20481 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL PUIN t r
building Probit Identification PERNRT NO.
Building Add.: O ) 14 _/� - 20481
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neve uce: Q ` one: A A
-751_O/� CITY OF CUPERTINO-BUILDING DIVISION
Canna N. : ll C Lu.No: APPLICATION /PERMIT
BU=NGELECTWCALPLUMBINGMECHANICAL CATEGORYCONTROL#
• Architect/Engiruer. Lk.N. _ _ -
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ELEC• - kit'TRIGPERMIT;:y'- ,, FEE, BUILDING PERMIT INFO.1DL
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Aeern>
❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE >� ❑ D
I hereby
af(lent that lmon Bcmaed under provblona ofCiwpwr9 feurnmeni, APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
(nmems'.ectlon affect
ftheBuYisaand PmfnNoiCode,and my
Lfxmeleinmil forJ�ane c.#_' PANELS �+
Da Class�-LCo # �✓'l ti 1 5
Date �D CoMnnar /a t 4 4'
ARCHITECPSDECLARA ON X11-1000 AMPS
_%O I understand my plana a hall be used as public records. OVERIOWAMPS SQ.Ff.FLOOR AREA S/SQ.Ff.
E Licensed Professional SIGNS ELECTRICAL
OWNER•BUILDER DECLARATION SPECIALCIRCNT/MSC
Ihercbya(flm that 7 am exempt I.the Contractors License Lw for the
F.,
following won.(Section 70315,Business and Pro(mbru Code:Any city or TEMP.METER OR POLE INST.
county mrequbesapertN alsorequimthconstruct,altar,4npmve,demo ch,orrepalr
any at signed
he i,alaortqupgthant to the lmauchps,mite pOWQ(DEVICES
file•algid statement But he t r licensed pursuant to the proWlom of the
�qy go.3.f the Business
Law(Gupttt9(commentlng eisi enion70W)of Divi- SWIMMING POOL C
smn3oftheBuatnnaand Professions Any or3utheb exempt thertfromany VALUAUQI�
2 the Mab fm the allegedjceitheexemption. My violatlmn of Section 73t15 vee any OUTLEISSWITCHES& /eye Q OO
applicant lora permX.ubjemthe appBanttoa tlWl peMltyof nn more than �J✓
`R2 filBLIrundred dollars($500). NEW REsm EL _SQFr. STORIES TYPE CONSTRUCTION
5.- LjL as owner of the property,or my employees with wages as their sole
compeistice,will doth ma"rd the structure It not Wended or offered for
E C p ssle(Sec 706/,Bwti�eas and Pmfmmm Cade The CoNractoh LImme Lw
5 don not apply to an owner of pmperry who build,or impmvn thereon,and OCC.GROUP RES.UNIlS
who doemuchweek hmuellorthrough hlsown employees,provided that such
impmvemetw art not intended orolfered for sale.14 however,thebullding or
improvement is sold withineiyearo(conpletion,the avner-bullderwW have
thuJiudee of Imving that he aid not build or Improve fee purpose of mile.). Q'fy, s;, _ UM PE ',FEE., FLOOD TONE APN
0 L as owns,of the property,am erclush ely contracting with Licensed PERMIT. AN
conmtlms m mmlroct We project Oce 7096,Bim®and Profesalom Code:
AN
TheCorms e*Limnos Lw don nn apply to an owner of property who
builds or improve thereon,and who contra!m such pkajects with a ALTFR.p W - n-
clailectes(J licensed pursuant m the Cmdnnoes License Law. BACK FLOW PR .DENT ". FEESUMMARV, -
LJ I am exempt under Bee B&P C for this won
Owns, Dm DRAINS ROOF,AREA,COND. SANITARY RECEBrI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
�I hereby aBlrm that I have a mMfkats o!content to mlf.ffiwm ora I7%TURFS'PER TRAP RECEIPT#
nnNot>"Worke_n'Com ruaHan lnsuranm m a nnBk.•d copy thereof LSce CAS EA.SYSfFM-11NC60UILElTi PARK FEE Y N
Polic3KOy
# CJ 9 f�'1--,.. �1� RFLEPI#
Pdky/ _/ OO _/ GAS EA.SYS1Tld-0OVER
Comm+nv - A. BUILDING DIVISION FEES
�CertlR Ecopy hereby-fu ed' CREASE/1lVDUSCRL WASTE INTERCEPTOR PLANCHECK FEE
C3 CerlNed copy b Mail with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREAM TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.MOFL Date Recei t#
(Me section need nn be completed B the permit It for one hundred dollars
(5100)mlo3 WATER HEATER W/VENT/E,ECIR ENERGYFEE Y_ N_
1 certify that in the performance of the work for which this permit b blued,
1 shag me employ any person in any runner n as to become subject to the WATER SYS[EM/TREATING
Workers'Compevatbn laws of California.Data PAID
) Z Applicant NEW RESIDENTIAL PLMB._SQFr. Date Receipt
O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you
should become subject to the Workers'Compematicn provblom of the Labor TOTAL:
N Code,you mut forthwith cmplywlth much pmvizioe or thbpermlt still be BUILDING FEE
dermsed reroked.� � CONSTRUCTION LENDING AGENCY SEISMIC FEE
L G l hembyamrmthat there It a comtrunlon lending agency for the perform TOTAL: ELECTRIC FEE
) Z ance ofthe work forwhlcb this permit b Issued(Sm 3097,Civ.C.7
) O Lender,New � PLUMBING FEE
I— Lender.Add w QTY. .:-:MECHANICAL,PERMIT.. '. _ FEE` MECHANICAL FEE
U I mrtaythat l haveread thisapplicationand statethatthe abominformat(on
IL bconect.l agree to complywith all city and county ordinances and state laws PFRMIILSSUANCE FEES PAID:
1 relating to building construction,and hereby authorize repreaenbtives of this
N city to enter upon the mbove-mmtloned property for Inspectionpts ALTERORADDTOMECH.
- Z (We)agree to wve,bdemNfy an d keep harmless the City of ped W Date Rece7 t#
ag.met liabilities,judgments,costs ndexpenssa whi ylna amus AIR HANDLING UNIT DO 10,ODO CFM) SUBTOTAL:
ago uta city• nseque of rating 1 rode CONSTRUCTION TAX
/> AIR HANDLING UNIT(OVER I O,fDO CFM)
:gi reo(AppRunt/Contncto to EXFIAUST HOOD(w/OLIGO CONSTRUCTION TAX PAID:
HA2ARDOUSMATERIA DISC OSURE
WBlthcappBantwfumrebullaing. ants orhandlehazardaus HEATINCUMT(TO100,000B1U) Date ReCel t#
material as defined bythe CupcAmoMurudpU26deChaper9.IZ and the
fleehh and SafetyCods Section 75531(,)? HEATING UNIT(OVER 10D,000 BTI) TOTAL:
❑Yes MN.
WOltheappliesntofumnbuildingocmpantu.eequlpmentordevi. VENTILATION FAN(SINGLE RESID) IS` DATE
which emit harardous ab contamW nt&as defined by the Bay Arca Air
Qua lity Mai gement District? BOILER-COMP PHP OR 1040(3 BT()
• Yn ❑T'INo i Qv O n,9
hive read the Fawou
ds materials requirements under Chapter 6.95 of BOILER-COMP(OVER 700,000 BTU) - ! 1 �g
theCalifrmh Health&Safety Code,Sections 75505,25533 and 15539.1 N,�y RESIDENTIAL MECFL SQFr
understand that lithe building does notcormntly have a tenant,that it is my /a Dips"
s --
resporum0itytonotify the occupant of the requirements which must be met Lijh! pf IiJ_IIIps aMt!
prior to issuance of a Certificate of Occupancy.
Owner or authodrad agent Dau ISSUED
TOTAL:
OFFICE COPY
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