22924 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingProod Idemifkation PEILWT NO.
Buildi;g Add�.2�6 22,924 ,
rt rs .me: me.
CITY OF CUPERTINO-BUILDING DIVISION
Contractor'.Name: [ Lk.N. APPLICATION I PERMIT C
BUIL.DING-ELE{IRICALPLUMBINGMECHAMCAL CATEGORY CONTROL.
ArchBM/Engineers .Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtaa PERtATI9TIANCE 1:1 ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hemby km that am Brosed under elovof C9(mnVvnc PPllNCRDFIA
Iegwth SocUnn W)ofXHilonJoftheBuaI.and PmfestalcoaCode,and toy— JOB 13E9CRIFT)ON
Iker.it,In had form and effect.effect. PANELS `
ataa.eb
Ca 1Jc1
D ''Cl7 LANs-!J'.
DatContractor UP TO 200ANIPSS
ARCHITECTSDECLARATR)N 1-1000AMPS
07U) IurdromaM ml'plans shad be used a public remrda OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Llo nxd Pr f.io ul SIGNSIUXIC RICAL
H S OWNER-RUILDER DECLARATION SI'ECLILC11ICIJIT/ML9C
Z Iherabyafflan that l am exempt I.the C.M.ctor'e Lket.Law for the
pp following maser,5eaim 70115,Bvinm and Pmfmbv Code:Any city or
OF Z� TEMP.MECFR OR POLE INST.
� muntywhkh rtqulmapemdt to mrutmca,ilta,impreve,dermWh,wr rtpilr
E�O11a ayatmeprim um prto Its hmrave,also requbeathe appdont!«mch permit to POWER DEVICES
�V file a signed atatement that he b Roomed pursuant to the pno talons of the
Q3 Contractor's Llceme Law(Chapter 9(mmmenring whit Seclon 7000)of DTH- SWDIMNG}WL ELECTRIC
sbn3ofthe Bualneamd Prdmlov Code)orthatheberemptthemfmmaM VALUATION
P Sat•7 the bath for the alleged exemption. Any Holatbn of Seelbn 70315 by any
appdont for a pemdt subjeea the appdcantto a dull penalty of not mom than OUTLETS-SWITCHES}TX(URF_S /rtJ
E � live sod owner of
property,
NEW RESID
uLaowerof thee wont and
my emtumia wtthween rthetrsole -�IORIES TYPE CONSTRUCTION
t mopenzation,-,7DK will do B.Inrae M Probdthe Cade:
ot IntendedC.ouadoe oroffcadfor 1M-
M sok bee 7014,Buelma and Pnfeabv Cade:The GONradOr.Wave law
does of apply to an owner of property who build.or Improves themon,and
Ca• who does such work himm4forthmugh his own empl yeea,Provided that such C.CROUP RES UNITS
bnprorcmeiva are not Intended oroffro,d f«eek.If,however,the build Ing« L TOTATIE
Impmvemeiu Is sold wWdn one year ofcompletbry the owner4,aUerwd)Farr "I
tr�arden ofpmHng that he did rot Wild or lmpnwe(«purpme ofsak.). QTY. PLUMBI
"L as owner of the Property,am..(JUS rely mntrrUng wW IImvM FLOOD ZONE APN
mntracces to mmtmci the pmyA((Sm 7004,Buslnm and Profmba Code: P�fIT ISSUANCE
The Cantnnor'•Lkense Law dos not apply to an owner of property who ALTERD1tA1N Er VEIJT-WATER(EA)
Wilda or improsv thereor, and who cornea f«inch p(ojeca wdh
�t�+ctoRil lkrnaed pu ntmthe Cano-aeors Limn Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE -
LJ I am exec un c B k P C for thio m
con DRNNS FLOOR ROOF,AREA,BOND. SANITARY Y N_
• Owner Date RECF7IvTe
Z
FT.SATION ECIARATION Fp^HJRpg PER TRAP SCHOOL TAX Y_ N_
❑1 h • rtlflmte consent to sed-Insua,«a R EIPT,g
mrtif to • rwrmm a¢rtifiedmpythemaf(SA: GAS FA.SYSTEM-1 INCA OUTLETS PARKFM Y N
3800 Lab
PO I GAS EA.SYSTEM.OVER 4ILA) RECEIPT a
o y BUILDING DIVISION FEES
naftffhishad. GREASE/WDUSR1,WASTE INTERCEPTOR PLANCHECKFEE
Ceme dty lvpeCbn dlHdon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRA' PAID
COMPENSATION WSURANCE SEWER- STORM FA 20OFT Date Remi t#
(f oaeRbn n«d nm be comple4d If the Perak hf«ons hundred dodan
�OOJar1ca) WATER FIEITTR W/VENT/ELECFR ENERGY FEE. Y _ N
Id norftffy that MtM pe.mom I an the work so as too wfuldh W ,subjecennit I,!.sued,
1 shall not.Apby any.Lawn f any manner so a to become subject to the -
WAT02 SYSII]N/TREAnNG
W«ken'Compenvebn Iowa of California.Date PAID ,
O Z Applicant NEW RESIDFNIIAL I'1lfB. �.FT. Date RCceI t#
Z O NOnCETO APPLICANT:If,after making thio CrAfficate of Exemption,you
N ahbecome
old subjeA to the Woro,w Contpevb
ssn provbv loofthe Labor TOTAL:
CC Cade,you at forthwith mm ply with mrh pmvbbnsorthb permit shill be
W > deterred rooked. BUILDING FEE
IL o CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
IheabyaNrm tluttMm ba mrwmctlon lending agency for the perform TOTAL ELECTRIC FEE
7 Z anmoftheworkforwhkhthbpcmJ[bbe (Sec.3097,CN.C.)
U O lender•Name PLUMBING FEE.
LL ~ Tendee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtlfy that l have read thisappliotboand etamtKi the above ln(ornutlm
banes.Iag.tocomplyw addy.m..tyordbunmandatatelaws PERMIT ISSUANCE FEES PAID:
-} N Wg m
relaUng to lldlermtmnd ion,ahereby authodae mpreaentatlues ofthis
f. Z city to enter upon the aW,e Aaentbred pmperty for peeclonpurpmt'e ALTERORADDTOMECH.
Date Recei t#
U — (We)sera to.eve,kdemN(y an d keep FarMm the Cfty of Cupertiro
agaWtllabWtles,�udgmerua,mate and expenses whkh mymany way aruue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against aild City In consequence of the granting of this permit
♦O ATR HANDLINGuNrr(OVER l0000cs'in CONSTRUCTION TAX
Sigrmture of Appdant/Contract« ( to 9 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HASARDOUS MATERLALS DISCIASURE
WDl the appdont«future buliding oavpant atone ser haMkharardo. HEATINGUMT(TOIW,0)0BTU) Date Recd t#
rrnterlalaa defined bytM pertlo Murddpal Code,Chapter 9.17,and the
FkAh and Safety Code Ion 755770)7 HATING UNIT(OVER 10,000 BTU) TOTAL:
Ye
hes At tutu WlldingocmpartuuegtApmeru«devkas VENTILATION FAN 6INGLE RESID) ISSUANCE DATE
e tha air aMvntaa.d dbyt Bay Area Nr
/0 Qu Ifty vg t t BOILER-COMP 01-11'OR 100,"BTU) PAI D
Y
read Teri brequlreAe un er Chapter6.95 of B011-ER-COMP(OVER100,0D)SIU)
tit vomt t kA ode by75 ave and 75576. 1 OCT 30 1991
sod t t l g aes a e rectud avL t hicb st hat it b rm NEIN RESIDFNiTAL MEt7i. SQFT
vmil tLL the aqui •whkh neat be met
P miam Certlf t of parry.
CITY QLLUrwiIIINU��
crororUad gent Date ISSUED BY: "�C�
TOTAL.
OFFICE COPY
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