22507 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Proort Identification PFRMH'NO.
Bu i" � 22507
b CITY OF CUPERTINO-BUILDING DIVISION
Contnuor'. an,<. Lk.N. APPLICATION / PERMIT —:2_'?—'?
BUNNNGEL&:fRICALPLUMBINGMECHANICAL CATEGORY CONTROL I/ /
`� A Bee neer. 'a Ip O
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
-- Addreu - d E -Wee PEFMTISSUANCE .
LICENSEDCO ACTOR'S CLARATI
IherebyaHbmthelam uoderp nmof Chaptnti(mmmenc APPUANCESRE [DFMIAL JOB UI5 IITION
uBwlth Sectba7000)d Divldm ofth.BuaIws rad Pnafeal.Code,.d
Ikerbe b In s fLorce and dfrsi PANES
licj I�d
ense ChaILY
Date CEc ar,Rm UP TO 200 AMPS
ARCHITECTS DECLARATION 291-IM AMPSq]'
µqqµ!!0ZQ,Q ]uwentawmy pant eluBbe usedvpubllcm
rcda 00 AMPS R S/SQ.FT.
6e�rj Licensed PmfembmSIGNSE
l � SGNSELECTRICAL
GG OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M
[hereby affinmthatl•meaemptfror ,,Contractor's License Law fee the
7p � following reason.(Section 7ml S,Buen®a w Pmfewlom Code:My dry or
F y Flmaruc, TEMP.ME[TR OR MOLE INST.
county, cl, amp toiU emd ,,,also aqui alter, orrtpdr
fOe.rmtlnre tamme t he he i,alaoraed pn uuum t the for inions of t1io POWER DEVICES
Ile,signed statement the k h IkenaM pursuant to the Provisions of the
3e Contractor.Lkense Law(Chapter 9(mendn
mmg with Section 7000)of DIW-
tija aion3ofthe Bu,lneamd Profmkm Code)orthe heb exempttherefmm,rd SWIMMING POOL ELECTRIC VALUATION
OO
Liar beat,,for the alleged exemption. Any vldebn of Section 70315 by any p(7(T,E.ISSNI.ICI,I6Fl%7.URPS 1 L
O applicant for a permX,ubjea4 the applicant to a dad"penahy,d net moretlun
$ IiNJ,asumdrtu er of ( An. NEW RESIDENTIAL ELDCTR
�n u 1,u owner of the Property,or my empbyeea with wage u their sok SQ'F7' STORIES TYPE CONSIItI1CTNJN
t compen,,eion,willdothewerk camnot
dthestruare isimendedor offend for
'$ O sok0$ec7ON,Buennasew Prefeae.Code The Contractors Umne law
�$$ don rwtapply to to owner of property who bul)ds or lmprovn thereon,and OCC GROUP RES IINUB
whodoavuchwork hlnueBcethwga hl.ownemploym,pnavded that such
improvements am nm tntmded oroffered fo uk.i(however,thebuildiag m 'NTA
improvement hold within or,eyearofcomplellon,theowner-bullderwW have
thX,kurdrn of pmvingtaat he did not wild or Improve for purpose of sale). QTY. PLUMBING PERMIT FEE Lj
L as ownof the property,am ehnlvely mntracHng with Ikeraed FLOOD ONE APN
owner- xo
oantractors to commuct the (Sm 70K Burn®and Profeaiom Code: PEtM1TISSUANCE
P odo
The a or lop Lioe�sse Lw dm not aPPN to an owner d property who ALTER-DRAIN 4 VENT-WATER(EA)
w4da or lorymvn Hereon, and who mmr,m for ouch p(ojMs with a
�ll,ctm(a)1lcennedµ,nusnt to theeontnaw:Llanse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
cU 1 am eumpl under Sm B t P C for thh rtawn
Owner Due DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N=
WOR"AN COMPENFIXTRESER TRAP SATION DECLARATION RECEIPTY
❑I hereby afn the I have a rtlilcaconsent te of ct to self-Inwre,ora ® Cd ODl TAX Y N
Mre
certificate of Workeri mmr CwnpeatiImurance ma cannifkd copy thc.smed(Ss �Y
3800,Loh C) GAS EA.SYSTEM-1 WC41 OUTLETS PARK FE Y_ N_
Pulley Y RECEIPT Y
GAS EA.SYSTEM-OVER 4(EA)
Co�myny BUILDING DIVISION FF.LS
I cczffled ropy b hembyth the dd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
SL�J CerlBicd ropy b f11M with the tlty ImpecHon dlvlelan.
CERTIFICATE OF G(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEW FR SANRARY SNRM FA ]OOFT Date Recti t#
(rhh uRlen need not be completed lithe permit b forone hundred dollars
(5lfa)«les.) ENERGY FEE Y N
m
I mmfythat in the perfoem of the work forwhkh this permit b bWATER HEATER W/VENT/E.CGIRused, �T
1 ah,B not employ my pennon m any manner ro u to brome subjed to the WATCR SYSIT7M/TRFA7INC
Worker; mb
Compensation Uwa of CAlfo .Date PAID .
icart
Z Z NOT[ETO APPLICANT.If,after making this CertRicateof Evemprion,you NEW RESIDENTIAL['LMB. SQ.FT. Date Recei t#
O should become subject to the Worlm'Comperuekan prerviabm of the Labor TOTAL:
~ N Code,you moot forthwith romply with such provisional or Udo pemdt shall be
CC5; deemed revoked.
BUILDING FEE __1[L74
UC CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. I hereby affirm that then b a comtmodan lending agency for the perform, X ELECTRIC FEE a� _
Z ance of the work for which thb permit b L000d 5m 3097,CN.C.) IOTA C.V
U O "ewer: me PLUMBING FEE a�
LL F Ie tall dnss QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OL) Icedi el haverewthbappBcatbnand eatethattheabovebrfomutioa
1 hrorr,n. ,gree roc lywhh aB cttyaw countyordlnummd rate laws PERMIT ISSUANCE Miles FEES PAID
} relating to Iding rutllm,snd hereby suthodu represenntNn o(thh
F y dty to eat upon vs-mentioned Property for Wpectbn purpaen. ALTERORADDTOMECH.
? (We)a ton , emalfy an d keep harmlea tit,CRy of Cupmrt s Date Receipt#
V ,g. u b t ,'td rd,,,....dexpen, which m.yU way mu AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL-
[ In er�ce of the m d apemdt
AIR HANDLING unTr(OVER 14000CFM) CONSTRUCTION TAX
Sigmte o A Bcan on pat EIU IAUST HOOD M'/DUC`D CONSTRUCTION TAX PAID:
HA OOUSMATERIALSD"SCLOSU
WW p mor mrewddingooupaotuore or lealanclotat HEATING UNIT(TO 100,ODO BTU) Date Recef t#
mueriala en cd by the Cupertino Municipal Code,Cha ,r 9.12,and the I-EATWCl1MT(OVER IOO,IXD arca) TOTAL:
Health enuSat Cade Secti.25531h)7
n4�Yn No
W ill the ape mm w mbuildingoccvpantuwequlprrentmdeAi VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
watch rout hazardeu s air contaminants as defined by the Bay Area Ab ��
qYhhmgement D❑fatrkt7 BOR.FRCOMP OI-0'OR 100,0(10 BTU) Q
4twand No
Tuve read theF van rruteriab raqulmmenb under Chapter 6.95 of BOr1 Fu-COMP(OVl7i1W,OfA BIlJ)
the California Health k Safety Code,Sectiom 75505,25533 and 25534.1 )'�C✓ B �
uwerNawthat"(the wilding don turremly notpu nhave ne.t.which
rustle mot NEW RESIDENTIAL N.El71. SOFT I
inpomibilfty,to notify the oavpant d the rrqulmmenb whtrh mars"be met /k{
prior toL..race da Crrtiflcate of Oavpancy. R
Owner or autheri'rTOTAL:
ed agent Date ISSUED BY:
OFFICE COPY