23218 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Froject Identification PE ..WT NO.
Bu Bit Ing Addrev: 23218
'L1 G-
rs ams: one: APPEJcAT
-
�_�H q CITY OF CUPERTINO-BUILDING DIVISION
.� Con l� � Z
r Lk�kTAPPLICATION / PERMIT
BUILDINGELECTBICA4PLUMBI MECHAMCAL CATEGORY CONTROLN
AmhBcct/Eegfner. IX.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrm
PE]tM1BTI.4UANCE ❑ ❑ f� F-1LICENSED CONTRACTOR'SR
DECLAATION L�
I krcby affbmthatlam lkmseduMnprovblaro of Clupter9(commmc
APPLIANCES-RESIDENTIAL JOB DESCRUMON
ing Mth SedW.700D)af DIAW.3ofthe Businouand PmfeWwsCode,and my
Ilrc"a.b In fuB fppe"Lceffect."�`7LZ� PANELS
Llceroc Clan TT
Contractor UP TO 2MAhIPS
ARa1TTECTS DECLARATION OV AMPS
OV
Z I uMm{Npd ng ph akry B be usd u public rcmrtla ER 1000 AMPS SQ.Ff.FLOOR AREA f/SQ.Ff.
II
R IK4l� ♦Lt/a-tet
l' Llanaed Profminnal 3GNS ELECTRICAL
6 By�l OWNER-BUILDEK DECLARATION $[rEQAL CIRCUf.I./MLSC .
I hereby aHlrm that I am exempt from the Contractors Lloeroe law for the
tqopq�y !-Bowing...filodim�7MIS,Basi,and Profmbro Code:My city or
FmY7 muntywhk mqubesapemdtmmro d,alter,Impm ,demo h,ormpalr iFA1P.MEfLR POLE INET.
�15Y anymmuure prbrm Ba bar he .Emn..u4mthe at W the meffo sof t e POVrrpR DEVICFS
Bk a xgnN statement that he b Ibeneed purauent m the pmvbbro of the
Ow
rn Ctraor'sLmee Law(Chaptn9(commencing with Sealan 7000)of DIWSWB`U'UNG LOO I],FGTRIC
- VALUATION ^
�30
n3ofthe Buelmmmd Prde+ Code)ort)uthebea theremmaM
Nonctre
a f3 6 the bmh for the alley il exemption. Any Welatlon of Section 7m15 by any OU"ILE.IS flXf[JR
O� appH..t permitora petlt objects theappkci
am to a civil penalty of not more than
� tl6.dmddo]bmt f500f. NEtiVRFyD L SQsr. STORIES TYPE CONSTRUC170\
�n I,uowrer afsk Property,or my nenpbyemwkh wagesutheirBole
cnnnperoatlon,willdothe work and thestmctum it,not Wended or offered for
Osae not
apply wan
ono aandf properry Code:The Cimprenex Liaroe Lew
�S$ whorl apchworkowcerofpmpemywhonempbuilds orlmpmvntherms,and -OCC.CRC)UP RES.UNITS
,mimme s ntA an rkhlmseBathraugh M1leownemp,fume pm theb thatud
Impmvemcw are of Intended proffered(a oak.If,however,the W Tiding or OTAIL
LnprovemeM hsaldwhhlnorcyarofcomplxbRthe ownnbullderwW love
tnlenofprevingthxkdld ombulldorlmpewefao
purpecdule.). QTY. PL GPERMI FEE
U1,as owner of the Property,am exclusivelymntnxting with Uceroed D ZONE APN
contractors to mretruct the project(Sec 7014,BuMnew and Profmbro Cade: PERMIT �•
The Centimeter's -License Law don not apply to an owner of property who ALTER-DRAIN4 -WA
Wads or improves thereon, and who mtr
nam for such p(o)em wflh
ogn4f or(g0aruedpurw ttotk Cmtmdo''.LI n Law. FEE SUMNARY
U I am exempt under Sec B 6 P C for thio reason BACK FLOW
S Owner Date DRNNS pIODR ROOF, XNITARY Y_ N—
RKM /
WOAN COMPENSATION DECLARATION RECEa Na
F11 thereby Affirm that I have a certificate a causnt to self-Invert,o a HXTUN�PER TRAP SCI TAK Y_ T
certificate of Workem'Comperaatlmro
lurmcert
ce ora lflecicopy thereof _ R£CEU'
3800,Lab CJ l.� CAS FA.SYSTEM-1 UJC4 P RKFEE Y I
pd;,N__ V_'I?1ktL-LL Iwv m.� F . G FA.SYSTEM-O 4(FA) F1P1'1'
Com ny B}li DING DI VISION EES
Ned copy is herebytumWed. C NW WASIF FPTUR NCHE TE
F-1Hl
Ccrted copy L filed with the city inspection division.CERTIFICATE OF EKEMPTION FROM WORKERS AI
COMPENSATION INSURANCE $ElyER-SOMI. FA.. Date Recei tp
CThlssectbn need not k complied B the pemdt h loorc hundred dallan
((SIM)alm.) EN- Y Y N
Imrtifythxlntheperformanaoftkwokforwhich W.pe=kis hued, WAiFA1�'ATFR / /p'pCTR
I shall not employ Any perms In any manner ro An to become object to the WATER SYSIVd/ TITS
Wmken'Comperoatlan Laws of California.Date PAID
Applicant Date
Repel to
Z D [NICE TO APPI,ICAM:IL aflcr making this Certificate ofExemption,you
NEW ItFSIDEMIAI,PLMB. FT.
should become sub}ct to the Workm'Comperoatmn pnevlsloro of the Labor TOTAL:
~ N Gide,youmxxfathw hmmplywlthachpmWsb orthhpemJ ellk
j deemed rooked MILDING FEE
CONSTRICTION LENDING AGENCY SEISMIC FEE
d Ihercby.ftUm tkttherehammtruatanlemingagenrybrthepertom ELECTRIC FEE
= any of the wonkfor which this permit Is leued a,309],Civ.C.) T
U O Lender'.N. PLUMBING FEE
LL F IcMc/.Acklmui QTY. MECHANICAL PERMIT MECHAMCAL FEE
O W Icertilythatl havercadthbappllatbnaMMatethattheabove information
bcorml.I.gree meamply whh.11 city and county ordbunm and date lawn PERMIT ISSUANCE PAID:
} N relating to building mmtmctoo,and hereby authorfm represent.tivet of this .
F vrod Inspection
Z city to enter upon the abocmentloproperty for mpection purpoA1.=ORADDTOMFCFL ReCei t#
— (We)agree to nw,Indemnlly an d keep harmlm the City of Cupertino P
agaHutha tim),d me ec
inanyway. ue AIRIiANDINGUNE 010,000CFM) SUBTOTAL:
agairot d i ntln Ispe '
_ ALR ETANULINc UNIT(OVER lo,oOocF\D CON R ON TAX
o&glratum of Apphcant/Contractor Date EXHAUSTIIOOD(W/DUCT) ST U NTAX PAID: `
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant orfuture WUdmg occupant More or iuMk harvrdon.. EIFATING UNIT(TO Im,000 BTU) D 'Rttei tq
material as deRord by the Cupertto MuMdpal Code,Chapter 9.1;and the
fie❑aH and Safety Cede Section 25532W? HFATWG UNIT(OVER 100,0M BTU) TOTA :
Will the.ppliant ur u=WOding oavrpant une equipment mdev{¢s VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardoun air comandantsas deflned by the Bay Arca Air -
QualityMavgeommDistrict? B0II.FRCOMP0HP0R 100,000 BTI]) PAID Yo No
havcreadtheh.,Q rroteriabrcqube nhunder Chapter6.95of BOMER-COMP(OVER IW,000 BM
the 011famh HeaHhk SafetyCode,Sedi..Z5W5,25M3 .d25534.1 SAN 21
undenxaM W
that lithe OdNn g donot currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.PT. 19
n P.nubmufty to notify the omuparn of the requirements which must be met Y r UPtk7J I14
prbriroM..of.CcrlifkateafOavpanry.
CITU!' C �)
/Y O 73IVU
a sed
Owner authoriagent D1
ate ISSUED L^/�!�
TOTAL:
OFFICE COPY