Q.FT.FLOORARPA f/9Q.FT.[G I N
E (0 Licensed PderLivl SIGNS ELECTRICAL D
< OWNER-RUILDERDECLARATION SPECALciRcu.I./AfTSC
;z Iherebyaffirm thatlam ezemp(raan the Contrufor'•L{mnr Law for the
Following mason.(Section 7MIS,Bovines card Profeabru Cody.My city or
OF TEMP.METER OR POLE IN
cwntywhth rcqubna permed tomrutrud,alter,Wprove,derroHeh ormpalrOW
qqq anyatmoom pA wltap°uance,alaorequirntheapPOantfar &per W ]OWER DEVICES /!.E
file a algid mtement Hut he Is loused pursuant to the provbloru of the 7` -r
�I- ContndorSLicense LAw(Clupter9(cornerencing with Sedan 700D)of Dlvl- S�yp wpct0LELEGI'RSC DATE
.JJ7] sb basis for the nefe i Prdmbv Code)orthatheb Secmpt 7MI,5 by and ALUATION
Sn the Ireb for the albged jeemptlon. Any lto.cw of Section.ot o by any
p� '°PPBmntfor a permH aubjeM the applfrant to•d�ll penalty dnot rrortthan tTUTT.EISSNTTCF@SH)(NRES
�.. five hundred dollarsOLW. NEW RESIDENTIAL ELECTS
7�a
F1 1,n owner of the pmpedy,or my eoyl y.with wag.as theIr sok Q'1' STORIES TYPE CONSTRUCTION
mmperuat] wild-theworkandthemumrmbrot Wendedorofferedfor
O
does
sleety706to alnowarWfpropeons builds
Llmroel�w
dors not ch.,1nowrer d throng his own employees,orimpmol dthats ch OCCGROUP RIM UNITS
S nd
whodaneuchwahxInten ed orwghed owude.ltowr,thebuiiidng h
Impmvemeds am wt Intended ors or room plea .the o ev builder l lIng m TOTAL:
Impmvcrrird baold wkhNoiycarofcornplrtbRtheownerbu0derw111 Tuve
tryc�aedenaf prodngthat he du not buOdor Improve for purpoaedsale.). TY. PLUMBING.PERMIT FEE
"L as owner of He Property,am eshuively contracting with lbensed F1.00D ZONE AM
mntradnn to mnexud the project(See.7064 Bootle and Prdesbns Code: PERMIT ISSUANCE
The Codrsdorl Llmroe Law don not spply to an owner d Property who ALTER-DRAIN k VEM-WATER
W Rda or toy.thereon, and who mmnde far such PNFda with a
9114a,tm(s)Ikenned pursuant to the Contradds Llvrue Law. FEE SUMMARY
U I am ezemp order Sec B k P C for this reason BAIX FLOW PROTECT.DEVICE
OUISI DE FITS
DRAINS FLOOR ROOF,ARRA,cct D, SANITARY Y_ N_
Owner ECL RECFII'1'
WORgNhe COMPENSATION DECLARATION pp(NgFS PER M& SCI100L I" Y_ N_
❑I hereby•!firm Con I have o mnsurao of aceaent to self-Insure,or• RWEIPT7 a
M,lots of Woiken'Camperuatlm[nsunnm m a orrtlfled copy (Sec.
38N,Lab C.) GAS EA.SYSTEhf-1 PIC60UTLEIS �w PARK FEE Y_ N
PdlcyI CAS EA.SYSTFAfOVER (FA) BUILDING DIVISION FEES
RF�E�f'
Com ny
crtifled ropy b hereby furnished. CREASE/RNDUBIRL WASTE INTFRCE'fOR PLANCHECK FEE
Certified copy ba heed with the city Impectbn division.
CERTIFICATE OF EXEMPT[ON FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCESEINER-SANTTARYSTOP EA.20OFI' Date Remi ted
ffhlaa sur,need not becomplded Rthe pmolt b faros hundred dollars
($1 col or leo.) WATER FrEATERW/VENT/v.r>=1-R ENERGYFEE Y N_
Imd0yth bthepedom nmoftheworkforwi ch Wpemdtisissued,
I°hallnot empby any person In any cosi¢,s•u to become ubfed to the WATER SYRTM/TREATING
WorlerYComperuatlon Laws ofGWornla.Date PAID
O Z NOTICApplieant NEW RESIDETIAlPIMB. 9Q.F1. Date Remi ted
Z O ? .1d TD APPbjmw :R, . maldngtw Certlflpmva E oftt a you
F N ahml0 bemmembFct uthe Warken'Compenutkm pmvbbns-Utes Labor TOTAL
Code,yrs rwrt forthwith comply with such pnwbloro orthb permit°Full be
LU > deemed my-ked. BUILDING
d c CONSTRUCTION LENDING AGENCY SEISMIC FE
I hereby afOrm that them b•mnstrudlon IeMing agerKy!or the pedarm ELECTRIC FEE
7 Z ante of the work!orwhlch this pemdt ie bued(Sec 3097,Cl,C.)
LL O LeMee,Add a PLUMBING FEE
LL H Lerdare Addre.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ormtfythatl HvernplywappOertlanaM fat°thotessemndasa Taw,
1 batingt building carutmetl handyardcouthorl nernmsaaWesolaws PERMIT ISSUANCE FEES PAID:
} Noting to building mmtmdlm,ard hereby authoAre rteeauri .,P of Fhb
F = city to enter upon the abwcrmn0-red property for Wpedbn purposes. ALTER Oft ADDTO MEQ?. Dale ReCei t#
V — Me)agree to aase,indemNfy an d keep harmles the City of Cupsrtlrio
agalrot HabWti.,judgments,osatsandez whkhmaylnanywayamue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL
agal 0 say C enm of ,tby of Reda permit.
////-J a ff�j-A jNQ� AIREunrouNc uNr['(OVER loaaacF�f) CONSTRUCTION TAX
Signature Appumnt/CantrMar /( Date F](HAUSTHOOD(W/DUCT) • CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapp"nt or future budding odupant atom or handle hazardous HEATING UMT(TO100,0000TU) Date ReceI t
nuterbl as defined by the Cupertino Muddpal Code,Chapter 9.l Z,and the
Fleahh and Safety Code Section 25532(1)? HEATING UNTT(OVER 100,D00ITHn TOTA
I— Y. No
Ill the applicant m tore building- pant ua,a Niprmet m devkes VENTILATION PAN(SINGLE RESID) 'ISSUANCE DATE
which emit hazardous alr contaMruntau defined bythe Bay Area Air P'4
�� I
Quality Marugemek Distriet? BDRFR-COMP OHPOR 1WW BTU) f D
Yea No
I have mad the hamrpous rrwerials mquiremenb under Clupler 695 of BOILERmMP(OVER IN,000 BTU) r
the Ca Hlamh Health&Safely.Codc,Scab 25MS,25533 and 25536.1 FED _ e
urdersUed that lithe building does not amrtly have a tenant,that it Is my NEW RESIDENTIAL MECIi. SQ.FT
responsibility to notify the oreopant of the requWersents which trust be metCI e
prior to Lsuarue d a Ceficate of Oceupaney. 7Y U1-
Owner car authorixd IIYU
TOTAL:agent Date ISSUEDBY:
OFFICE COPY