20013 (2) APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
__B.lIdI.j Pro" Idemlf"t I PERMITNO.
Building Address: S .JL4 0 V,
Z3 oa p OIJ 2 0 013
s ams: one
p [Y(ZQO� CITY OFCUPERTINO-BUILDING DIVISION
c In m "• /A� /ns /p b."o: APPLICATION/ PERMIT �O
`' • T BI1fi.DINGELBCMCALPLUMBlN MFCIUMCAL CATEGORY CONTROLY
rc /Englroer.
R.— —s QTY ELECTRICPERMFT FEE - BUILDING PERMIT INFO
Address (00q e,S.F PERMITIWUANCE ❑ ❑ .❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
•0lrm that l am licensed under provisions of Chapter 9(mmmnc APPLIANCES-REMENTIAL —{ Ky N
Lloensebgectlnufieganf effea,3ofthe Bunlreva dPmlevlauCode,and PANEJS
Datey�ConYractorLv UP TO 2DOAMpSN
ARCHITECT'S DECLARATION zn.l000Amps 1
N ]undereard myphmehaBbe used as publleremrda OVERI000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
WO
y Lieensd Profesebnal SIGNS ELECTRICAL
thatInn
OWNER-BUILDER DEe Cordon ON SpECLALCIRCUIT MBC N A L E D
Z I,ieAt owinrby afflrmthatla 7MI S,B!Toroth.CoMneadoni¢rax law forth. /
following reason.CxW on 71D15,Bushes and Pro(mloro Code.My city or
O I.ppp TEMP.METER OR POLE MST. M P 1 , E
F� , county m rtgoltea pemdtbmrubuttires thalter, .pU.tfor sueh,ornpalr 'V, U
S
any sroctun pmnnentr to he heissuance,abesedi pursuant to the pmwiom of to POWER DEVICES ,
Q
file•signed ice.La that a b 11¢nsed pursuant it the prodsbns f the
r Contractors License LwlChapbr C( e)onmg with mptb erdmlDid-
3�1 mn3olthe Buelneu and Prdeeebns Cade)orthat hebesempt NeMromard SWIMMING POOL I7ECCRIC
the Web for the alleged nemptke. Any Wdatbn of Section 70315 by any OIJ7i,EISBWI.ICF�SFDCRIRFS ,!
e,pBant for.permit sublets theappB .t to•Wil penalty a(not mom than
° n-�nmarea aall.n D.som.
LJ L,ere owner of the property,or my employee with wagn n their ole NEWRENTALF ECR BET' STORIES TYPE CONSTRUCL00N
C rompenaatlon,will do the work and the structb rot UMed
u re deor offered for '
5' O sale(Sec 70K 1 uelnn•and Proleatbru Code The Contractors License Law
Pj r3'$ does not a pply to an owner of property who builds or improve,thermn,and OCG GAIN RES.UNITS
0.0. who doe,such work hlmaeUmthrough his own employee,provided that such
Improvements art not Intended oroffered foreale.If,however,the building or TOTAL `
improvement bsold wlthinoneyearofcompletbn,theovnerbulic iB have
t burden of pddid rot ng that he dbuild or improve for purpose olsee.). QTY. PLUMBING PERMIT FEE FT.00D7DNE APN
mty
4 as owner of the proper ,am escWslvely mntraeing with Iken•ed
PERMIT ISSUANCErentnctm to ounemel the proect(Sae 7044,Bumm and Professions,Cods:
The Contractors Llmnse Taw doe not apply to an owner of property who AI,IFlt-DRAIN k VEM-WATER(EA)
lou Bd•or Improve thermn, and who mmncte for arch plojem with a
cath tor(a)unrued panus.t to the Contractor's Llorue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I on esempt undn Sec B k,P C for thY neon
QUTS1 DE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
® Owner Date - RECEIPT Y
� { WORKMAN COMPENSATION DEMRATION FD(TURES PER TRW' SCHCOLTAK Y_ N_
..CC--{{nyli�hereby aBlrm that 1 Wve•aerdf{ate of consent to opyt ern,O • RECEIPT Y
=0,Les
so(Workeni CwnpewNm��innwnnnaeoacertBfed mpytherrof 6ec. CAS FA.SYSTEM.1 ING4 OUTLETS PARKFEE Y N
33881olleyY / DI W RFiFF1PTa
GAS EA.SYSTEM-OVER 4 CFI)
Ce y („( Le f BUILDING DI VISIO\FEES
CertTed ropy b hereby furnished. / GREASE/IN)USIRL WASTE EJTERCEFTOR PLANCHECK FEE
�y�eaNed ropy billed with lW Cltylmpectlon division.T CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEFAH10T
INER-SANITARYSTORMDate Ret:cI t#
Rhes..Rion r�eM no be completed B the SURA b(m ore hundrN dollen
(5100)nlene') WA]lR I-IFarFx w/veer/FI,I�rR ENERGY FEE Y N_
Ioentifytheb theperforsanaofthewmkforwMchtMa Peen bowed,
1.ha11 not ernploy'any person b any manner ao ere to become object to the WATER SYSTEM/TREATINGWorker'Coonpenaelon Lawsof Callfamb.Data PAID
OZ Appllant NEW RESIDENTIAL PLMB. 9017. Date Recei t#
Z O NOTICE TO APPLICANT:If,after rrobng this Certificate of Esemptbn,you
should become wbj ct to the Woruenw
'Competkn provisns ioof the Labor TOTAL:
CC N Code,you nustforlhwith comply with such provisions or this permit shall b,
deemed revoked. LDING FEE
OW CONSTRICTION LENDING AGENCY EISMIC FEE
CL IhenbyafRrm thatthenba mnsumWonterdlogagerryfortheperform
TOTAL: ELECTRIC FEE
� Z once of the workfor whkhthb pamdt slaved(See 3097,CIv.CJ
O O IeMerb Name PLUMBING FEE
U. Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O
O W Ina lfythat l have mad this appllatbn and state the the above Information
is l agree to comply wfth all city and county ordinunm and elate lawn FfR_MTT ISSUANCE - FEF9 PAID:
Nnladng to building mM1strotlTan,and hereby auNorlu repreaentebms of this _
f. Z 'dty to enter upon the aber nnentbned property for lnsb
pectn purpoan. ALTER OR ADD TO MECR
V a (We) bgrreee,to ser coif an a harmlm the City of Cupenirm Date Recd t#
ger I yin anywaymve AIRHANDUNG UNIT(TO I0,000CFM)- SUBTOTAL-
agabwaald sequerrx a mingeft emdL
! AIRHANDLING uNrr(OVER 10,000CF1D CONSFRUCIIONTAX
Sig ,w Appgant/Conn err Date EXHAUST HOOD(W/DLC'D. CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBont o/utum but3ding oenrpantstore or hands harardvu, HFATINGUMf(TOIX,0)0BTU) Date Recti [#
rrolerlal as defined by the Cupertino Murat dpal Code,Chapter 9.17,and the .n
i Le.lth YeM Safety Cad oi 25
L572(.)7 - HEATING UNIT(OVER 100,000 BM TOTAL: d
❑ e
WBlths.ppllo tun building oaupant use equlprnent ov devices VENTILATION FAN(SINGLE RF9D) ISSUANCE DATE
which emit hanrdaus rentambunts u defined bythe Bay Area ATr
•
Quality Management District? BOILER-ODMP OM'OR 100,000 BTU) !c
❑ Y. M I Wvumislithe h ouymater,Sb l u 25505, underC 25534..95 of BOIL-ER-COMP rovpt 100,000611n., _ JUL 3�
the GlBonblieahh safety Code.Sections 5505,SSV and 25536. 1 l99
uMmbrd that Bdingd ndyW atevnt that ltbmy NEW RESIDENTIAL MECH. SQFI' v
�ponuibilityt the. he m.which mu at be met Cfh/ r
prim to aCertl o pa 1. ( q�
O(vneror authmlred agent Dib ISSUED BY:J`a /ISI V-a(��R.F-��.f
TDTnL:
OFFICE COPY