22052 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Foaled Id..6fication 1'k7LwT NO.
Building Address:
L10730 ✓ t(_Q-' 22052
ane:
r.nLE7r-
PL) 7 CITYOFCUPERTINaBUILDING DIVISION ,
cantnttar.N.me: ua.No, APPLICATION /PERMIT
WP �JB L-�r-/ltf_k, / 7Sf BUfIDINGELECCRICALPLUMBINGMECHAMCAL CATEGORY CONTROL♦
Architect/Engineer. y Lb.No:
� ,l^ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addree7/Y - �(/ (_ /J'�'C / PERMITISSUANCE �l.raT/ ❑ ❑
LKENSEDCONTRACTOR'S DECLARATION
I hereby aflrmthat lam Bceued under provhlonsofChapter9(ounmenc APPEIANCFSRESEDF.NTIAL JOBDESCRIPTION
ImgwithSection70)0)of Divblon3ofthe Butd.and Pr ,fess!.Code,and my
Ikrnse aIn B r¢ ddfect �(C 5 �f PANELS
ARCHITECTS DECLARATION AMT'S
Q7 ]underetard my Fix.ahall beud u moods, FRFT
public mds. OVI(DOAMPS SQ. .FLOOR AREA $/SQ.FI'.
OC
Licensed Profewbnal SIGNS ELECTRICAL N A L E D
OWNER-BUILDER DECLARATION SPECULCLTCUIT/MISS p�■-,/w,
I hereby affirm thatI am exempt from the Contractor'.Licerae Law for the P U TE
qw folbwmg mason.(Bectlo�7015,Bu.inea and Profe>ebra Code My ctty or
7
TEMP.MITER OR POLE INST.
.uy ty khpry t.lape ,.I mrvp a er,lmpmve,demow p mpdr 1�/�/
Me amuctum pdstatement that
he is lasomgd punuant to the fawtam of It a POWER DEVICES � /
Me a signed Leel.Lacwt he b,9(orm purnram to the ovbbm of the
gQQw Con3ofth.Lkerae l.w(Chapmr Code)ort ng whitSection mp"heWm Dlvl- VA A
ebn3oflhe Basins.and Pro]mbuCwe)orthat hebeumpteherefromaw SWQdh9NG POOL ELECTRIC -
^� the bub for the alleged exemption. Any violation of Sohn 70315 by.ny �/ �[p D
a ppUwtforapermltmb�%Uthcappl anttoadMIPerohy afnUmmt Mn �7 OUTLETSSNITCFIGSFl%Tl1RE5 7a:�
Evehundredd lian(X+00/.
F1 1,as owner of the property,or me y employewith wage as their sale NEW RESIDENTIAL EI,LT.TR SQJ.T. STORIES TYPENNSTRUCTION
mmperwtbn,willdothewok,andth<rtructum is rot Intended or offered for
IFYF O axle C.70K Buatraa and Po ferbv Cade:The Contractor.L oe.IA. •J ire -
��$ doe notapply to u owner of property who build.or improves thereon,and OCC.GRDUP RES.UNITS
who donsuchworkh4naelf orthrough hbownemployms,provided thatuch /v
improvements aro not Intended oruffernl fo,ale.If,however,thebuliding or TOTAL:
improvement bsold within.nrycarofconple ian,the owner-bullderwlB have
Lben of proving that he dm not bulla or improve for purpose ofule.). QTY, PLUMBING PERMIT FEE
I,as owner of the property,am exclusively contracting whh ilrx cad FLOOD ZONE APN
.h.t.to mrdtroct the project(So.7014,Btulnmaw Prdeabro Code: PERMIT ISSUANCE
The Contractor's Li¢n,e Law don not apply to an owner of property who ALTER-DRAIN&VEM-WATER ffA)
build; or Impious thereon, and wlm pv nh contracts for such t,ojew . - FEE SUMMARY
cW4 dor(.)homsrd pursuant to the Contndoe,Lluerae Law. BACK PLOW PROTECT.DEVICE
U I am exempt under Sec B&P C for this mann
OUTSIDE FE99
• Owner Data DRAINS FTAOR ROOF.ARRA, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RFS:[IIT s
❑i hereby M.that I have•¢rtiBnm of aaueot to.elf-Inure,o a FDGIIJRES PER TRAP SCI100L TAX Y N_
¢ni0¢teofWarken Camperuet on Imuran¢¢a¢nlfied copy thereof(See. R_ s
3800,Lab CJ �+�t GAS EA.SYSITM-1 WC40I177.EI5' - PARK FEE Y_ N_
7'diry♦ PC / 1 �6.5�3 -
RECEIPT M
GAS FA.SYSTFA4-0VFR 4(FA)
Cam ray J !�A BUILDING DIVISION FEES
ertlfbd mpybhereby fumlahed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
cedWed ropy b rBed wile the try wpedbn alwdan. .
CERTIFlCATE OF UWPEION FROM WORKERS GREASE TRAP PAID
CSATIONINSURANCE
UTla.ectbn need n0 be completed tithe blorone hundred dolbn SEWER-SANITARY-STORM EA.20OFT. Date Recel t#
-
(slEo)eleaa.i WATER ITEATFR w/vENr/PI.F-cTR ENERGY FEE Y_ N
I¢rtlfy that In the performan¢of the w¢k forwhlch tMa permtt le bg,ed,
l ah H not employ•ray perem N any manner w u to become object io the WATFl(SYSIFM/TREATING
Wokera'Ccroper,atlonl.w'aof California. Dam _ PAID
PP NEW RESLDENILIL PLMB. SQFp.
A uent
Z p NOTICE TO APPLICANT If,after making this Centl/bte of Eu ion,you Date Revel L#
.hould become anbj•ct to the Wotken'Compewbon ptovbiov of the Labor TOTAL:
N Cade,you covet fudlo th cvmplywlth such provblom orchis perout doll be
JMLDING FEE
W > dermad revoked.
a O CONSTRUCTION LENDING AGENCY SEISMIC FE
Ihemhyaff] Datthenb•cammWonlendlogagencyforthepedomm ELECTRIC FEE
Z ante of the work for whkhthb pemdtbbg,ed bee3W7,CW.CJ TOTAL-
(.) 0
OTAL(.) O Lender.Name PLUMBING FEE
LL F fewer,Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢glfythat l have mad this application and gatethatthe above lnformrtton
d bcortect.lagooto comply with all dry and county ordmancea and gate laws PERMITISS :
UANCE FEES PAID
N Mating tobuilding corutruction,and hembyauthomempc,antative.ofthb
F U) city to enter upon the above-mantio i property fee Iropectbn purpo.es. ALTERORADDTOMFCH. D2IC ReCCI t#
(Wey agree to•ave,tndemntly and keep harmlm the City of Cupertino
fJ bWtle,}idgmera,, andex wh mayin yaotxue A1RFIANDUNGUNrr(IOI0,000CFN1) SUBTOTAL:
agairst dCRym the n gof IL -t AIR HANDLING UNIT(OVER 10000 CFM) CONSTRUCTION TAX
SI roof AppB¢nt/Codrad¢ Date'! D(HAISTHOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL DISCLOSURE
WBlthe.ppIk,W or future building oaapant.mm or handle haeamlous HF.ITBJGUNR(TO1((1,0D0BIV) Date Raei t#
material a•ciefincd by ham Cupertlw Murddpal Codc,Chapter 9.1Z and the
Heahh and Safcty Code Section 75532007 HEATING UNIT(OVER IW,=BTU) TOTAL:
❑
Y. n No
WWthe applkant or(uturt building occvpantum equlpmrnt adevim VENTILATION FAN(SINGLE REQ) ISO
which emit hararciou,air contaMmnm a defined by the Bay Area AU
Quality Management Dvurltt7 BOILE=R-NMP OFB'OR 100,0M BTU)
4 Y. c toy
have mad the naw out numrbb mqulremenb under Chapter 6.95 of BORERNMP roVpt 100,000 BILI
the California Fleahh&Safety Code,Sections 2550.5,Z 13 and 25530. 1
understand that if the building does rut currently have a tenant,that It boy NEW RESIDENTIAL MECIT. SQFT.
rnponubility to notify the nceupant of the roquhoments which must be met
prior to issuance a.CertlfIxam of Occupancy. tl1�Y W
Owner¢authoriad agent Date I%UEDBY: "
TOTAL
OFFICE COPY