19810 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
/ - Lundin Pru+ee IJmtlfkadmr PERMIT NO.
BwdAdd.:
�� L O(1�E ,� 19 810
vers ame: one:
GeoKC.�E- ocJKG�R 25"2-6$� CITY OF CUPERTINO-BUILDING DIVISION
C.Mrador.Name: Lk.No: APPLICATION/ PERMIT ! l L
�uTilve PL-, l'aq 1) ; BUII.IXNGEI.ECMCA MLTMBINGMECHAMCAL CATEGORY CONTROL
Amhk /Engineer. Ile No:
QTY ELECPRICPERMIT FEE BUILDING PERMITINF0
AldPnre�y 4-A 1 S0ATa6A —Saev e
SAO O' PERh9TISSUANCE
LICENSED CONTRACTOR'S DECLARATION 19 El
Iherebyalflrenthat lamlkmaed uoder prwktlon.of Chaper9(comment APPIIANCESRESIDENML JOB RBTION
ingwith5m n7000)ofal 43o(the Budrmsand PrefessionsCode, deny
limnse la In full fora and effe& 3PANES ¢—
Damj,(-7GomnnnrL�un�rlt7�T.,sYG Y1(a.vUP TO 2DOANIPS •1 Ute. 1V'
ARCHITECTS D CE LARATION 2014000 AMPS
K7 IunderamM myplamshallbeused as publicremda OVER1000AMPS .Fp.FLOOR AREA
Lkcnxd Prdcsehou l SIGNS ELECTRICAL
<<< OWNER-BUILDER DECLARATION
IhembyafBrm that l am exempt from the Conkractora License Law fee the 9'FCIALCEtCNT/MLSC
�gq following reason.(Sedim]m1-5,Business a od Pmfewbru Code:Any city or
cwntywhkhmNqub ape tomrWru Z, r,Impm ,demo h,orrepair r'MEFAOR OSINS.
anysemdumprl«tolbl ame,abompdr ffieappha tf«=&Fwr to
K t3 file•signed statement that he b Itu need punawnt to the provisions of the POWER DEVICES
Du, Contrador'aLkerue Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
F�OQ sbn3afehe Buelndeand Ped®bmCode)orthrt hebe.empttherclmmaod VALUATION
�'•]] the basis(or the alleged exemgbn. Any NdNbn of Bedbn 7(B15 ly any
0� .ppBantfor•prank subjntstha•ppllukt toss dull pemlty dna morcthan OTl11R7SSWITCFIE-FD(711RE
owner
pro NEVRESTDENTLLEECTR SQ}7. STORIES TYPE CONSTRICTION
as owner of the property,or my employed with ended as offered
sole
mmpematlon,will Bothe work,andthe structure b not Intended.r o/feral(or
dole not apply
Bwircw andf property
ropeCode:The or Lrynlora Limnu Taw _
({�g don not
ssuehw 1,owner of(pmxagh his whonemoy.,prnlhercoRand th.t such OCC.CROUP RE.UMTS
C whodoeswork Intendedolf rwferedowne.If,h m,Pmvidedildirg or
improvements arcrotithindedearofco ptoak,If,h.wev.ntheertitlingve TOTAL
Improvamerk bad"within orcyearafcompietbrotFe ownerbu0derwW have
D;preden a proving that be did not villa or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
"1,as owner of the property,am exc'Iuahvely cmtndbg with IImvM
mntrtda to mrutruct the pmjed(Sm 7064,Business and Prefenbm Cade: PERMIT ISSUANCE P.Q{�
The Cormador's License Taw does net apply to an owner of property who ALTFRDRAW 4 VEM-WATER(EA) -
WOda or improves thereon, and who coram for rueh pkajnm with
rnador(a)Ilcensed pursuant to the Contraetm:Lieena,Law, FEE SUMMARY
L�1 am exemp under Sec B k P C for this reason BACK FLAW PROTECT.DEVICE
Pvner DRAINS FIAOR,ROOF,AREA,GOND. SANITARY Y_ N_
Date RFCFRef R
WORKMAN COMPENSATION DECLARATION FDCILRF_S PER TRAPz SCHOOL TAX Y N
❑I hereby of/inn that 1 have a ceMOrate d cement to wB-wort,«a a.�D
cert Lab of Workeri C«npemrtlon Imuranm«a certllbd copy thence pec. RECEIPT s
3800,,LbC.I GAS FA.SYSTEM-1 WG40I17TRI5 PARK FEE Y_ N
Pu0cy s GAFA.SYSTEM-OVER t(FA) RECEIPT i
Co BUILDING DIVISION FEES
mmed copy Ls hereby fuMahed.
Ilo9In CenNed copy b filed with the city impecwn dlvWm. GREASE/WWSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF COZMPFION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR.SANITARYSIORM Eel 211&T Date Recei t#
(This need net be completed if the
permit b fm one hundred dollars
(SI00)«ly that
WATER BEATER W/VENT/E.ECLR ENERGY FEE Y - N
I certify Hut o the peva n in any he work so a to this m subje toed, —
I er), vac employ any Perron d any miner so as to become a.bjea to the WATERSYSIFM/TREATING
W«ken'Compen.ubn lows of Gk(«nb.Date FpJp
O = Applicant NEW REIDIW'RAL PCMB. SOFT'. Date Revel t#
Z O NOTICE TO APPLICANT:IL atter nuking this C.rtif"m of Exemption,you
should nnesubject to the worker:Cemperuatl«s provbbm of the Labor - TOTAL
~ N_ Code,you mut forthwith ovnpiy with such provblom orthb permit shall be
aG
W m
] dera reavkad. FEE
G CONSTRUCTION LENDING AGENCY SEISMICFEE
I hembyafRrmthat there hammbudim lendingagency forthe perform dE
V .� ELECTRIC FE
7 Z ante of the work for which this permit b levan CSrc 3097,CW.CJ TOTAL. 3ELECTRIC EEE Q, D
O fender:Name
ELF Lenaar.Addnga QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifytlutl luvertedthbappllmtbnaM saethattheabovelnformatim
boorr Y.Iagrcetocamplyw h.Uctyardcountyordwnmando.ielaw. PERMIT ISSUANCE FEES PAID-.
} N reletingtobuildingmmtnudiogandterebyauthor mpr uuvdofthIs
F U) city to enter upon the above-mntbrcd property for Inspection purposes. ALTER OR ADD TO MECH. -keep mDate Revel t#
— (We)agree to save,Indemnify.^d ep hadess the City a Cu pert fro
against lbbiltld,Pdgments,costs and etpensn which my In any way aurae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
.eawtIW�d C((yU rth,�'dbg a this pemJt
a(�/ (aim'/_w ;_(_W AIR HANDLING UNIT VVFR IO,000CFM) CONSTRUCTION TAX
Slgoa.m.l Appllant/Contra"., Data FxHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WOltheappllomor tumUding. pentstomorMM[cha rdms HEATING UNIT(TO 10D,W0 BTU) Date Revel t#
material as defined by the Cupertino Munlcip.l Code,Chapter 9.17,and the �s
1 ae❑.lth and Safety Codee Selection 2SS37(a)r HEATING UNIT(OVER 100,000 BILA TOTAL: 0 b
W
Y. applirant hi r1'a cF.RT1s
Illthe ha,ando,a tunendua,ngodefirui by th Bay Area
VENTILATION ItE9D) ISS ATE
N.
whkFeMahagemnt air conbmWinsas deRmd by the Bay Arca AU
Quality Management Do
BOILER-COMP PI-m OR 100,IXD BTIJ)
Yn No
/ 4love ra the ha�nrmerbb mrylrom05,25S and 255M.
of BOILER-COMP(OVER100,000 Blit) rri lty T�7�
the Californiatandtfifth&Safety Cale,Smlom75505,ve a t and 75534.1
redpomandyto lithe WBdl parddoes of the currentlyhavetenant that it batty NEW I(EIDFN'ML MECH. �Ff. ,
rapomlbWty to notify the omvpaa"the requirements which mat be deet City of rTIDP,Fh RO
FLprior to Lxuarceda Bate o! �nry.
Chvnrr.r authortred agent Date
TOTAL ISSUED BY:
OFFICE COPY