21664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALLPOINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION Z7—� /
n (pJ APPLICATION / PERMIT _ l
r " • BUMDINGELECR()CAI PLUMBMGMFLtUMCAL CATEGORY CONTROL#
ArehRen/Engineer. Lie Na
QTY ELECTRICPERMFT FEE BUILDING PERMIT INFO
Add. I'Q(h9TI55UANCE El ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that l am llcenaed under prwesiora of Chapter 9(cortmen APPLIANCES-RESIDENTIAL JOB
Ingwlth Secdon70m) fDtvisim3ofthe Bukl aro PL�/pfe(a��puCode,and
liaerex t In fu fen.
/3
7 ! 5 PANELS
LI¢nx lam b# {{--
Dale Cc.Nranor
CHITECPS DECLARATION 1-1 AMPS
Ore Z I urdemard my p no,shallbe used u public itud OVER 1000 SQ.FT.FLOOR AREA S/SQ.FT.
O SIGNS
Licensed Prolembnal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
Z t.., Ihercbyaffi.that l am exempt from the Conlranor's Lioeue Lawf¢the
lolbwirig reason.(shim 7m15,Bu.in®ard Ihefmbu Code:My Rey or
U I"' munry which nquireapermNtomrarmn.+lten improve,demo0sh,or repair TFMP.METQt OR RJST.
4vl Q anystrunurep.brtolbbsuaneCat requb theapphantfmsuehpe to D.w
P." U Bk a signed statement that he b licensed pursuant to the provhbm of the
3 r`rn Craradar'e License Law(Chapter 9(mmnrt.eing with Section7000)of DTvl- Cpgl
rekj& slon3afthe Businemand ProfabvCWd )orthehebeaemptthertrromard
Eljp" the Gsb for the alleged oemplbn. Any violation of Section 7MI5 by any
< appll¢nt for a permR subnb land jthe applt to a dvil penalty Rea moat than F1XTl1R6
w Me hundred dollars MM. NEW E� Fr EC R
j? ❑I,u owner of the property,or my employees with wage as thcb wk STORIES TYPE CONSTRUCTION
C < mmpensabm,wBldothe work+ndtheetmmarc boat Wended or offeredfor
S ❑ vk sec 70K Buslrseu and Profembm Code:Tie CoNranoYs G¢me Law
does not apply to an owner of property who builds orimprovnlhaeon,and
OCC.GROUI' RES UMTS
whodo¢suchwork hlmReBorthrough hbownemploj ear,provided that such
Tmpmvement art not intended oroffered fm uk.If,however,the building or TOTAL
Improv m mi "dwhhboneyvarofcompletb theowner-WMer MliWve
t rdenofpmvingthathadid rotbu(Idorlmproverorpurpouotule.). QTY, PLUMBING PE IT FEEFLOOD ZDNE APN
LJ L as sorter of the property,am e.cluaivey oantracdng with Ibmsed
mntactaa to rovtrun the proka(Sec 7066,Buslnm.rd Profembra Code: PERMIT I59JANCE
The Cord d.r'a Lid.Law does not apply to an owner d property who ,��-DRAIN&VERA-WATER(EA)
hu0ds or Jorproves thereon, and who marana for..eh p(o}eav with . FEE SUMMARY
�fanor(s)I^"«s puntant to the Cmtnnor'a Llcenm law. BACK FLOW PROTECT.DEVICE
LJ I am eaemPl order Sec. B &P C for thio mason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
. Owner Dale RFLEEef#
WORKMAN COMPENSATION DECUBATION FIX.IVRFS PER IAAIa SCHOOL TAX Y Er
❑1 Tea affirm that I have•¢itlflab of cmmN b uhf-bsuRe,da RF�IT s
¢rtlflabd o peryxI lnsunn¢m• ified the GAS F.A.51STEM-I WG4 OUTLETS PARKFEE Y N
3800,lab C /l/G• RECEIPT g
Pollry# GAS EA.SYSTEM-OVER 4(EA)
Com Rey a BUILDING DIVISION FEES
❑CertNed mpybhereby fumWM / (� GREASE/INDUSDtL WASTE IlTORCEPTOR PLANCHECK FEE
❑CertiRed ropy b filed with the cat n I
CERTIFIGTE OF EXEM"ION FROM WOR KERS CREASETRAP PAID
COMPENSATIONINSURANC6 gEWEI(-gANppARYSIORM FA N(B,'I. Date RCCCI l#
(Th1..enbn need nn be e¢npined Rthe pemdt b fm onehundred dollar
aIm)mlem) WATER HEATER W/VERA/TLC{:"IR ENERGYFEE Y N
lmdifytM1 btheperfomen¢oftheworkforwhlchlhbpemds1.baued,
I slu0 not empty any peram b any manner n u to become subjen le the
Work Cmnpenartbn lawn of Califamb.Dale WATER SYSEM/TRFATING PAID
Appliant
Z 0 NOTICETO APPLICANT:11,ager rvk1ng 11W CMRialed Evempbn,you NEW RESEDENTIAL PLMB' 9QFr. Date Recei to
F- N ahould herons mbjed to the wodmn•Compematbn provbbne ofthe Labor TOTAL:
Code,you forthdr
with mpy with such provisions orthbm
pedt shall be_ BUILDING FEE
Wyou n > deerred revoked.
CONSTRUCTION LENDING ACETO- SEISMIC FEL
CL C Ihertby a(Onn tluttkrt bamratmnlm krdmgagency for the perrarrn .Ay. ELECTRIC FEE
7 Z anddthewoh for whkhthb permit ttsued see 3097, N.C.)
U 0 Lender.Name PLUMBING FEE
LL F Lender:Aaaro. QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
O W Icertlfythatl have read thio appllatbnand 9atethat theabwe WamuHm
bmf .I agree to amply with all cdyand muntyordlnandsand state laws PERMIT ISSUANCE FEES PAID:
} S A.g. bfflties,
ISpon the above-mentioned property!¢imp wr,par rpm.. At=OR ADD TO MFCII.
to vve,buiemNfyand keeplarrn1 mtheCitya!Cupertino Date Rmei tp
judg msband pe. iehmaymanyway a AIRHANDIdNGUNTTCTOl0,000CRA) SUBTOTAL:
lytmn dtbe `�gtldlo
AIRHANDLIN'GUNIT(OVER11La00CM CONSTRUCTION TAX
Sigrutumof Appliant/Cmt m Dauf EiIHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI E
WWthe appllaa or futumbulldlmgXEF.&EnT7om orputrufle hazardous HEATINC UNIT(TO Im,000 STU) if Date Recei Iq
rmterlalaadellned by the Cupertino MuN pter9.17,andthe
Heahh and safely code i25532(p)7 F♦<ATWGIJMT(OVFR 10,000 BTI]) TOTAL:
qYea Non o
l the appllantm building occupant um equlpnem or devices VENTILATION PAN(SINGLE RESTD) ISSI.(f��DATE
whkh emit hoard salr ambmivas u defirN by the gay Arca Air D r�
• Q.Afty MawgemeN 7 BOILER-COMF DIET,OR 100AM BTU)
❑ Ya D��-+Qt No q (�
I have read the hank.materlab requirement under Chapter&95 of BOILER-COMP(OVER 1m,000 BT1n MAR /� O 19$1
A. a1111;h1hft.ild
hSafety Code,Sectbrw 25505,25533 and 75530. I
ln oey Rea*�Uwh
t That it b my NEW RE9DENIIAI.MECFi. SQF7.
Ret oflmust fret (a ,s�rtl f ofOwnerm aulM1 lid agentat FlUTAL 3fA ISSUEDBY:!=AL
V I/
OFFICE COPY