23798 IPI APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
!' Buildin Proe r Idenrifknian PERMIT NO.
BauaIngnaaa,: �-Cg 23798
iFi
J "2.0�3o G-�Rm6o� b�. G�tl.-� .
`/1 DIn � p 7� 3CITYOFCUPERTINO-BUILDING DIVISIONFhoe
( l APPUCAnON A
c °•dam^N•nr �j (1 APPLICATION I PERMIT (i
BUILDING-n ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
A ncv/En,gfreer. kNo:
BUILDING PERMIT INFO
95 EAG c4,j)� os Qtt ELECTRIC PERMIT FE
PERM ITISSUANCE
LICENSED CONTRACTORS DECLARATION -
lWmbydfbmthatlamBcenaeduMerprwtloruofChapter9(mmmen APPLIANCES-RESIDENTIAL JOBD N
ingwlth Seclbn7000)ofDMA=3&f eBuleeseand Pmfesleu Codsand
Lloe la In fuR(o d dfei � / PANELS / �W L
D.to Clan�Lk.g tet' J
Date Contradar IX M 2QQ ANIPS _
ARCHITECT' E L A 10! 1-1 AMTS
{Q�QCO luMeTW nTplauaWBWusedupubllcremnla OVERIOOOAMIS SQ.FT.FLOOR
AREA $/SQ.FT. -
E 0 Licensed Pmlcsbnal SIGNSELECTRICAL �LJ L`TlyL7
<«<�S 61 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MI'TS
71„?� Ihereby affirm that lam exempt from the Contnctor'sLkxue law for the
O YA follo i g maron.(5ec,imt 7MIS,Bu.l ..M Prufewbu Code:My dty or 4�
OZF.Epp TEMP.METFRORPOLEIN . �T
�� countywnkh requbnapermdtomrotud.ater,impmve,demoWhar r
any atrudurtprbrmltel tement r he h aborequpnsuant t the forialum oM�to POWER DEVICES
0 5 Cofile aa, 'Ped la—LawIihabr9(comsl pumnnt it the pmviWO) ofthe
f a� Contractori Llceroe Law(Chapter 9(mmnpndng with Section 70110)of Divl-
F nbn3of the Bulnmand l}dmbro CMe)ortha hebexempt thertlromaMSlV^MJKG ECTRIC VALUATION
4 0 S the W eV for the alleged exemption. My violation of Section 7MI5 by any 1
applicant fora permit subjerts6it.ppllcanttoa civil penalty done morethan iCE�SFU(7i1RE5 ` S a I —�
$ five hundred dollars($.(5(10).
7 ❑1,as owner of the property,or my employers with wage as their sole OEIs'fIA1 � STORIES TYPE CONSTRUCTION
Zmmponsrtlan,will dothe worn,and theamn nam b rat intended or offend for
same Cee.7014 Business;and Professions Cade:The CoMrsctoes Deerue law
dm not apply to an owner of property who build.or Improve thereaR and
( e- who dm such work himself or through hlsown employ.,provWM that such OCC GROUP RFS.AMTS
I lmpmvemenb art mrt Intended oro(fertd for aak.If,however,thebullding or
improvementbao thinomyearofcomplNO tl owner Merwlll Wve
t men atpmdng tha Wad net wua artmp,wef«wma•^af••1•k QTY. PLUMBING PERMIT PEE
( LJ L as owner of the property,am exehutvely mntracling wtlh M IkenaFLOOD ZDNE AM
mntracton to mrotmct the project(Sm 7014 Bu1neseand Prof®Ions,Code: PERMITISSIIANCE
The Contractor'.License Law dm not apply to an owner d property who ALTQLDRAIN&VENT-WATER
buildsimproves;th
or improves; c;N and who mrdrsm fee such pWJeds wkh
ry➢1Eador(.)Bo sed pursuant to the Comrades.Lice.Caw. i FEE SUMMARY
LII am exempt under Sec B& P C for this reason BACK FLOW PROTECT.DEVICE
F ® DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N Owner Dae RECERrT
WORKMAN COMPENSATION DECLARATION FD;TTTRES.PER.TRAP SCI100L TAX Y_ N
❑1 hereby ork that I have o losorme of consent to sepythe of(S • RECEPI's
I 3K0,IAbcertificate Worken'Cornperwtlonlrounn¢ora¢nBled mpytheraof(Sec. GAS FA.SYSTEM-1 INCL OUTLETS PARK FEE Y N
3800,I�6 C-)
Pdky I GAS FA.SYSTEM-OVER 4(EA) DI NG DIEIPTVISION
R
it y BUILDING DI VISION FEES
Certified mpy b herebyth thehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLAN�HECKPFF
� cenllied mpybnkd warn th<dry inspection division. l/O(�,J��(.a�J �
CERTIFICATE OF EXEM PTION FROM WOR KERS GREASE TRAP PAID -
COMPENSATIONINSURANCE 9EWMSANITARYSTORM E.NIOFT Date Recti tp
(TMs.<Ian rued rad bPENSATI iftINISURRbfaon hundred down
($im)orlew.) WATER W/VF1JT/ n.R ENERGYFEE Y N
Imnlfythat Intheperfa un¢oftheworkforwhich W.pencillel. ,
I s W B not employ any person In any manner an as to become subject to the WA.TGR SYSfEkI/TREATING
Workers'Comperuabn lawn of California.Dae PAID
O = Applicant NEW RESIDQJl1Al['LMB. SQFI'. Dale RCoei tN
Z Q NOTICETOAFMICANT:toften rrukingtM,Cenlfbte of Fiemptbn,yw
should become ubpd w the Workers'Comperoatl¢n provl•bu of the Labor
~ N Code,you mut forthwith amply with cad pmvbloro orthb permit shad be
7 deemed cooked. DUILDINGFEE
CCONSTRUCTION LENDING AGENCY
p S I MIC FL•E
d Ih,mbyafflrm tWttk 1...ratmdiwkMingagemyfortheperfor
Z
ELECTRIC FEE
an¢o/the work for whkhthb pemtltbbuM(Bee 3071,C1v.C)
U 0 1<Mers Nime PLUMBING FEE
LL F- I<Mer.Add. QTY. MEC14ANICAL PERMIT FEE MECHANICAL FEE
OW I¢nlfythal have read thb.ppBcatbnand late tna theabove Information
a bmrnad.Iagreetocemplywhh.Rdty and oTunty ordlnencvand Y.telaw. PERMIT ISSUANCE FEES PAID:
�( >_ relating to building corutructlon,aM hereby authortre repreentatNn of this
�1 F.. N
Z city to enter upon the above-md entbmuproperty for lropdbn
epurposeIL
s. ALTERORADDTOMEGDate Refel tq
— (We).gree to save,Indemnify an d keep harMao
se the City of Cupenb
against lWbWties,Odgerents,costs and expenses which may tnanywayamue AIR HANDLING UNIT(TO 10,000 CF),)
ag.trot said City In con•equ Pn¢of the gra oting d this permit. SUBTOTAL:
AIR ITANDUNc UNIT rovFR tomoclml) CONSTRUCTION TAX
Signature o(Appnont/Contndor Date EXHAUST HOOD(w/DUCT) CONSTRUCTIO�N�TA�X�P•AID:
HAZARDOUS MATERIALS DISCLOSURE �Ly,�a��y
Will the applicant mfuture bu0ding orropant store or WMle naaardous HEATING UNIT TO 100,000 RTU) Date. C• 'REcci�k
i nulerialudeflZIbytM peniro MumdpalCMc,Chap¢r9.1 Z,and the
lieahhend Safety Co loon 25537(+)7 IAEATING UNIT(OVFR 100,000 BTU) TO
I— Yn
Iilihc NNOR
applicant Wwrt building oavpantuseequlpment ordevka VENTILATION FAN 4gINGLE RESIT) ISSUANCE DATE
whk'h eMt luvrdaus ri0 t vw as defined by 1M Bay Area A4 P
• Quality Marogemcm rrt BOM.A-COMP PHIPOR 10D,0(D BTIq
4 Yn p�
Wvere H"h & wter,Sb t.0 25505tsunder d2SS . I of BOILER-COMP(OVER 1W,000 BTU) r A I D
the CaIB¢nla Heakh&Srfety Coda$eetloro E.505,7G5]3 and 25536. I ,
underst.Mthatif thebulld don cot mmentl ve•tenant tWtitbmy NEW RESIDENTIAL h¢CK SQFT T�
nsporolbWty,to ity the th mentawhnan rruatW met U, 28199
p to daQ
,gent Date — n C l liBYdUr� ,f r _
OFFICE COPY