22909 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.Ildln Pm'en ldentHkatlon PER.WT NO.
cul 2QAddrtv: � h` Gr 22909
w A
nen. .me "4 CITY OF CUPERTINO"BUILDING DIVISION (� !^ L p
Contratlola Name: APPLICATION / PERMIT U .r ?- 1,
BUILD ELBCERICAL-PLUMBINGMBCHAN'ICAL NTROLI
Arehttee/Fsgineer. Lie.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFRMTISSUANCE El 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcered under provblons of Chapler9(mmmmc APPLIANC6RESIDENTIAL TOB DESCRIMO
Ingwith5tttbn 7000)of DMvw3ofthe Bunressand Pmfe onsCode,and.
License Is in full forre and dfee. PANEZS
Wrtem Cl.. Lle.s
Date Contractor UP TO 20CAUMI�
ARCHITECPS DECLARATION =" PS
X ]urdertland my plavehall be used u public weds OVER1000AMPS SQ,FT.FLOOR AREA $/SQ.Ff.
COCIy U Lfcenxd Pr.fmbvl SIGNS ELECTRICAL
z
OWNEReBUILDER DECLARATION SPECIALCIRCUIT/ML9C /
TherebyafOrmthatlam l-5,B.r ..Comraeor's Ck rs� w for de:l ydtthe /
following reason.6eeim 7¢115,BusNm and Pmfmbv Code:My city or
FI"'p❑ con hkL Ona wmvteu alter,ion W TEMP.METI]4OR POLE INS!.
y m pe, permed 4 ppbmntfmwch,orre 4
aa anystmeurttatemelts that
e,Is Beereelulmthssetto antforsochpeof to
to
Bb a signed statement that he b Iirvcd pursuant to the provisions d the POWER I3EZICES
X05Ccuumeor.Lkeeue taw(Chapter 9(comem.Mg with Seubn 7000)of DM.
dun3ofthe Busbmsnd PrderbvCodel orNst hebeump<thereLomand ''lVIMMING POOL DECTRIC VALUATION —
6 5 the basisfor the alleged exrmptbn. My vldatbn of Seebn 7[015 by any
app0ont fora permit cubectatheapplicanttoa dull penaltydna..than OUTUEISSWTICHES-FIXTURES
five hundred dollan(5.AVj.
..�o ❑I,as owner of the property,or my employee with wages As their sole I NEW R®FMLN'ELECIR SQ'FT' - STORIES TYPE OONSfRUCDON
t mpenk
ten,will do the wc' and Neatmeureb rot intended or offered for
5 n mvaa1e(Sce.701t,Buelros and Prefembv Code:The C.mraeora License law
�sg does not apply to an owner of property who builds or improve theemn,and OCC.GROUT' RLS.LINERS
who doessuchwork hbreielforthrough hbownemployees,provided that such
impmvcmcwart ret Intended oroffered f rsale.If,hmever,thebuildinger TOTAL
impmvemertbsoldw hbomyearofmnplebNthewvner-bullderwiTuve
thiLturden.f pmvingthn he did notbuad or improve for purpose fsale.). QTY. PLUMBING PERMIT FEE
LJex
1 as owner of the property,am cwy beemtractlng with homsed EI'DDD ZONE APN
mntnctors to covtmet the project(Sec 7064,Bualnm and prdmbre Code. PERMIT ISSUANCE
The C.mmetors Lkeve Law don not appy to An owner of property who
WE"or Improv.thereon, and who mmnm for soeh Iun*ets wish a ALTER-DRAIN&VENT-WATER(EA)
orTleterW mu
ho, .ed puant to the Contneesa License,Lw. BA6:FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B& P C for this reasonn.
Owner Dale DRAMS FLOOR,ROOF,AREA,CONED. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RFGFDT
` ❑1 hereby affirm that 1 have•ormflosm of consent to selFleuum,or a FIXTURES PER TRAP SCI TOOLTAX Y_ N_
mrtiBatr of Worken'Compermatlm Insuanes or•rertlled ropy Ihemof pec. RE=a
380,Tab C.) GAS-Ek SYSTEM-1 NCA OULE75 PARK FEE Y_ N
Comry s GAS EA.SYSTQ.T-0VER 4(EA) DING DIVISION
y BUILDING OI V ISION F'EFS
Certllled ropy b herebyfurnished.the, ed.
CertN.d ropyhflied with the mYlvpeebn dhdnm. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXETAPTION"OM WORKEIIS' GREASE TRAP PAID
COMPENSATION INSURANCE gE}ypR SANTTAAY STORM EA fiOFf Dale Recel [#
(This a,ebn need not he completed Bthe pend[b fm one hundred dollar
(f100)orfy that
WATER HEATER W/VENT/E1,l=it ENERGY FEE Y— N
certify Ibe perr.rmanlaorthe work brwMehtw pem,ttblwed, N—
I shell not employ any person m any manner an As to Meme subject to the WATER SYSTTM/TREATING
worker: mu
Cipmatlon laws of California.Date PAID
lleant
Z Q NOiTCE TO APPLICANC:If,after reading this Certificate of Exemption,you NEW RE4DEVRAL PLMB. SQ}T. Date Remi t#
F-' N should become subject to the WorlxAm'Compevatbn provbbv of the Lahor TOTAL:
Code,you rustf.rthwlth comply with ouch pmvbbv orchis pemtlt shall be BU
ILDING FEE
j deemed voked.
LU
re0 CONSTRUCTION LENDMG AGENCY SEISMIC FEE
I hereby afPrm that there ix..avameien lending agency for the perform ELECTRIC FEE
7 Z An.of the work for whkh this permit is 30 Y/
is Issued(Se ,Civ.C.) TOTAL
U O Lender'.Name PLUMBING FEE
LL F Iendee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImrtBythnlha me thbappllatbnandstatethatheabove lnformrtlm
bmrmt.IagrtocomplywhhaUckyando ntyuedbanmandstatelawn PERMIT ISSUANCE -� FEES PD:
relating
relating to building vm
teine,and hereby authore en
lrepeestatlw ofthis
F Z city to enter upon the abovo-mrnlored property for WpetWn purpose. ALTTRORADDTOMFLH. De at� Revel t#
— (We)agree to vve,Went y an d keep furoum the Chy of Cupentoo
ag.but WbfiRies,ludgmew,ousts and expense which may in any wayaceue AIR HANDLING UNIT EDD 10,ODO CIM) SUBTOTAL•
egaWt said CLLy,y.....quer¢.l tFe ming dtisk pemdt.
�2 A e "AIRHANDUNGUNIT(OVER10,"CH7ND CONSTRUCTION TAX
Slgrature of ArppLa ,once = Date - EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or future building. paotnortor handle haaandoue HEATING UNIT(TO 100,000 BTU) Date Recei tp
rulerial as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health sad Safety Code hm
Si25532(a)? IU)7 HEATING UNIT(OVER 100,000 STOTAL:
❑ Ym No
W01the;pplhmor tune building«cvpant use equipment or civ VENTILATION FAN(SINGLE REEID) - ISSUANCE DATE
whkh rout hanrdow atr contambuntsas defined by the Bay Arta Air ' t
Qu Iffy Management Dbtrfet7 BOE11I 002W OHPOR 100,000 BTU)
I❑"]YnII��II No
Ihevc read the haaaeoua materials r.qutrcments under Chapter 495 of BOILERmMP(OVER 1.,000 BM
theCaWonh health&Safety Cede,Seebv 25505,75533 and 25534.1
undentarul that if the building does not.rre.tly have a tenant that It is my NEW RESIDENTIAL MECH SQ.FT
responsibility to nmly the occupant d the requirements which mut he met OCT 251991
prior tp tsuar�m o(a Certlfka—y olOmtpaq�. / -
,��(�w�. /h {•tom/%A/1/ /�lpj/� BY: / I IN
(arvner.r authorlaxd ag� Date' / ISSUED BY: /
TOTAL:
OFFICE COPY