23794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification - PkRWTNO.
Banding Adds: 23794_
r• amu cora
CITY OF CUPERTINO-BUILDING DIVISION
Cmuractm'e Name: // � Ten Na APPLICATION /PERMIT
� f0
O)FIA VC II-w /ak0'\T BUILDING-ELECIUCAI- UIMBING-MECHANICAL CATEGORY C
A hect/Engineer. Lb, ICW
' a d-�1J�9. C y
Rca39 S AHC /�'Gr1 j�IPj S7Z 1 QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A - PFRAffCISS(lANCE
-LICENSED CONTRAtroRTIDECIARATION I LF lie A
I hereby affirm that l am Bcentud under proionro of Chapter 9(crmmenc APPLIANCESRESEDENSDAL ]oB IDESC
ImfaWm
Mth5edbn90(D)uf Divktlm3oftheguslnmand PsCode,and my 6F r.)w L
I :bin fullfo and effect PANELS �r
V Lteruc Class_ Lle.I
Dater GOrdndUP TO WDAMRS
ARCHf1ECD 1-1000 AMPS
x P OVER t(DO AMPS FI. O ARIiV.
Ir zQ7. ]uMertlard mypWvahallbeuaed aspubllcrtmda I `SQ. F L''Tfl it 3/SQ.FT
Licensed PrAeolorol SIGNS ELECTRICAL ^/
t ILT� OWNER-BUILDER DECLARATION SPE)CIALCIRCNT/M19C pi,
I hen by afflnnthat l am exempt from the Contractor.License Law for the
7.9 folbwing rtawn 0iectlm 9015,Butlner and Pro(®bro Code:My dty«
I�iiS� muntywh"m'qul aper towwmMalter,Improve,de=likormpalr P.MEIFROR
a nyetacturtprbrtolt.b me,aL requimtheappUa tf«wchpermit to 1'OWFRD CFS
I O 0. file a tlgned rLtement thvt W b Ilceved ptnuant to the proWbv of ,he
YY..rr Contractor's Lkeve Law(Chapter9(comrendng with Sectlon 7000)of Dvi
sbn3ofthe BuNnes.wd ProfembroCWe)orWthebewempttherefrom. ,POOL ELECTRIC VALUATION �_
E1�n......^777]7] the b.
the the.paged esemptbn. My violation of Section 7m15 bj ^ �-2j-1`
apPRcantfor a permit srbjetsthe applicant to a civil penalty Ante moretW SWIM�FIXTIIRIS La
E Eve hundred deltas(5900).
❑I,as ower of the property,or my ampby.with wag.a their sok NEW RESIDENTIAL ELECTR _ STORIES TY MN SIRUCnOK
t mmperoatlon,willdo the wort,and the Yaetem h not Wended or offered for
5' O sok 6ec 70Ef,Bualn�and Pmfembv Crede:The Cr7o"does Wcerx Taw
I$3$ doesnmt.pply to an owner A property who The
or Improv.the.,and OCG GROUP RIS UNITS
whodoanuchworkhlmseB« m
thrurgh hisowneployeey provided that such
Impmvementa are net intended oroffered f«agile.If,however,the building or
impmcamant la"within ovyearofcompletbn,theowner-buWerwlll have
t"Aien of proving that he did rot build or irnprove for purpose ofuk.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
it LI L as Owner of the property,am erchulvdy contracting with licr d pp(Mn.L4UANCE
mntrat«.to moa ruct the project(Sec professions Buslneae and prru Code:
The Contractor'.Llceve Law doeo,nor apply to an owner A property who ALTIIf-DRAIN&VENT-WATER(FA)
Wlids r Improv wm thereon, and who ooafer such pwJem with a FEE SUMMARY
�p1(actor(s)Iloensed pumawt m the Cmtnd«i License Law.
I LJ I am eumpt order Sec B&P C for this renin BACK FLAW PROTECT.DEVICE —
Owner Dee DRAINS. ROOF,AREA, SANITARY Y_ N
WORICMAN COMPENSATION DECLARATION RECFLeE
[31 hereby affirm that I have a certificate of..t to s<If-Wore,«• FD(TURES-PER TRAP SCI IOOLTAX Y N
certificate of Women'CompenvHm Insurance«a mrtNM copy thereof isec. RECEPT I
3800,L bC.) GAS-EA.SYSTEM-(ING4 OUTLETS PARK FEE Y_ N_
Policy I GAS EA.SYSFEM-OVER 4(EA) RE=a
Cy BUILDING DIVISION FEES
ertNed copy b hereby furtdshed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHEC E
J �CerlNed copy is flied with the city lvpeebn Aivision. jf
' CERTIFICATE OF EifEMPTION FROM WORKERS' GREASE TRAP P {W
COMPENSATION INSURANCE SEWED-SANITARYEA-70�T to RCOC t# W
(f ort tion neN nn becompleted Bthe permN 6f«ane hundred down
(S1 W)certify
WATMI-[EATMW/VENT/ELECTR E FEE
I genet cop In the penacm en o/the w«k so as to b,co permit c Issued, Ar
1.h.B not employ any person b any manner at as to bacon:sublet to the WATTR SYSIEM/TRFATING
Worlicant mpewtion Taws of California.Date PAID _
'. 0 Z Applicant - NEW RESIDENTIAL PLMB. SQFI'. Date COLI t#
i' Z O NOulCEcemAAPPLICANT:stote after madompenhat Ctice,p wisons often,you
should bemes subjecttothe ply with
it'Comprovisanprwbbvofthetabor OTAL-
EI—CC Ul Code,yomvo. .mhwth mnplywtha hpro ebro or this R^^ shat lbe
I W � d«cocci rewkM. 1^R
CLCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflnnthat then h a covtmchm Lending agency for the perform ELECTRIC FEE
M Z RAM of the work!or which this permit is boated(S,- 3097,Cl,C) ^
00 Lender.Nan. PLUMBING FEE L.
W I— lenderaaddretts MECHANICAL PERMIT FEE MECHAMCAL FEE
O W I ren Vy that l Wve mad thio application arad state that the above NfomWiAn \
It. ionium(.Ilgm to c«nply withaB dtylnd county ordWnm and tlate law. PERMIT 6SUANCE FEES PAID.
relating to building avtnsctlon,and hemby.uUmoce rtmu off this
H Z coy to enterup.A the above-.mloned property fee Wpwien purposes. ALTER OR ADDTO MESH. Date RecCi t#
(We)agree to save,Indemnify an d keep harMe.the City of Ce P.Aiw P
V ego Wt BabWtie,)udgnvne,cmeand eapero.which may In anywayamue AIRI NIXJNG UNIT(I010,=CFM) SUBTOTAL:
ag.WtBald City In Mn ocf...of tie granting A this perm R.
AIR HANDLING UNIT(OVER I0,0D)CFM) CONSTRUCTION TAX Z '
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DI)CE C NNSTRU
HAZARDOUS LO
AZARUS MATERIALS DISCSURE �
Will theappllcant«future building ocryraHFA
pant eon or handle haA:Im. TINGUNTT(f0100,00)BTU) Date - RCCCI #
material as defined by tis Cupertlno Munlclpal Cade,Chapter 9.1 7,and the
Heahh and Safety Cod 1.7S537b)7 HEATING UNIT(OVER 100,000 BTU) T
Rill
—I Y. 11Q No
flemIt applicant tvot Wilding onvpant use the BRyerea Air VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emllharardotaab,ariet? MnaNeas defined by the Bay Area AU
. Qu Ilty Management dd7 _ BOILER-COMP pFQ'OR 100,000 BTU)
4Y. No
have naHealt materlatinquiremenbundcand2553r495of O FR-mMPOVERIOO,OODB A A I D
the California Health&SaI Code,SMbro 85@",8573 and 7:534.1 p1
understand that lithe building d notartently have a tenant,that It b my NEW RESIDENTIAL MECH. SQFT.
reepovlbfltly to notify the rat of the rtqu nuns which must be met 'JUN 2
P a ICertlfl eof ray
rat a r[
ISSUEDB
OFFICE COPY