20555 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Project ldenti(cad PERMIT NO.
Building
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APPLICATINV�=I AL DA IL
` 1 nl�V t•{ CITY OF CUPERTINO-BUILDING DNISION
Co tr ...NN`;; Uc.N. APPLICATION / PERMIT �f
BUILDINGELECTWCALML INC-MECHANICAL CATEGORY CONTROL d
Architect/Engineer: Ur,No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddresK PERMITISSUANCE ❑ ❑ ItZ. ❑
LICENSED CONTRACTOR'S DECLARATION bT
withhereby n7ODO)tlamliceruedheB provbloaef L]umaCoe,r dr API'LIANCESRESIDENITAL J08 DFSCRI'DON
Ingwlth5ectbn7000)ofDWidon3ofth<Budneuandl'mfestlonaCode,and
,V LS:-ylimn.b In full f�d effen. PANES
Linen.Caes Lk.p
CnlDate_6 Tna6
an eC anica 1 LU 1 L 1 f
ARCHILRCPS DECLARATION MI- MPS
r,OZ !understand nm
yplaeha0beused aspubemN
crea OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FI.
O
Z
�j Lbensed PNembrul SIGNS ELECTRICAL
6 OWNER BNLOU DECLARATION
SPECIALCIRCUTT/MEIC
71.., Thereby a(flrm slut lam eaamptfromthe Covr,ctors Llceve Lwfo the
C foliewing reason.(Section Business;,Busineand Profemlov Code.My city or
5� TEMP.MEIIA ORIOLE INSI'.
F
5 county which requlrnapermit toconslruct,dter,lmpmv<,demolish,ormpdr
a[Jp any Mructvrt ptorto lb leuarce,also requW the appe.ntfmsuch permitto POWER DEVICES
Cp C. file a signed statement that he b licensed pursuant to the provisions of the
3 r` Contneor's Lkerue lAw(Cl pts 9(mmmentl g w h SeNon 7000)of Divi- SWEdMING POOL ELECTRIC
OJ abn3o(the Buslneu and Prdmio.Code)mthet he le esmptthertlromard VALUATION
•7 the basis for the alleged exemption. Any violation of Section 901S by any
0 eppeont bra permit subjects theapplicast to a civil penalty d not more than OUTIETSSNTTCHESFD(TURFS
$ flv hundred ddlus(f50O). NEW RESIDENTIAL ELEC[R SQ}T. STORIES TYPE CONSTRUCTION
1,as owner of the property,or my employees with wages u their sole
mmPeoMLIw,w8ldoim work andthe datum Is not Intended or offered for
Osale(Sec-7014,Badness and Profmluns Code The Contractols Wove law
$ doss not apply to an owner of property who builds or Improves thereon,and
c-'s^ who does such work himself or through his own employee.,Provided that such OCCGROUP RES.UNITS
lmprovements art net intended oroffered fm uLe.lI however,thewllding m TOTAL
lmpr ce mbwWw hlnorcyearofcomple Wl theownerb MerwWlove
tl�rdencfpmv1ngthahedld rot wild orlmprove fee purposeof sale.). QTY. PLUMBING PERMIT FEE
LI L.owner of the prop ,am eselvWely mntracting with 11mosed ,FLO
ertyOD/ONE AM
contractor,to oumnrt the pm)et(Sm 7044,Budnes.aod Profesdov Code: PFRMTTISSUANCE
The Contractors License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
wilds or improv.thereon, and who contvcts for such En jcv wkh
onapaeturW Breneed pursuant to the Comms Lleense Law. FEE SUMMARY
U I am rxempt under Sec B k P C for this rescan BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
r� Owner - Date RECFIPIa
WORKMAN COMPWSATLON DECLARATION FDCIURESPFRTRAP SQTODL TAX Y_ N
®L hereby affirmorken that I Fria •mtlflate of covert to copy
thereof
o e. Rf EPT E
m01),Laeo(Worker,'Compevadm lwnncemamNfled copy thermft5ee GAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y N
Policy
Iib CJ
PdkyEPT•
Com an cns EA.svSTEtovER4(FA)
.�p y_TiTaD 5.911 TPS- o BUILDING DIVISION FEES
I XI CertWel copy b hereby hammed. GRPASE/INDUSIRLWASMINTFRCErroR PLANCHECK FEE
eL�Ji CcnNed ropy is filed with the dty imps tion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION fft INSURANCE SEWER-SANITARYSIORM EA.70Qrf Date Reoei tlf
RWe.(tion need not ed completed U the SpermitURA b for one hundred dollars
(5130)mld.) wATERITEATERW/VE'Nf/ELECTR ENERGYFEE Y N_
I mtdylhat b the petorrtun¢of the wvk forwhlN this permR b issued,
I dub not empty any per,m In any manner at u to become objet to the
Wm4un'Compensatbn Lawn of GlifonbWATER SYSTEM/TREATING. Date - PAID
-
z
Z ApplicantNEWRESIDENTIAL PLMB. SQFI. Date Recei t7f
Z Q NOTICE TO APPH
LICANT; ,a Ree maks ng this Certificate of Exemption,you _
N .hold become subFct to the Warkers'Compevatbn provbbv of the Lbor TOTAL:
du at forthwith mm ply with such provisions orthb perms Wil be
ed. QUILDING FEE
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a mnsimction leMing agency for the perform
TOTAL ELECTRIC FEE
Z anmet'sNaoek forwhkhthbpermitbbeaed(See 30Y7,CW.CJ112c
O O bender's Name PLUMBING FEE
F• Ierderb Address QTY. MECHANICAL PERMiT FEE MECHANICALFEE
O W Inset.I.Stl tooroplywappllcitbnardataty ordlheabovedstat�foion laws
bcoingtolagreetomento,wkh all hereby
muntyordlnanroand state lease I'QLMI'I'ISSUANCE FEE$PAID:
y w citytoetobulWbgmv uClon.aMhertby.uNoi epre.ntaRvno s
FZ cll(W)aree to sae,Indemnify
d property Wpe Cit pfCoper AL77R ORADDTOMLCFI.
(We)agree ro�H,lndemdfy an d keep mode.the eery of cupeMlro Date Recei tN
I..T agaiM llabWtles,PdgmerN,coaxed expe�a whidt may In any wayamue AIR HANDLING UNIT'CTO 10,003 CFM) SUBTOTAL:
against Wd Chy In®usque tees of the Starting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
atumof Appear/Co,tracer Date EXHAUST HOOD(ns/DUCT) CONSTRUCTION TAX PAID:
fIAlAR OUSMATERIALSDISCLOSURE
Weltheappllant orfutureweding occupant Mort orhaedle havrdous HEATING UMTOD 100,000BM Date R3cei IN
matetal as dcOred by the Cupertivr M.Ndpal Code,Chapter 9.12,and the
Ik,tIbam Safety Coe Setion75537Od? HEATING UNTI(OVER 100,000 RF(n TOTAL: Z
WYes
MNo
III thespplfammNotre bulldingoavpaolu.equiponmt erdevim VENTILATION FAN(SINGLE RESID) R991 `-F
YOD- DATE
which emit mraMous air runlamW ds a deflrud by the Bay Area Air
L-7'V �+ -
. Qr lity Management 199U
District? BOILFROOMPOHPORIOO,O(IOBM .
4yes
h.wreadthehavrd.m ate riabrequirementaunderChapterG95of No OLER-COMProvFRiW,OD BM JUN X. 6
the Califomb fiedlh k SafetyCode,Sections 755ES,75533 and 75534. I
understand that if the wilding does rot currently have a tenant,that it b my NEWRES.'DENIALMECH. SQFI ^^�
responsibility to notify the oreupant of the requirements whleh mrd met et OW Wa„w
pdorto ®uanceofaCcdifk teol Occ panty.
G ;2 — LU j
r rGvuero authorlud agent Date �
TOTAL: ISSUED BY.
OFFICE COPY