23574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bu£�Addrv-..u1Win Pro Identlrlutlr �Y PERMIT N23574
me IY
Q�a a,re Q S CITY OF CUPERTINO-BUILDING DIVISION
• vats ,N J k.N« APPLICATION / PERMIT
d 5 BUIIDI ELDCTRICALML INGMECHANICAL
CATEGORY CONTROL
Amhft /Englreen IIc No:
/� QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Add.10,C! (q ILp A142CL t PFRMITISSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby afflnn that 1 am 11censed under prevbfora of Chapter 9(commanc APPLIANCESRE9DEMIAL JOB FSCRfi'ITON
Ingwlm Sml n7000)ofDlvlNm3ofthe BuslnesandProfetams,Codpand
Ikerue h In full for¢and d PAPANELS
Lkenx Cha b.01 L
Date ComraRm UP TO 2DDAMPS
ARCHITECTS DECLARATION WI- 0(X)AMPS
m0 Z I understand my plan shall be used as public remrda OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
06 E Li enact Profesbnl SIGNS ELECTRICAL
6Dl OWNER-BUILDER DECLARATION SPECIAL CB(CUIT/MISC
71.,F�, Iherebyafllrmtlutlamexempt(rmnthe Comra or's Lkanw Lwfmthe
pp (olbwbg num.(Scctim 7m15,Rusinesam Prefeslon Code:My dtyor
($2 ti TEM'.MEM OR POLE INST.
�,� aarntywhkh r,qubes permltto alsor"plonstheaprove,dfortuh orrnht
any atructvn prbrresto ts Issuance,almreti pntuant w the fa,,,lo.of t e POWER DEVICES
O w file a signed mcens eLa that he 11¢roed pursuant it me provhbro of the
E Contnctor'e LicenseI.w(Chapter9(odl).ncing ek umpt 7(100)of aruf
30r^ ebn3ofine Bualnnsand Profmbro Cm,)ormrtM1ehexempttherafromam SWENMINC POOL FI.ECIIi1C VALUATION
ES Se,g the basis,for the alleged exemption. My vloladan of Section 70315 by any,
Ian ti appll¢ntfora F,mdtsubjedsmeappBcanttoadvllperohyofnatnv¢than OULLEISSVITCIIIES�HXTURES
6 ° five hundred dollars C>;500).
'9..' F�l,as owner of the property,or my employee with wages a a their sole NEW RESIDENTIAL ELECTR SQFF, STORIES TYPECONSTRIJCION
6z5�� mmpensation,will do the work and theawRure b intended ended or offered for
..g F0 Le
Le 70K Bushes,and Prvfembro Code.The Comntols Eloe.Law
t.55$ don not apply to an owner of property who bulbs or improve,thereon,and
DD:: whodoesse& orkMm+elforthmugh hlsownempleyees,provided that such OCC.CROl/1' RES UNITS
Imprevenems arenot Intended oroffered forsle.Iflumover,thebuildlogar . TOTAL'
bnprowe mhaoldwhM omyearofcomplet Ntbeowner4 MerwWlove
t"rden a proving that he did not hued or Improve for purpose of axle.). QTY, PLUMBING PERMIT FEE p� mNEE APN
LJ 1,ai ownm of the property,an,e.Iuakvely contracting with licensed
mnwtms
to construct the project(Sm 7004,Business and Professions Code. PERMIT ISSUANCE
The Comnctor.Llrens LAW doe not apply to an owner of property who SLIER DRAIN S VENT-WATER(EA)
bas Bola or improve,theeoa and wins mmram for such p(o)em with a
�yRtTac�or(,)B¢nsed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
DRAINS FLOROOF,ARESANITARY Y— N_�
OUTSIDEFFFS
Ows<r gp�,).0
WORKMAN COMP aNSATION DECLARATION
A,CONTI.
❑I hereby afllnn that I have•¢Muret,of consent to ser( g FDCURES PER TRAP SCHOOL TAX Y N-
-InRECEm
¢MBoeni teofWorkCmnperwllm Insurer.mcertified copy f GAS EA.SYSTEM.1 INCA
Polley
0 CJ PARK FEE Y_ N—
Com a GASF.A.SYSTHN-OVER4(EA) BUILDING
Y � BUILDING DI VISION FEES
CertNed copy is hereby(urnlshed. GREASE/WDUSTRL WASTE INTFRCE1OR PLANCHECK FEE
CedNm ropy h filed with the cttY Iropect Ivhlm.
CERTIFICATE OF EX NFROM WORKERS' C1tFASE TRAP PAID
COMP' ATION INSURANCE SEWEILSANH'ARYSIORM Fl 200T Date Reeol HI
(Tms,ectbn need ns, completed if thepermN hr dred dollen
sm)arlea.3 A:HFATFRW/VENT/E.ECTR ENERGYFEE .Y N
op
I¢rtifymrt bthe pe nron¢of the work for peenNh —
1,IaR ns,employ any pe In any Wer me sub' tom ATER SYSTEM/TREATING
O Work neen'atbn 1. of cabfam D PAID
PP NEWRESIDFNTIALPIMB. SQFT. Date Reoei til
Z Q NOTICE TO AI'1'LICAIYT:U, fter rtaldng CeHf ba
ahmldbeconesub).ttothe deer:Co tlonp o naofthe r TOTAL:
~ N Cade,You must fonhwim romp Mm such pnvvhbro rthfs,Rrrrdr the
LU ] deemed r_led.
W _ CONSTIlI1CT10 LENDINGAGDtCY SEISMIC FEE
BUILDING FEE
11 f] Ih,reby.fili her it on tIm Lemingagency Hepsrforov T ELECTRICFEE
7 Z an¢o/the work for whkh rob pemdr Lesued(Se<.3097,C .CJ
V O 1e"d°�'N"^' PLUMBINGFEE
U. F lender.Add. QTY. MECHANICAL PER IT FEE MECHANICAL FEE
O W Tmnlfythallhavenadthbapplletbnan tette theabovelnformsdm
a hmnot iagry to cmnply ovum sBdtyamm NWnaysnd satelaws PERMIT ISSUANCE FEES PAID:
N misting to Wlding mrolvctlaa and herebysuth.r mpreentatfveafthis
Z city to enter upon theabove-menuored property for Inspection purposes, ALTER OR ADD TO MECH. Date ReCel r#
— (We)agree to rove,Imm
emfy an d keep harmless the City of Cu pertlno
agawt WbWtln,y m,w,caasame whk .y,inanyway.mue AIR HANDLING UNIT ITO 10,010 CFM) SUBTOTAL:
agar IdC ens o(t g this molt.
AIR HANDLING UNIT(OVER IQ=CET) CONSTRUCTION TAX
re ppucant/cont Date D(HAUSTHOOD(W/DDn) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the.ppllcentorfutere bufiding aaapart stare or handle haaardous HEATING UNIT CTO 100,000 STU) Date Receipt
erial as defined by the CuPeMrw Mumnipal Cade,Chapter 9.17,and the
I ealthand Safety Cade Scafm 75537(s)t HEATING UNIT(OVER 100,000 RTI!) IOTA .
Ye No
I theappU..tor lure building occupant useequlpmenr or dovb VPNl1LATON FAN(SINGLE RISID) LSSUANCE DATE
hkh emlr havnlous air mnlambann as defined by the Bay Area Air V I o•
myMarogam,mDistr417 BOILER-COMPOIE'OR1M000BM Y to
Y a r�No
*a have read me ha rimarrweriahrequirementsunderChapter6.95of IOfLER-COMP(ova 100,000JIM }994
rW Calllornla Health k Safety Code,9nibro 25505,75533 and 25536. I
um,ntam Hat lime building does nm currently have stenant,that It b my NEW RESTDFNTIALMECH. SQFT
.panronnymnalfyth ampamaCmenyuk,nnnt,whkM1nustbemct „I INV
prior to Laua oce of a C,Mfkate of Oaupa ncy. CITY Vr VUrr.
Owner or authmiud agent Date
TOTAL ISSUED BY:
OFFICE COPY