22671APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
ownn Pm Identlfletlon
Building Add tw:
l
PERMIT W.
22671
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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BUILDING-ELDC RICALPLUMBINC-MFLHAMCAL
CATEGORYCON7Sp(M.I'/`
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/- gineee IY. Nu
QTY ELECTRIC PERMIT FEE
.BUILDING PERMIT INFO
Address
IaFRM1T15ST1ANCE
Lm CONTRACTOR'S DECLARATION
that I s
Ikreoybo 70thatl t .3.fhe ptwaotudChapter 9 (mmmm
luamseh t hill7000)ot delffect the Buslnesand ProleslonaCedeandrnY
license bin /uB � and ]fee.
LI¢ Las Lb.a Yb�-s�i
APPIlANC610E5mEM7AL
JOB TN'
PTO P I
PANELS
e Camnaor
UPT02DOAMPS-
-1000 AMPS
ARCHITECTS DECLARATION
IuMeewMerry phren ehaBk used epublfe record•
-
OVER 1000 AMPS
Fr.
S/SQ.FT.
LI¢raed Professional
� �SQ. �FLOOR
'aAylft.F�A1
1'L 5J LJ—J
\3a
SIGNS ELECTRICAL
OWNER-BULDER DECLARATION
I hereby affirm that I am exempt !menthe Co rraetors License Law fee the
SPECIALCI iCUrr/MISC
TEMP. METER OR POLE INST.
following reason. iSmBon 76715, Buslno and Prolesbns Code: Mytltyor
many which require a permit tocomment, alter, Improve, demolish orrepalr
anystroavre prior to Ib lemmrce,abo maprbnthe app8ant for sucM1 pemm to
file a signed statement that he Is licensed purauant to the provisions of the
POW me DEVICES
SWIMMING POOL ELECTRICsion3
Contrsaor's lJcease Law (CI pt. 9(mmmmeleg wHh Sxiaon 7000) of Divi-
of the Bu Moen and Prdeskma Cade) orthat he b axernpt therdromsrd
the bash for the alleged exemption. My Igla ar, of Secloo 70315 by any
app8ontforapemdt.bjectatheapplf ttoadullpeskydndmomthan
VALUATION
�-J
OUTLEISSWITCHFSFLCfURFS
NEW REZDFNDAL Fr S= SQ.FT.
five hundred dollars ($W.
F1 1, as owner of the property, or my employees with wag.. their sole
STORIES
TYPE CON' RUCTION
mmpero a lon,wW do the wok, and the'r{ucum b not bderded or offered for
vale 6ec. 70K Buslmia and Pmfmbn Code The Contnaote U.. Law
does tot apply loan owner of property a l'b builds or lmpmms themoa and
whodoessuchwork himxBorthtwgh hbowtri
neployee ch , provided that su
improvements are wt intended mothered fcesale. If, however, thebullding or
Improvement back] wlthinoneyearofcompletbathe wvner-bullderw have
OCG GROUP
RES UNITS
t Nen of proving that he did rot build or improve for purpose of sale.L
I, . owner of the property, am excluatvely ortomting with lleenid
motmaons to mnsteua the proyet(SK 70K Busbesard Proferbru Cade
QTY. PLUMBING PERMIT FEE
PERMIT 66UANCE �•
FLOOD ZONE
APN
Ther Contmcori Limnse Law doe not appy to an owner of property who
Wilds, or Improves themem, ud who contracts for such P" with a
licensed pursuant o the Centimeters Limese Law.
LJ I am exempt urder Sec B k P C for this reason
off,
ALTFRDRAIN&VENT- WATER 0'.0
FEE SUMMARY
BACK FLOW PROTECT DEVICE
DRAINS FLUOR ROOF, AREA, COND. -
SANITARY Y_ N_
RECEIPT 0
Owner Date
IIIIIIIIAL WORKMANCOMPENSATIONDECIARATION
10�by affirm that I have a nkifhh of consent to self-osues, ¢ a
_ d Werk.
e' Compensstlm Insurance ora oenif ed ropy thereof (Seem
3000: Lab C.I
Fp(NgES- PER TRAP
S040OLTAX Y_ N_
RECEIPT .
GAS F.A. SYSI}M-I INCA OUTLETS
PARK FER Y_ N_ .
Pams
CAS PA. SYSTT]d-0VER4(EA)
Y
BUILDIINGD VISION FEES
Cenined ropy b fled withay to eity
Ihd ropy bfikd with the dy inspection division.
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(TMaaectbn need nor k compla.ed Btk permit b for one M1undred dollars
GREASE/INDUSIRL WASTE INTERCEPTOR
PQLAN2CH�ECK FEE
//`` L
PAID \p�O^
Date Recd t# 0
G1tE l4.7AAI'
SEWER -SANITARY -STORM FA 20gT
WATFRHFATERW/VINF/ELECTR
ENERGY FEE Y_ N
(SlfaOatu.)
I certify that b the perfoman¢ of the work farwNch tMa pemdt b issued,
I shalf not ampby any penton b any manner su 4 b become subject to the
Wmker Compensation haws of OWenau. Date
WATER SYSTEM/TREATING
/ e�
PAID G 4
Applicant
NOTICE TO APPLICANT: IL after making this Ceniliate of Exemption, you
should bemma subject to the Workem'Compenutbn pmvbbnsof the Labor
Date Recel t#
NEW RESIDENTIAL PCMB. SQ.FT.
TOTAL:
Code,younusfoethwk campywithsuchpmvbomorthbpermitshallbe
deemed revoked.
B GS—, -9:5
SEISMIC
CONSTRUCTION LENDING AGENCY
I herrbyaffirmthat them is a mnsUoalon lending agency for the perfortm
ante of the work for which this permit b issued (Sec. 3097, CW. C.)
TOTA
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING EE
Ierdcle Name
ddrees
1 mitlfythdI have mad thbappliatbnand mtethat the shove lnfomatlm
bmemet.I agree to comply whhaB dty,w countyordbances and state 1.
AL
MECHANICAL FEE
I PERMIT ISSUANCE '�
FEES PAID:
relating to binding construction, and hereby authorise represenbtWe of this
elty to enter upon the abowementbaed properly for impassion purposes.
CWe) agree to save, Inclemently an d keep huhu the City of Cupertino
Date Receipt#
ALTERORADDTOMECH.
SUBTOTAL:
against lhbWtbs(udgments, treat" spew whleh may In anyway ao�rue
a4utsal consequence antbg dtNs permk.
?�
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER IQWOCIM)
CONSTRUCTION TAX
ar Appbant/ rot or rote
E HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA2 RUOUSMATERIALSDISCLOSURE
HEATING UNIT(TD 100,(= RTV)
WOltheapplfantorfutumbu0dingoaupantstareorhaMl ha rdma
r Wt lasdefieudbythe Cupeni.M.Nd,ICade,Chapter9.12,andthe
Health and Safety Code Section 25532(a)r
RnnL.
Yea,- I/�, Na
ul the appllcam or fu m building occupant use equipment ea devlus
which enet havrdous air oonbmW ma a defined by the Bay Area Air
Date Rece1 t#
HEATING UNIT (OVER Ifa,000 BTU)
TOTA
VENTILATION FAN 6INGLE RESID) t
ISSU ATE
OHP OR 10gIXA BTU)
h&Plhn res mem District?BOTLFJ{OMP
ve read the hon mu materials requirements under Chapter 6.95 of
OCTJ 023'9(�1
BOILER-CUMP(OVER 100,(100 BTU)vRomb
H.Ith k Safety Code, Setlloro ESfS, 25573 and 75534. I
that lfthe building doe ret cumenty have a tenant, that It is my
CITYard OF CUPER7INU
NEW R67DENTIAL MECHSQFTV
mBey, to natty the oaupam d the requirements which =9 k met
fsuar. da Crtifl.mof Occvparcy.
76p;:--
ISSUED BY
I
m authorised agent Date
TOTAL6 NA
OFFICE COPY