23510 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulming Ponnt Identification PERMITNO.
BuOdbg Add.:
aj ✓me: me: nONSUBMI FrAL DATE
D. li • )WIf O 5 t CL,vo CITY OFCUPERTINO-BUILDING DIVISION -q 1.Z
Contratlala Name: LIB Na APPLICATION /PERMIT —1, 1.
' BIrILDING-ELECTRKAL-PLUMBINGMDCHANICAL CATEGORY CONTROL
Amhlteet/Engtrc<r. Lk,Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. �l PL If MUCH
—PERMITISSUANCE
LICENSEDCONTRAC erp DECLARATION I'YT�-1
I hereby dflrmcoati)t l=301ucB p and rofh ter9(�nmmc APPLIANCFSRESIDENTIAL
IOU IJS KIPIION
bgwlth5Mbn form1 )ofd eff n3.lthe Buslrimand Pm(eadauCode,and
Lioems b h/uB(ora ud d@ad. PANELS
Lbenr C . L�a
Date COntnaer
ARCHITECTS DECLARATION 271-1 OOOA
q�+N07p lurderrtand myphvahallbeurd up1,11crecrurds. IOVER1=AMPS SQ.FT.FLOOR AREA f/SQ.FT.
k lj Gaunt Pmfmbnal SIGNS ELECTRICAL '
G OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/MISE
t..,�G IherehyafBrmthatlienezempl fromilu CoMract.e.Lkerue Lawfmthe
7 9 following reason.(S tl.70315,Bualner ant Pmfubu Code:Any dty or
O G t, TEMP.METER OR POLE INST.
an a signed
hie Is aborequbnthaat to the fasurhpermlte POWER DEVICES(Ile a dgned statement that ha b keens m pursing to the Prada 0D) of the
�30�^ Contnnor'e License Law(Chapmr9(commencing with Senbn 700D)of Divi- SWppgyONG TOOL ELECTRIC
don 3 of the Buslnmud Pmfmbru Code)arthrt he b eumpt therefromaM LUAI]Qt�
'�_ the ba.b for the alleged ezemptbn. Any delatbn of Seetbn 7015 by any OIIfLE1SSWRCFQ'SHXIUR6 We) v C�
Qn Ppli—tfor.permit subjects the.pplbam too civil penally of no more than
lav ndred dollen(S.SOVj.
�n uowrcrof[M NEW RF9DENIIALELE{'iR SQ}T,
pmo t1the orkaormyetithe ucturen tto vngnathebsok SIOWCS TYPE CONSIRI1C110N
I- e,,70n,Bolldess and rkudionsCdurehe,Comtetded License
Law O k(Sec 7064,to Bossiness Professions Code:The Co mpro,r .the. Law
don eon.ot ycoin owner of throughproperth1a.w who .ropoyees,p Weds t and OCC.GRON' R VNIIS
who vem nhamr himself or through Nsow .l how Pr thledthatsuch
Improverrcnd art not Waded caroti<red(orale.If,hwvevu,the building or T
Impmarrcnt bsold within cane yearo(canpletbn,the Bunts'-bullderwlll have
thalturdenofprovingthathedidl notWBdorlmpm..e(orparposeofale.). QTY. PLUMBING PERMIT FEE F DZONE APN
Lj 4 as owner of the Property,am a Iualveoy contracting with limnxd
contractors to mntrutl the Project(See 70/4,Bo.ln.and professions Code: PERMIT ISSUANCE
the CoMnctol.Lkense Law don not apply to u owner of property who ALTER-DRAIN&VENT-WATER(FA) l
builds of Imp.theme.,and who mntn<L for NTA Mjem Wtth i
�acter(e)line^rd pursuant to the C.ntnaor:Lk:nr Law. BACK F7DWPR0[TCf.DEVICE FEE SUMMARY
LJ 1 .m exempt under Sec B &P C for this moon —
DRAINS-FLOOR ROOF,AREA,OOND. SANITARY Y_ N
® Owner Dale RECElppra
WORKMAN I loom.J Boa N DECLARATION
❑1 hereby ork C 1 love a Trt..e.f.au l( to rl then ,a a FOCIVRFS PER TRAP SCIdOOL TAX RECEIPT e
MONab of Workers'Canpematlmsluuruaaaastif4d copythertrofbee GAS F.A.SYST124-1 ING4 OUTLET
3800,lab CJ PARKFEE Y N
Poky I RECEIPT/
Co GAS EA'SYSTM-0VER4(LA) BUILDING DIVISION FEES
yfid ubGREASE/INDUSRtL WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified ropy b(fled with the city Impenbn dlWdo..
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID I�
COMPENSATION INSURANCE
(TIds.Mbn need nu be composed lfthepemnJtbfororehundreddollars SEWER-SANITARY-STORM EA'7001'T Date Rcoei t#
RIOOJa Inas.) WATER HEATER w/VENT/ELECrR ENERGYFEE Y N
Iart((y that In the pedomena.f thework for which this permit i.hsucd, —
I slaw not employ any person In any manner so as to bemme subject to the WATER SYSTEN/TREATING
O yi AWorke�t ompernatbn Laws of Califomla. Date PAID
PP NEW RESIDENTIAL PLMB. FT. Date ReCel t#
Z 0 - M7TICE TO AI'PLICAM:1l,aqn mildng this CerlBkate of Exemptbn,yw _SQ
J.7.
odld e subject to the Workers'Compen.atbn pmd.bu of the Labor TOTAL:
CC _LO Ce,younu.lfmthw hownplywbhachpmW. morthlapemdt.hdlbe
W ] darned revoked. BUILDING W C CONSTRUCTION LENDING AGENCY SEI IC FEE
CL IherebyafOrm that there bamutrutlton leMingagency forthe pedon,
= T ELECTRIC FEE C 0
7 ane o/the workfarwhkhthb permX bbved L5ee 309l,CIv.CJ
V O lender's Name PLUMBING FEE _
ly I- Lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Isnotythrtlluver dthbappllatbn.MdatethNtheabaveln(orrrwlon 4_
O W bmrretl.lagree to comply whhaBtltyaM county ordlnanonud Rate law. PERMIT ISSUANCE FEES PAID:
} N relating to bullding mruuuctlun,ant hereby authehm mpreaentattvn of this
F Z city to enter upon theabove-mentbrcd property fee inspection purposes, ALMA OR ADD TO MT . Date RCCCI t#
— (We).gree to save,bdN
emty am
an d keep hdeas Cu
the City of pertNo p
against liabWtln,pdgmino,coaaaM e.penses whl<h may In uywayaoerue AIR HANDLING UNIT CFO 10,000 CFND SUBTOTAL
agaWt old CNybmnrquen¢ g d granting; thin permit.
9G AIR HANDLING UNTr(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Appbcant/ContrxYor Y Date E)o-lAusr ttooD(w/Duca CONSTRUCTION TAX PAID:
HA]AR DOUS MATERIALS DISCLOSURE
Will the appgontorfuture WBding occupant store or ha le havrdous HFATING UNIT(TO I M,000 BTU) Date Rccc'
material u defined by the Cupertino Munldpel Cede,Chapter 9.17,and the
Health and Safety Code+—Seaton 7S37p)7 HEATING UNIT(OVER 100,"Bm TdV A
❑Yea LJ No
Will the applicantorfuture building occupant use equipment or devicewMarc1 VFNIIIATION FAN(SINGLE RESID) AIi1C ,DATE
which emit"rde air comant.as defined by the Bay Aa Ab So LSSC,Y
Quality Management Dortrkt7 BOILER-COMP DHPOR 100,Q7D BT1n
4hY, F�Nn APR 1 0
ave read the ha:ar�w,mat<rlab requirements under Chapter 6.95 o/ BOILER-Cb.KP(OVER 100.00D BTU) 199[
the California 11-Aolh&Safety Code,Sedlom 75505,To533 and 25SM. I
understand that tithe bWlding does not currently have a brant,that It b my NEW RESIDENTIAL ME(:FL _ SQFr
micas'to mnm,of Ccnif<mpantoripsmy.b<rrcnD wht<n mat be met CITY Uf(;urenI uv
prior to Lwyto n(ay the cats o/tofthe eq l
Owner or authorired agent Date ISSUED BY
:ISJJ
TOT L
OFFICE COPY
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