24042 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project ldenHfkatlm /J /�1 J - PE]LWTN 4 f2
a b�Tdi�Addmia: p 1 I 0 .�1 "I �S a 1 1 O 4
2o1.L3 ynCDa�.ISIpE ¢Irt� "P f..o
ypV Ia MFWL_II 7u-2-19'7 CITY OF CUPERTINO,BUILDING DIVISION
C.mider'.Name: LIB Nor APPLICATION I PERMIT
ArchBect/F Rinser. IAC N. BUILDING-E,ECIRICALPLUMBINGMECHANTCAL CATEGORY CONTROL♦
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. - PERMITISSUANCE E ❑ ❑
.NTRAROR'S DECLARATION
thereby
LICENSED CO
affirm that l am licensed under provisions of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DF
SCRIPTION
ingwith$cation 711W)d DIvLWon3otNeBusiresand PmtemloruCode,and myysaa -
Lici se b tors tort and c.# PANELS - U� /f_ `
LI¢rue Clam LIffc y [/•/TI[J�a, VC
Date Contra
— UP TO 2DO AM5
ARCHITECTS DECLARATION 201-1000 AMPS
ppqq��9 7O I wtdergard my plans shall be need as public records, OVER IOOO AMPS .Fr.FLOOR AREA $/SQ.FT.
Fe Licensed lid®renal SIGNS ELECTRICAL 'e\,1,,
OWNER-BUILDER DECLARATIONI,, o�
t., IhenebyalBnam
n that lexempt(rein the Contractorla
Contractors Ltemse w far $♦'FICIAL CIRCUIT/MLSC
the
>Q falbwing rtuan.Qectlm 7lD15,Buelne�aM ProfessionsCode:Any city or
F/� TFMp.METERORPOLEINST. /� ^�
5 mygm lchre tolU a attomrutrun,altheaphv tfmivaprrepair L/.
to
S any gronurttatemeibbinakSallnated kntheat to the
to POWER DEVICES HIL'
��054 O 5 ilk•signed is mss,La Llan he b r 9(cot ening to tSe pmvbiom d the
w
Contractors of tre uelmea andProepter9(mmmentlng with xemptthctlem 0rxfn VALUATION
don3oHh<BuetreesandPMmbroCode)orbuthebexempttherefromad SWQ.ih9NGI'OOI.ELECTRIC
K' the basis for the alleged exemption. Any ddadn of Senlan 7m I.5 by any rFLYfURFS ��
applicant fora permit subject the applicant too nud ll penalty not more than p(T,E.ISSI4FIC1-�T
E �^ By,S�hundrdneroft AQ. NEW R®WTIAL ELECTR SQF[. SIl7W6 TYPECONSTRULTION
u I,u owner of the property,or my em dire In with wages an there sole
�7Q compenaaiKflo,dothe work,and the s Code: brotbdeMed orofbrtdfor
p axle not apply
to an ow er Ppmpebro Code: or Impoor.IJaron law
Pj5$ dm weappy torn owner d pmpmty who
.empay.,pre.thereoRandwho OCC.GROUP REB.UNITS
w impmv suchwohhlmte dedoroffe hf..employ., rovidedthat Nd
improvementarenotblended orrofcc forsalt.ILh r-b, Bder ldingve TOTAL:
Improvement resold wlthinoneyrarofcompletbR th<ownerbullderwBl have '
enofpmvingthxhedtd ndbuudorimprovefnrpurposeofula.). QTY. PLUMBING PERMIT FEE
r owns of the property,am exclusively contracting with licensedFLOOD TONE APN
tractors to cormron
tthe Project(See 70K Bunlnes and Profeabv Cade: PERMIT ISSUANCE.
Codranor'.Lice.Law don not appy to an owner of property who ALTER-DRAIN&VENC-WATER(EA)
Wilds or Improve thereon,and who contrsm fee such projects with, FEE SUMMARY
WN(+ctor(a)licensed purwant to the Contractor'.License Law. 'BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for thio re..
Owner DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
WORKAN COMPENSATION DECLARTI
AON RECEIPT 9
F11
heM
reby affirm Nat I have a mtl0ate of consent to self imm ,or FSS'PER TRAIP. S OOLTA% Y_ N_
conifi teofWorken'CompewU lour asattitiedcvpythermf(Sec. REGEPTr
'W,lab C.) GAS FA.SYSTEM-1 PICT OIJTLEIS PARK FEE Y_ N_
Co bJ'r GAS EA.SYS[T7d-0VER 4(FA) RECEIPT
y BUILDING DIVISION FEES
Cemlied copy b herofiled with
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE,
�Cenl/ied mpybfued with the my Inspection division. '
CERTIFICATE OF G( MPTION FROM WORKERS GREASE TRAP - PAID
CM S T INSURANCE
OTIsnbnnMrembcompldeffiepeNbforore hundmdollue SENER-SINTIARYSTORMFA 70QT Date ReLCI til
61luftifyth WATERT-EATERW/VENT/E-ECTR ENERGYFEE Y N
Isha]snot emp oy any penton m m th arcer sorwhiN thio penNt b faucd,
Work not empty any person In any canner at a+to become object to tic WATER SYSIEN/TREATING
Workers'Compensation hondGlBornla. Date PAID
O Z AppBont NEW RF5 DIN IAL PLMB. 9QFi. Date Retei to
Z O NOTICE TO APPLICANT:If,after inking this CrnBlale of Exemption,you
should become subject to the Workeri Comperuatkm pmvlsbn,of the Labor TOTAL
~ U) Code,you moat forthwith comply with inch pmvislom orthb permit gull be r
Q > deemed ontoked. -
W p CONSTRUCTION LENDING AGENCY SEISMICFEE I
BUILDING E
a ,hereby a/firmthattherebaconatrudimkdingagencyforthepMonn
7 Z anceoftheworkforwhichthbpem NWued(See3097,CLv.C) TOTAL: ELECTRIC FEE
U O Lenders Name PLUMBING FEE
ILS Ledre.Addtess QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iconi!ythAllavemadtN appllatbnindp tethetheabove Nfomatlm
a bconrd.l agree to comply with a0 city and musty ordinances and gate laws PERhffT ISSUANCE FEES PAID:
} N relatingtobuiklingmrutmctlm,and herebyauthorissrtpresenbtWnofthls
F in city to cot ahoy me Boned property for Inspection purpose. ALTERORADDTOMECH. Date Recel NF
—
agree ,ltd yand keep harMmthe Cfty dCupenlro
ago tliabil se gine s expensnwhirhmaylnanywayareue AIR HANDLING UNIT(TO 10,00 CFW SUBTOTAL:
erg tsai I a ofthegra"ofthirpemat
AIR I-TANDUNC UNIT rovFx la,000cE:Mn CONSTRUCTION TAX -
tureofAppllont/C tractur Date E)GAUST HOOD(W/DUCD - CONSTRUCTION TAX PAID:
HAIEARDOUS MATERIALS DISCLOSURE
WRltheappflc` rare building oavpant store or handle M1aaandw. HEATING UNIT(TO 100,000 BTU) Date Recef til
materlrl as deftmd by the Cupertino MuWdNl Code,Chapter 9.17,and the -
HeAth and SafetyCode Section zss37p)t HEATING UNIT(OVER 10D,00D afire TOTAL
F1Ye L No
Will theappllant or tare buBding occupant use equipment arde VENTILATION FAN(SINGLE READ) ISSUANCE DATE
which emit hazardous a4 contaminants as defined by the Bay Area Air
Quality Management District? pt BOILER-COMPOHPOR 100,000
1� es ON.
1.y e read the B1U)
the,GB/omla Health&SafetycCode,Sections terials Gi 15505,75SV a dh755M. 1 of IIOrIFR-COMP(OVER 1 W,000 BTU) PAI D
understand that lithe building don wt currently have.tenant.tlat B is my NEW RRADE.TIAL MECH. SQFT
AUGtepommilay,to notify the necrnpant d the requbemeuug m
s which mbe at AUG .Tit
prior to Lvua tired a Cervi Bate of Ocrupa nry. - 19
Onmrrorauthcmi .gem Date ISSUED BY.. ( J-l4y
TOTAL
OFFICE COPY