20025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'co IdmtlfirmionPECMITN'O.
Building Add]�rrv,/:� �/' a 20025
/ • A A A
Ow., /a CITY OF CUPERTIN0.6UILDING DIVISION
Cera orsNotrr/� 'JLic Nm APPLICATION / PERMIT 1lrY
!J a-. J� BUILDINGFLECTRICA -PLUMBINGMECHAMCAL CATEGORY CONTROL x rQ1 j
Architect/F+i r. a Llc.No: J �J
.ELECTRICPERMrr FEE BUILDING PERMIT INFO.` ."
Address: I PERMIT ISST:ANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECW TIO
I hereby affirm that am Bemsed under provisions of Chaptcr9(rommene- APPLIANCESRESIDENIAL ]OB DESCRIPTION
Ingwith Sectton7000)of Divlslon3ofthe Businessand ProfessionsCode,and my PA[JES r
license Is in full form and effect.
Lieve.Class Lit.x
Date Contractor UPT02MAMPq1 _ V
AI�C�sITECFS DECLARATION IDI-1000ANIPS
atzO O I uoddrs n ITy p�Q,,,�all�{ysad as aspublic remrda OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
J� I� i< YII/l�I.l.Yl/ 9CNS ELECTRICAL !Q/
y j y ONT'ER-BNLDER DECLARATION
SPECIAL CBKUIT/MISC <(' /
Ihembyaf . hm l am exempt from the Contractors License Law for the !mss
(oL'owing reason.(codon70715.Businessand Professions Code:MEM
Any city or 7Ph4TERORPOLEINST. 7
county which requiresa permit toonnumct,alter,improve,dennlish,or repair `
Syaa anystructum prim to its Issuance,also requbesthe applicant forsuch permit to POWER DEVICES v
file a signed statement that he b licensed pursuant to the provisions of the
>- ContacmrsLlce.Law(Chapter9(commencing with Section 7000)of Diel- SWLM.MNC Si�OL ELEC[RIC TION
SOS sion3oI the Business and Promsmoru Code)orthat he b exempt therefeemand
- y^ the bash for the alleged exemption. Any violation of Section 7NI5 by my OUTLETSSW77CHF.rEXI'URFS O
applicant for a permit subjects the applicant to a civil penaltyof not rrom than a
five hundred doll.($5DO). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRI.CTION
tf Z a ro❑I,as owner of the property,or my employees with wages as their sole
mpensatlon,willdothe work andthe structure b not Welled or offered for
i�O vie(Sec.706y BuaNem and Professlom Code:The COntncters License Law
does not apply to an owner of property who builds or Imprwnthereon,and OCGGROUP RES.UNTES
who doessuchworkhlmseff orthrough hlsownemploym,provided that such
improvements are not intended proffered for sale.Kit er,lhebulWing or TOTAL:
improvement issoldwithinoneyearofcompletlorysheoixe I ullderwlll have _ T_`Sy
th Nen of proving that he did --- -"—res LAAA1A ^�^" APN
UI,as owner of the property,
contractors to mmtmd the project / 10 C t r� 1 7
The Cmdrames License Law doe 10,20, ,a PERMIT ASPECTIM ACTIIITY FOR PERMIT 1 _
0025
Wilds or Improves theater,and MERCEDES ROAD
m�21actor(a)Bansed punuaN tot IARY;•,pe%.:- .,`.,•
Lj I am exempt under Sec
Owner INSPECTIDII CATEGORY 101
WORICMAN COMPE
❑1 hereby dfbm that I have a
aNOateofworkedeompemad----r-ATt—OTO TYPIrOF INSF'EGTION - IIISPECTOR CODE - P/F COMMENT.
3800,Lab Q WA I
Policy 5/04(RO RETAINING WALLS . F
�mCedified copy b hereby fume 5/10/40 REAIMTIMG-WALL W.D.A.ttt WA f' PARTIAL FEE
edified copy is Ned with t -
CERTIFICATE OF FSF
COMPENSA
(rhb secilnt.ardnub,compl, - -
($100)oriess.) - ,,...,a, diW/VENT/E.ECTR ENERGY FEE Y_ N_
I certify that In the perfomunecof the work forwhich this permit Is Issued,
I AsaB not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawsof Ca Womb.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei1#
ZNOTICE TO APPLICANT.U.after making this CertRkam of Exemption,you
FO should become subFct I.the Workers'Compensation provisions of the Labor TOTAL:
U) Coda you most forthwith comply with such provisions at this permit shall be BUILDING 'EE
K j deemed re.°ked' SEISMIC FEE
111 CONSTRUCTION LENDING AGENCY
d O Iherebyaffirrnthat there is a construction lending agency for the perform TOTAL ELECTRIC FEE
D Z ante of the work forwhichthb permit is lssued(Set,3077,CIv.C.) _ PLUMBING FEE
V o Lenders Name
U. F- Landers Addmss QTY. -. MECHANICAL PERMIT `- '_FEE MECHANICAL FEE
O w Icertlfythatl have read thisappliatlonand statethaitheateveidlemeation FEES PAID:
Isru eo.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE
} 0. relating tobullding construction,and hereby authodae representatives ofthis
U) city to enter upon the abovcmenuoned property for inspection purposes. ALTERORADDTOMECH. Dale RecelPt#
(We)agree to save,Indemnify an d kee arMess the City Of Cupertino
against llabiBtles' gments'(.1 rad ses which may In any way acme AIR HANDLING UNIT(TO 10,00 CFM) SUBTOTAL: 76.Ya
again al Iryl cos ort Ming permit AIR HANDLING UNIT(OVER 10000 CFM) CONSTRUCTION TAX
n �?
Date EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
5 mturc of Bant/CaNranor
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant orfuture building occupant store pr handle haaallous HEATING UNIT(70 I00,0D0 BTT) Date Reuel t#
material as defined by the Cupenino Municipal Code,Chapter 9.12 and the
Health and Safety Code Semon 2e,32(x)? HEATING UNIT(OVER I00000 BTU) TOTAL: .�
❑ Yes M No
Willtheappliant or future building occupant use equipment Ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdous air contaminants as def red by tM Bay Area Air
Qu Iity Management District? BO(LER-COMP(3HPOR100,0(0BTU) PAI®
Ym No BOILER-COMP(OVER 100,000 BTU)
haveread thehazeaom rCod,brequimmenbunderChapter. 1 of
the em:a dthatifth ds Safety Code,not currently
ntlyh�505veate25533 tend nant,
I T�s�JJ s TPf+�
undersand that if the building docs notamcntly have atewnq that ltbmy NEV RESIDENTIAL MECH.—SWT �1T is
mapomibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Occupancy.
Owncror mthorisd agent Date TOTAL: ISSLBDBY:
OFFICE COPY