23919 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bwildbg Aednns:na S 23919
O6c(p . r 2�-7 43 CITY OF CUPERTINO-BUILDING DIVISION
centraaN.rl/nq�narYa/ Lle.Nn. APPLICATION / PERMIT I �/
BUfI.DINGO.ECIRICALPLIIMBINGMEC IAMCAL CATFLORY CONTROLX
Architect/Fitglrcer.. Lie.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addnxs PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby af(m„that l am licensed under protworu of Chapter 9(commenc APPLIA14C6RESMEM7AL pB DFSC
RIPTION
n hSecHon7000)of3ofthe Bud s+adPro(eWmaCode,and
1kr.lslnfuBfar¢adeff.LPANELSLicenseCoe n C Dae contractor
1L�'
ctor
ARCHITECTS DECLARATION 201-10D]AMPS
WZ I understand my plans shall be used u publlcrecorda OVER IWC)AMPS SQ.FT.FLOOR AREA $/SQ.FT.
UCO
z(� Licensed Prdnebnl SIGNSELECTRICAL
Q OWNER-BUILDER DECLARATION $IrFf IALCU2CIlIT/Ml,�
1hrreby.fRrrnm
thatIaexempt fmnthe Contrufor'a Lkenm Lwfathe
OZfoliowingreason.(Section7m15,11uslnea and Pmfessium Code:Any eit�r TEV[P.METERORPOLEINST.
rM mrntywhkh requbn.pemdtbcormhuct,alienimprove,demoWRor¢ r
anYMM=mpriortolbbvangalwrequlresthesppbmntfonsuchpemdtb Q POWER DEVICES 5 file a tlgned statement?lase he la Ilcensed pursuant to the provision of the
0. C.ontractore license Lau,
dwn3oft1e Buelnemand Prof®IonCode)ortha he bsaeer tthenefromand SWIMMING POOL ELECTRIC VALUAT]py�
•tt the hvb for the alleged exemption. Any violation v(SMbn 70315 by any V�
p appIleantfora pemdtsubjectatbeapp"ntto.dvilpenhyofnot morethan JDUMETSSWITC�FIATURES
fW�, ..drtdddlan(y50Pf. W�DINIIAIF1'E{IR SQFr.
y�pRt�c TprE CONS[RIK:f)ON
�n u 1,a owner of the property,or my empkyees with wage u their sola "
coerpeaatlm,wtlidothe work and thestruclure la not Intended or offered for
Male Sec 7014,Buebea and Pdoee.Code:The Contractors Lame Lew
fll S don not apply to an owmr of property who W llds ser Improves therms,and OCG GROUT' RES UNITS
33.• whodoessuchworkhmr
ieU orthroagh tJsownerrplgem,provkled that vela
Improvemads are not Intended oroHered forsee.It howevu,thebullding or TO
Improvement leaold whhinonyearofcomplctbM1theownerbullderwBl have
the burden of proving rex he did nM WOd or imprere for purpose of ala.). QTY. PLUMBING PERMIT FEE
L as net of the property,ant excW.Nety mntncting wtth Ilcensed FLODD LONE APN
contractora to mntruct die projeet(See 7014,Buslueu and Profeebn Code: PERMIT I%UANCE
The CoMncars License Lw does rat apply to an owner of property who ALTER-DRAIN&VENT (EA)
Wilda or Improve themor, and'who..nota fon such P�ojem wt
gatfader(s)u¢nud pureuat to the Contractor's License law. BACKFLOW PROT9CT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason
Owner OUTSIDE FEES
Dae DRAINS A,FLOOR.ROOF,AREGOND. SANITARY Y_ N_
ITNWORI011AN COMPENSATIONMTI
DECLAON RECEIPT
❑1 hereby affirm that I hast a certiBate,of consent to ash-Inure,or a F XMRFS PER TRAP t• SCI OOLTAX Y
¢rtBlWeofWorker'Compensuimlnsunn¢uacertl(ledcopytheaof(Bec. - RECOPI's
3800,Lb C) GAS A '� RK Y_ N
Policy GAS Ise. -0VERI(EA)' t -• RELF]IPfI
Y BUILDING DIVISION FEES
Cenllled copy is hereby fumlehee. CREASE/ S[AI.WASTE Ll"NR i^ LAIN, FEE
CertBled copy la filed with the city Inspoetbn diW°ion. - -
CERTIFICATE OF U U,11FTION FROM WORKERS' G TRAP n-- AAI
COMPENSATION INSURANCE BE
ABY_ DaIC RCceT l#
(IM..ectbnneed net bec¢npleted lithe permit b(oromhundroddollan
mW)alesa') WATER EIEATpt W/VENT/ELE=t ENERGY FEE Y N
I certify?last In the pedemnof the work forwNch this pemdtlalasued,
1 soul,.not employ any.Lawn fit In
W . canner o a b become object to the WATER SYSTEM/TREATING
orkotn Compenutbn Lsys of GIB
ornla. Date PAID
O = Appgant NEWR®DFNTIALPLMB. SQFr. Date Rec'ei t#
Z O NOTICE TO APPLICANT:H,a fter making t Ala CertRlate of Exemption,you
N °houId beome aub}•ct to the Worker'Compensationprovlalons oftha tabor
_ Code,you It forthwith� vin m
piy with such prosioor this pedt•halI be
TOTAL-
CC > dnM«
mvoked. '
W G CONSTRUCTION LENDING AGENCY S 1 MIC FEE
S Thereby afBrmttuttherc is.mnstroctlm restingegerry forthepedorr,
ELECTRIC FEE 7 Z arm of the work(car whkh this pcmdt braved C+ec 3097,Civ.CJ
Q O Lender:Nano eand sUtethathe.bovebfomutim PLUMBING FEE r+
LL ~ Lender:Addy® QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertlfythal Hve rtad thbappllntb
O W Iecorted.Iagreetocomplywith.Bdco
ty.nd untyordba
uncesd swa lnelaPERMIT I%UANCE FEES PAID.
�. 4 relating to Wilding orretroetim,and hereby•utheriae representatNn of this
1"' = city to enter upon the abovcmenlbred property for Wpedbn purposes. ALTER OR ADD TO MECH.
V _ (We)agree to save,bdemMfy an d keep haaNee the City of Cupertiro Date RCCCIpO
g.trat Babilltin,Ndgmeno,maa.M expenn whkh may In anyway.. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agabut2a Cfty In of the grarungdWsp t.
nIR HANDLING UNIT(OVER loan cost) CONSTRUCTION TAX
gnum of Applleant/Cmtranor Dat — E LIST IIOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
Will the appheard orfuture building oaupnt store or handle havrdcus HFATING UNIT(TO 100,000 BTU) Date RCCCI t#
outeriel a deBnd by the CupeAim MuNdpal Code,Chapter 9.12, it the
I leallh and Safety Code Section 25532(.)? HEATING UMT(OVER 100,000 BTU) TOT
❑ Yes I M No
Will the;ppllard or future WBdingomrpant use,equipment ordevices VENTILATION FAN RACLE RFSID) ISSUANCE DATE
which emlt hanrdous ab rontamW Ms as deflmN by the Bay Area Air
Iby Management District? BOILER.COMP(3HPOR1W,0(DBTIn P A I D
Yes No
CIO a, re.citheha nous nuterlab rxyulrenenb under Chapter&95 of BOILER-COMP(OVER 100,000 BM
the C.Wvc In He.kh&Safety Cwde,Secibru75505,25513and255M. I JUL _ .s 1992u Meatandthatifthe WBdingdweswtmaentlyh.vL.tenant,thatltbmy NEWRINIMI IALMECH. SQFI 1
mIponsbBRy to notify the oeeupaM of the requlmmeMs whkh mull be met
prierto Lauaneewfa Cetlflaten(oev,paney. CITY Gr Cur
Owneraaulhod>dagent Date
TO ISSUED 1021 '
!
OFFICE COPY