19754 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building 4ect ldentlflcatl PERMIT NO.
B°'07 vies: 19754
ante: one: - A
�l)T RO �(77 E5 CITY OF CUPERTINO-BUILDING DIVISION
' u,�-�B/�i�G APPLICATION I PERMIT �'--2-�jo
. BUrLDING ELBCMCALPLUMBINGMFGHANICAl CATEGORY . I CONTROL,if
e{ L No
p /f�VC.. QR
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A / wS PERMITISSUANCE ❑ ❑ ❑
LICENSED CO ACTORS DECLARATION
I hereby affirm that l am Ikecaed under provblosu of Ctupter 9(commene APPLIANCES-RFSIDENTTAL OB DESCRIPTION
Ingwilh Section 70W)of Dbd.ion3ofthe Buairessand Pmfesetatu Code,and my
Ikat binc7�drmucto5a PANELS
n.¢. �co mann
ARCEIITE 201-1000 AMPS
2 I urdentand my plana ehaR h used as public remrda OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
Iyy[O[
Limmied Prof®loyal SIGN`'EI-ECTRICAL
�Q OWNER-BUILDER DECLARATIONgtpCIALCDtCU1•I./h95C'
Z1.., Ihemloyafimothm lam exempt from the Camramorb License law for the -
following mason.03action 70315,Hub...d PmI.kn.Cade:Any aty or
��� muntywhlchrequU apem Wmv Malter,Impmry demolLsh,ormpar TEMP.METFRO LE
,,,,�� anyatadu¢prlortolbbsuame,aLiom-qu ffieapplluntrmsuchpem to POWER DEVICES
0 fU a signed a [anent that he b B¢rued pursuant to the pmViscm of the
O Contractorb Uceroe Law(Clupler 9(mmmenang with Section 7000of Divi- SWIM NG C
sbn3ofthe Bualnruand Prdessbro Cade)orNd he6ese Nert(mmard VALUATION
~ < tFe Mala for the alleged esemptlon. Any violai of Section 70315 by any
OU"ET"
eppnant fora pcmdl vobjects the a pplicant to a ana am
vll PC" of not o¢tFan
E 0vMhondrcd dollars WM. NEW RES7D AL ELEC7R SQFr. STORIES � TYPE C7ONMUCTION
�n I,as owner of the property,or my employees with wages u thio axle
` O msamnum4wBldotewkndthestuctebmWorofemdfor
k=7But,=and
Profe,%om Code:The Contractor.Lime Law
don applymano mrofpmpertywhobWWsorlmpmuethermn,and
�'$" who doaeuchworkhMeBarthrough hbvwnemployen,pmvWMlhat ouch OCC.GROUP RES.UNITS
Mpmvemenu am not Intended oroffered for sale.IL however,thebuilding or TOTAL
Improvement h"wRMn oneyearofcomplelbn,the owner-builderwill have
tlW,krrdeo of pmving that he did not bund or lmprne for purpoae of sale.). QTY. PLUMBING PERMIT FEE
U I,as owner of the property,am eachuHely contra-mg with Ikmrd F1,001)ZDNE APN
contractors to cororu
td the project(Sec.7044,Businm.rd Profeasbro Code: PERMIT BSUANCE (-3 oa
Tae Comnnor's L3¢ne Lw dm not apply to an owner of property who ALTER-DRAIN VENT-WATER(FA) I L
bullds or irmprowa Neon, and who contracts for ouch p(ojrcts with a FEE SUMMARY '
cQntfactor(a)ucenmd pursuant to the Commaors License Law. BACK FLOW PROTFGT.DEVICE
u 1 am exempt under Sec B k P C for this reason (
Owner Date
DRAINS FLOOR ROOF,ARCA,COND. Ib ao SANITARY Y_ N_
• RLCFRrI'R
WORKMAN COMPENSATION DECLARATION FlX'NRES PER TRAP SCHOOL TAX Y_ N_
0
1 teff orfkm that I have• l rtcone of cmmnt to self-Insum,us a RFGms1•a
mrtirioteofWorkers ComperaaHonlrounn¢era¢rtiffcd mpytherto((Sec.
3Wm,LbC) GAS EA.SYSTEM-1 CNG40U
PARKFER N
Cllry IF .SYSTEM-OVER t(EA) R➢ II
yvo
BUILDING OI VISION FEES
rtRiedmpybhrrebyfumkshed. GREASC/1NDU5DU-WA5IEINTFRCET1OR PLANGHECK FEE
CertBled ropy b filed with the aty Iropea3on dlvlalon.
CERTIR(ZATEOFIXEMPEIONMOMWORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SKIVER-SANfTARY-SIORMEA 2011ET Date Recei t#
(ITleeectbn need not h MSATed B the SURA[b fusorc hundred dollars
mammleaa'> WATER EffATERWfVENT/EILCTR ENERGYFEE Y N
I¢rtBy thrt Uthe perbrman¢of the wvk(orwMch WepenNl la issued,
I shall not employ any person In any manner so as to become subject to the WATERSYS IN/TREATING
Workeri Comtpematbn Laws of California. Dane PAID
ZZ Applicant NEW RESIDENTIAL PLMIk 9Q17T. Date Reee1 tM
O NOTICE TO APPWCANT:R,after making this Certificate .1 you of aeptio
should become wb)ect to the Workers'Compensation provhioro of the Labor TOTAL:
W Code,you mrst forthwith comply with ouch pcmd,daro or thio permit shall be
lL > dmnW revoked.
BUILDING FEE
cONSTRI/C DON LENDING AGENCY SEISMIC FEE
oto I hereby affirnNat there Is a construction leMing agency for the perform ELECTRIC FEE
:) Z anceof the work for which this pomdt b bvied(5ec.3097,Civ.C.) TOTAL
OO lender"Name PLUMBING FEE
LL ~ t<nder.Add. QTY. MECHANICAL PERMIT FEE MECHANICALFE•E
O W Icertify Nat l have read this appllatbn and etatethatthe above information
iamrrect.IagreetocanplywlthaBckyandmuntyordimnmsandgatelaws PERMIT ISSUANCE FEES PAID:
} relating to Wilding corwroalon,aM hereby authorlu reprernuthv afthb
F cGy to enter upon abvacr¢mbrcd property for Wprctbn purpoe. ALTERORADDTOMEGH.
Z
(We)agree to.eve,Indemnify an d keep hamrd.the City of Cupertino Date Recei tit
O .&nat lkbwtles,judgmew,metsand evpenrs which mayln anywayaccrue AIR HANDLING UNIT(T010,000CPM) SUBTOTAL:
agalrot said City in conmquen¢of the granting of this pemna.
AIR HANDLING UNIT(OVER 10,000 CEN) CONSTRUCTION TAX
Signature of Applicant/Contractus Date D03AUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WOl the appllantor tutu building oavpantst morhardleha cans HFATINGUNIT(TO1W,000BTU) Date Revel 1M
materialsdeRrcdbyz pertlno UMPAICode,Chapter 9.12,and the
I kahh and Safely Code ion 25532(a)7 HFATING UNIT(OVER IW,000 BTU; '�L,
❑Yes No
WRllheappBantm tvrebuildingoavpanturequlpmemusdmiom VENRIATION FAN(SINGLE RFSGy' I$$' 'ATE
which emit hazard it umbonla u defined by the Bay Arta Ale
• QualnyManagcmemDmNo BORER-MMPOFB'OR1W.0(UBM rG� x ;11990
l Yes alSyd
love¢ad Neh r oue rtaterlab rUquirements under Chapter 6.95 of B0R-ER-comp(OVDt1W,000 RRL)
the California Health k Safety Cade,Seabru 75505,25533 and 25534. I //�s
urdentaM[teal i(thebulldingdmrotamentlyhave aterunt,that lthmy NEW RESIDENTIAL W-CH. SQF7. COX !If rtIpewl
rieporoibnfty to notify the occupant of the requ rrcm ntz which maul h mat „-
prior[ an �Cy\tLB��/y of panty. � �////(yf�� /� �,� �{-q�R�\�Y
���ioriaed.gem T ]late ISSUED BY�w �tom-'w'�`"'`71_
TOTAL
OFFICE COPY