22670 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bottling Procet ldemifleation PERMBTNO.
Building Addn,s
�b33o -wU_P� LN__h 22670 .
U -, L-�d 2.]7 20_;Li CITY OF CUPERTINO-BUILDING DIVISION .3O�
c Q�V C Lm.Nn: APPLICATION / PERMIT
l iJw BUILDING-ELEMi A1,ML, BINGW:(A ANICAL CATEGORY COcu� /
' AreAHM/Englrmer: IJc Na: �D b
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERRUTISSUANQ (Q 1:1LICENSED CONTRACTOR'S DECLARATION I/�
Ikreby oQ?0 thatlaml on3o order provbeonedChaortsCoie,and c AI'PLIANCFSRESIDEMIAL )OBD N
Ingwlth5ectb on3ofthe8udnesan feWonuCode,and
Llano Clas�ctyl PANELSUP TO 2DO AJAPS
11,
Date ARCHI,ctorCT` l_
ARCHITES DECLARATION 201-IODOAMPS
cd)Z I uMenbM my pbm,haU k used v pubic reooda OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FI.
SIGNSELECTRICAL \VO e- E D I N
Licensed I'tv(eselonal 1 v
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MW
7Ihercbyaffl.thatlamexemptfrmntheC mit oe.LkenwUwfmthe C
following on.
Yah wing reas (Sectlw 7m15,Bunmm and ProfetsAny or h s Code:Aci � 1 P G
I
F��. muTEMP.METER ORIOLE INST.
� ntywhbh nequboapemdtcoruerucL roaleer,lmprwe,demolish,ormpalr Q'J
anfilystmcture prior to lbbwrce,alsorequlm theappBont(asuch perrtdt to POWER DEVICES I `-7
/ /
xa e a signed statement that k b Bormed pursuant to the provatbns of the
Contranoes LicenseLaw(Chapler9(commeneingwith Section 7000)of Divi- SWIMMING POOL ELECTRIC
O5 sion3 oflhe Business and RofembnsCode)orth,t he b exempt therefromand VALUA71
�5yp+' Sn the hasd for the albged ex,mptbn. Any Wdnbn of Section 70315 by any6 '1 [_Q�r C.)7'prs't appUtforaperm bjMatheappB ttoadvllpcmityof a =mtHn Es� ) `-a
o
Be odred delta.(S500).
I, ers as owmr of the property,or my employwith wages as their sole NEW RESIDENTIAL F.LECTR SQA. STORIES TYPE CONSIItUCIIDN'
6
�7t compensation,wflldoehe wait and the drueeme isnot Intended or offered for
5 O sale(Sec 7014,Busbm,rd Pr fmloro Code:The Conlnctots Karst Law
$ does not apply to an owner d property who builds or Improves thereon,and
,- who dmmehwork hiselfathmugh hleownemployes;provided that such OCC.GROUP RES.UNITS
improvement are not lolended ot.ffered fasale.If,howevep thebulming or TOT
Improwement baold within oneyearofcompleUon,tk owner4milderwBl have
t burden of ping that he did t bufld or Improve for purpose of sale.). QT-y. PLUMBING PERMIT FEE
eerro1,as owner of the Property,am exchuhely contra Ping with Reenact FLOOD 7ONE APN
cmdrarmes to ce m d the project(Sec.7044,Bovines and ab
Pmfiero Code: PERMIT ISSUANCE
The Contractor's License Law dm not apply to an owner of property who
Wilds or Imp.thereon, and who contracts for,ueh pRojcv with • ALTER-DRAW 4 VENC-WATER(EA)
rypI(acta(U lbenad pursuant to the Comrades License L�. FEE SUMMARY
u I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
11.ITII n none
Owner Date DRAW^ FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
•
RFGf]rl's
WORI(MAN COMPENSATION DECLARATION
❑I herebbyy affirm that I have a artlRoh of consent to self-Tore,a, �N�S��TRNP SCHOOLTAX Y N
oertNatem orkerYComperuatlon Inutrance a a certified copy thereof Sec. ass� RECEIPT
IfS
3800,Tab Cd GAEA.SYSTEM-1 INC-4 OUTLET'S fW PARK FEE Y_ N_
RECEIPT a
rco I GAS F.A.SYSEEMOVER 4(EA)
� Co ny BUILDING DIVISION FEES
ertNed ropy b hereby hrrnbhed. CREASE/INDUSLRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy Is filed with the a ty Inspealon division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID 0"IiO Cit (�
COMPENSATION INSURANCE SEWER SANITARY STORM EA 20QT Date
(Ilia section need not becompleted Ifthe permit b fa ane hundred dollars
1f100)ala.) WATER HEATER w/vENr/ELEcrR ENERGY FEE Y N
I anBythat In the perfamrncecf thewmk for.hl&this permit b blued,
1 shall not employ any person m any manner so m to boons,subject to the WATER SYSTEM/TREATING
Waken CanpansatlonL wsofUWomis.Date PAID
Z NOTICE PD APPLICANT:If,after making that Cartlflale of Exemption,you NEWRESIDTNIAL IrLMB. SOFT. Date Repel tk
should become subFct to the Wml,eri Compxmotlon pnevitio.of the Labor TOTAL:
N Code,yw=at forthwith comply with surh provbloro or that permit shallhe
deemed revoked, c
Lu ' CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebya(Orm that there ba mru eion)endingageney forthe p,rfom` ELECTRIC FEE
TOTAL. /�
D Lender's
N.ork forwhichthis permRlot ed(Bee 30Y1,CIv.CJ 0D
(J O eder'•Name PLUMBING FEE
LL l— PeMer,Adare,. Qct.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerify that l have mad ehbappBeatlonand ebte that the above information -
d bmrmt.lagreelocomplywWaUdtyaMd ntyordW andetatelaws PERMIT ISSUANCE FEES PAID:
. red rebting to building corserudion,and hereby authoress mprmentnes ofthb
say to enterupon u�-an�rrcntbried property(a Wpe<bn purposes. ALTER OR ADDTO MECH.
(We) to tax .nn, h,rmlm,the coy of ca,penw Date Recelptu
agaWt Us uitln,ydg ami pman whld,may manywaysovu, AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
agar , tam sty ion o(the ntingdthbpemdt. AIR HANDLING UNIT l0000CFM) CONSTRUCIIONTAX
24, C
red pp8ant//C trot , EXHAlJSTIIOOD(W/DTX-D
CONSTRUCTION TAX PAID:
HAZIA DOU s ATERIALS DISCLOSURE%
WilltheapplloMorfuturebu dingoervpantstoreorhardleharardws HEATING IINTT(TO100,00011M Date Recei tit
material as defined by the Cupertino Munleipal Cole,Chapter 9.12,and the
Ffuhh and Safety Cone Stolon 25532((.)7 HEATING UNIT(OVER IDQODO BTU) TOTAL.
❑ Ye No
Will the appllnrd a nmxboBding.pant use,qulpnent ordevkez VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air comamW nes as defined by the Bay Area Ab -
QualOy Manugemene Mtr[c1T HOMER-COMP(31MOR 100,0(10 BTU) PAI®
1_1Yrs No
I
love aced the haze ws materlsb requlrtm,nb undcrChapler 6.95 of BDILGIR{OMP(OVFR 100,0)0870) r]
- the Ca WombHealthkSafetyCode,Sections25505,25533and25534.1 SEP 2 J 19$1
u Merslardthatlftheb Ddingdaesnoec ntlyl veatenant.thatitbmy NEW RESIDENTIAL MEIN. SQ.FT .
responsibility to notify the ocettpant of the requirements which treat ne met
prior to L,suana d a C,rti(intc olOavparcy.
f�\�Of Culmium
Owner or aueharlred agent Dote TOTAL: ISSUED HIME"
OFFICE COPY —
1