21338 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -:— USE BALL POINT PEN ONLY
Ruilcling Preen ldentlfiatim 7 PFRWT NO.
Building Addreia:
Lam• 21338
2 F \ WIti
rcr• am: one:
Z 141 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lie.No: APPLICATION / PERMIT
BUILD:NGELEC7RICALI1l1MBItiGMFGtUMGL CANARY CONTROL/
Ar<hlted/[Uglrcer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. U155 I�IJiVJ�t� AvE PERMITISUANCEDD ❑ {� El 1:1LICENSED CONTRACTOR'S DECLARATION faJ
I hemby affirm that l am llcersei under provblons ofChupter 9(commun APPI]ANCESRESIDENIIAL OB DF'SSRII'rION
Ingwith Senbn7(1W)of Divblm3ofthe Bual andPmfe m Codgandmy It..b In full fora and effe PANELS �j n
Date Comncto
— UP TO 2DO AMPS
ARCHITECTS DECLARATION 291.1000 AMPS
m0 2 I uMentard my phms shag be used u public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA f/SQ.Fr.
WIyCOC
yL(3 Liverued Prdesslonul SIGNS ELECTRICAL)
6 OWNER-BUILDER DECLARATION
Ihereby aflm,that l am exempt from the Contractor's License haw for the 9'E1IA[,CII(CNS4SC
]9 following renin.(SHm 7m15,Busbm and Profmbru Code Any tlty s a
OG1-�� 1 TEMP.MEI'FRO EI J ('
rr, duntywhkh requBeaprrMttocouetvd,aitec improa,demoWh,ornpj
qg anyatruduretateme R.hat he b Ikerequlreesuattothet faalompn
of ll IVWFR DEVICPS ��� .
6 fileCo a signed tletemeLathat he(Chapter llanecd pursuant it the provbbru d" e
O Contractor's l.keroe dProfmto C( e)encingobeh moues )of 'rI Heil n �)
�o tbbasis for
theO-ged Prdmlon. Any violation of
7MI-5 and SIVQ.Q.9NG ELECTRIC VALUATION
65 the basis fort hermit sujeetsthea Anyviolationtolatbn of Section not any l � �S .rc}(pgN
O
applicant fora permit wbjects the applicant too tivll peraltydnn than A - er
It undred dollars%SM. �� NEWft FNTIM,gi , SQ.P I'. STORIES 7YPE CONS[RI1CIlON
]�n I,as owner of the property,or my employee with wages as thelrmle -
�7a rmnpewtlm,wBldothe workand thna crumisrotintended pr�redfor
5 O vie(Sec 7044,Buslrim mrd Ihafml.m Code.The Comradoe.(dame Law
7 j$ dm nut apply to an owner of property who builds or Improves thereon•and , _ ••6b] I OCC-GROUP R6.UNIlS
R whadws &workhimhelforthrwghhlsownemployee,PmvMed that ach
improvemems an not Intended ordlered(a eek.If,however,the Wild Ings l 'J TOTAL
Improwmem bsdd wfthln.neyearofcartiplelbgtht Owner-bullderwlBhaor '
xben or proving that he aid not bund ortmprow fee purposeofsaleJ. QTY. PLUMBING PERMIT FEE
I,as own"`of the property,am ex<wWely�tracting wW IlaruM FLOOD ZONE APN
ntr dos m wretnd the projed(Sec.7014,Business and Iarafmbrm Code: PERMITISSUANCE
IT.Co..'s Llanse Law does nes apply to an ow e.of property who ALTER-DRAIN& WATER(EA)
Wilda or Improve Hereon, and who romnds for such Mietla with a
oral ll.ereed pumrant to the Cmtradoh Liceuue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
jhd I am exempt under Sec B k P C for this reasonOUTSIDFFEES
DRAINS FLOOR,ROOF,AREA,COND.' SANITARY Y— N
Own Dat [�1 e RISERxrI
WOR AN tQOMPENSATION DECLARATION e27_1
❑1 hereby affirm that I have a artikate of cauem to seRdmmn,or a FDnURF_S-PER TRAP SCI OOLTAX Y N—
nlfice
cete of Workrn'Comperoa[Imsu
Insurance a an
a Bied copy thereat Cleo. RTLFRxr h
38W,Lab CJ GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y— N_
PulCam GAS F.A.SYSIEAi-0VER4(E1) RECEIPT If
y BUILDING DIVISION FEES
CrrtBied mpybhereby fumbhed. GREASE/INDUSIAL WASTE INTERCEPTOR
P17NCHECK FEE
Cedlfled copy b filed with the hay Irupedbn division.
CERTIFICATE OF EK( ~TION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM E.A.31mrI. Dale RC i 111
Rw seUlon need rad be completed B the permit b for one hundred dollen
(Tt00emlyth) WATEREEATFRW/v /ELECTR ENERGY FEE Y N-
1¢n t that in performance ofthe pem,Rbbv e
L shah rues cmproiny any personlaws In any,runner m u m besot arb)ect to the WATER SYSTEM/TRFAIING
Worken'Compenntbn laws olGW.rnb. Date PAID '
O = AppBrant NEW RL9OFNMLYLMB. 9QFT. Date Recti tH
Z O NOTICE TO APPLICANT;1l,after mulling this Cerafirste of Exemption,you
should becooe.ub)e to the Workeni Comperoatlon pmvbiu..fine Labor - TOTAL:
CCN Code,you—9fathwfth comply with such provisions.,this pemJt.hallha
W ] deemed T new ant. .
CONSTRUCTION LENDING AGENCY S 1 MIC FEE
CL Ihereby.fRmfo'rwhthem bacomrwdlmd(Sec 097,CNorthe perform~
M Z once ofthew.rk lorwhkhthb permit blmned Sec 309'7,CIv.CJ TOTAL ELEC'T'RIC FEE _ V0
U O Leuder'sName PLUMBING FEE
IL Ledefswdd. QTY. MECHANICAL PERMIT FEE ' MECHANICAL FEE
O W Iceitlfythatl lawmad thb.ppnotlenamd statethatthe above bforrvtlm
bcormd.I,greetocomplywfthalltlty.M.m ty.rdinancenamds td lawa PERMIT ISSUANCE FEES PAID:
(L relating to building rorutructim,and hereby amhorlu representative ofthb
F Z coy,to enter upon the abowtnentbred property for lrup Hon purposes. ALTERORADDTOMFLFL Date RCCCI ff1
— (We)agree to aaw,bdmMm
eudfy an d keep harthe City of Cupertbo
against liabilities,yd8 ma,cods and expenses which may In any way amAIR HANDLING UMI,IT010,000 CPAU
beus SUBTOTAL: _ O
agot dCByb ofthegrantlegdtwpemnN.
a AIR HANDLING UNIT(OVER 10,aooCFh) CONSTRUCTION TAX
o wppu minds Date WIAISI HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllont orfutun building oaapant mon or handle harandous HEATING UMTOO 10D,000 BTUs Date Recel t#
.tor lasdeflnedbythe Cupealm Munidpal Cade,Chapter9.1Zandthe
I leahhaMSsfely egeetlm2S3](a)7 HEATING UNIT(OVER IM"BTU)
Yes No TOTAL: 00
Will the appllont m tune buBding omupmt use equipment or devinv VENTILATION FAN(SINGLE RESM) - ISSUANCE DATE
which colt hazardous air conlambants as deRned by the Buy Area Mr PAIL)
Management trlctT BOILER-COMP OTB'OR 100p(U BTU)
YeaNo
have madthe hares w materWercqulnmcnn under Chaplet Q95 of BOILER-CVMP(OVER 100,000 BI1n
'f n
the CalB.mblle.Ith&S fdy Code,Snfbro5505,7S533and75534.I OCT(1 r" 31 �Qyo
urd". dtF.t Rthebulldingdoenwcvrrentlyhaveatenan4tMtltbary NEW RESIDENTIAL MECH. SQ.FT. Vw
porubBRy to rad Uy the oca am dthe mGulnmems which const be nret
P rior t. uamc da Ce wOcapanry. City Of Cupertino
ih /� enc Date ISSUED BY: City
TOTAL:
OFFICE COPY