23883 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preed Identification 7PERMIT NO.
Building Addreu:
Ev f)(-5 \j I- PL 4g 238
83
am. me
C, Y'0 .) Z gIS oS--LI CITY OF CUPERTINO-BUILDING DIVISION eZ�
Cmntraaer.Name: x` Idc.NO APPLICATION / PERMIT
Z)faaq BUILDINGS.ECTRICALI'LIJMBINGMCCHAMCAL CATEGORY CONTROL.
Archltea/Engrcer. Llc No:
A"� I 1.._py,DN\ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
O O Q�h oA. ' SJ
i Add. Q�L"1p IPFRFRTISSUANCE
LICENSED CONTRACTORS DECLARATI
Ihemby0thatla licensedunderpmvly ofClupter9(mmmmc APPOANCESRF_4DENfIAL JOB DESCRII'TI)ON
�eoOt immffi Sedbn7000)of Divlebn3ofthe Bu.iv dPmfeas Code,andiM
Iimn.e la in hB fp¢e and effmr. ,( PANELS
Lave Chi Lie g �O�Q '�' J N47 1�
Date CoMrador UP TO Me AhT�5
ARCHITECTS DECLARATION 1-1000AMP5
u�X IundeW&nd my pbmetull be used u public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
'Vy r
Licensed Professional SIGNB ELFLTRICAL 2{cq 5 (�rna J 113
III 6 p6�j OWNERexempt
x ILDERmptfro DECLARATION SPKIALCIRCUIT/MIS t ♦ _^ t �/A
f' 7 Iheneby&lflrm thetlam exemptfromthe Comngor'elfmnse law for the r!G, L `VX
7 '� f
rontywhrtkhrenq.u(lSmMa1opne7MQiIt5o,mBuvme,&aMlteI,Prmope ro ,de=d Whoyrdrttyatmr
TEMP.METER OR POLE INST.
S any assigned pdmtoltahat he is licensed
rtatheat to
foreucoresof ter POWER DEVICES
file a signed statement that he t r9(commencing
purcn g hi the hno 70 ) of tee
30, Contuaors Weevelaw(Chepter9(mmrcnMg wbh Seatlon 70M)of� 1Rd- VALKJV�Om
S alun3oftheBuslnsandProfemlonsCode)Orthl+ nd TIPN
atheexempttherefromaSWPA9NGiVOLELECTRIC 2l3
S
the buab
ts,for the alleged exemption. Any violation of Sen 7(015 by any OUTLE15SWITCIlESS%MtES 11W 0-
rm
p� O
applicant fora pek subkm d
theapplicant too vil pmo
enalty of.. re than I
Me hundred dollars($SM.
NEWRESIDENMALELECTR FT.
�n ❑I,as owner of the property,or my emptayen with wages u their sole _� STORIES TYPE CONSTRUCTION
romper utlm,will do the work.and the structure Is not W ended or Offered for /11
Osale(Sec.7004,Bushes and Pfefmiov Code:The Coranaors License Taw V.7
�$ does net apply to an Owner of property who build.or impeown thereon,and OCC GROUP RES.IWITS
who don ms
such work Melfvr his..through hisn emnplryenvdsuch,proed that su
ImryrovemeMs arc not Intended orofered forsale.If,however,thehu dirges 7 -
Improvement issod wlthinovycarofcomplabn,the ownrr-builderwW have
t enofprongthathedid embuildorimprwefnpurposeo!sale.). QTY. PLUMBING PERMIT FEE
� das Owner of the property,am excWtwly mntricting with licensed FLOOD ZONE APN
mntn tommtudthepmia(Sm7044,Buslneaand Pro Wm Code: SIT ISSUANCE
The CoMnaor's License Law dm not apply to u owner d property who �T.pR DRAIN 6 VENT-WATER(EA)W Bda or Improve mmmna- w'
therms, and who aa for such ptojth&
ryR¢�aor(a)Ilnrnsed puesuantto the Contradd.Lava Gw. BAIX FLOW PROTFrT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B 4 P C for thin musico
"u'SIDE FELS
DRAINS FLOCK ROOF,AREA,COND. SANITARY Y_ N
Owner Date RFCEPT 0
WORKMAN COMPENSATION DECLARATION PLY.TURF4 PER TRAP SCI{OOL TAX Y_ N_
❑1 hereby affirm that I have a mrtlfiate Of coruent to calf-Inure,oraREcte,g
certBlata of Worken'C«npevatlon Insurance Or.oertifkd copy thereof Sec. GAS EA.SYSTEM-1WUOITR.E15 PARK FEE Y
38 _ N_
00,lab CJ
Polley/ GAS P.A.SYSTEM-OVER 4(EA) RING DI g
Cery-Cert }.�\< i x RIIILDING DI VISION FEES
14❑-'rIFCeOa1�I led espy is herchy filed
the ed. CRFOSE/WDUSTRI,WASTE INTERCEPTOR PLANCHECK FEE
NM espy b(0ed with the dty inspection diV Wm.
CERTIFICATE OF EXEMPTION MOM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEVER-SANITARY-STORM EA 2X:F Date Rccei I
(Thio udbn need nO he completed Rthe permit b faorc hundred dollars
($100)orlea.J WATER I-IFArER W/VENT/E.EcrR ENERGY FEE Y N
I certify that lo the pedorn erce.f the work f trwhich this permit is lesned, —
I ahu0 not employ any person in any moor m u to become subject to the WATER SYSTEM/TREATING
Wvrken Compensation Laws of Glifornla.Date .PAID
O Z Applicant NEW RESTI
DENAL PIMB. SQFT. Date Rccei ted
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subject to the Worked COmpereatlon prodsiuv of the Labor TOTAL:
Q N Code,you moot forthwNh comply with such pruv6bv Or this pemat"[I be I
LU > deemed r Iwsf. _
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyafflrm that then b a mvtruglon lending agency forthe peAorm ELECTRIC FEE bw
Z ane of the wofkf.'r which this pe b bared(See 3(197,Cl,C) T
(� O lender.Name 1, 1 n PLUMBING FEE O
LL F Iendcr'a oddness 'Tf QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 oeditythat l have read thio application and date that theabove Information
1 bcorred.lsgreemc« plywhha)ldtyardmuntyord =v ands telaws PFRMITLSSUANCE FEES PAID:
>-
N rclatIngto Wilding ronivgian,and hertbyauthWertprQntath edible
city,to enter upon the abovo-mentbned property for inspection purposes. ALTERORADDTOMECH.
Z
V Z (Wr)agree to save,Indemnify and keep hamdes the Clty of Cupegloo Date Receipt#
agaivt Bab Wtln,Ndgmeras,coie and expevn which myln anyway aaxue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
age Wt said City In con.arye�of the granting Of thls perm! AIR HANIXI NC UNIT(OVER 1QWOCFTD CONSTRUCTION TAX l
� .A. _�� 3�\ \o�ZhC� CONSTRUCTION TAX PAID:
Signature of Ap loot A RDOIaor Date FXFIAIIST HOOD(WI DUCT)
NAlARDOU9 MATE IALS DISCLOSURE
Will ia the a e defir red by
future Perrinuild ingo
niciplCe1r, orhendle h,end
HEATING UNIT(TO l00,W00TU) Date Recel t#
matelot as droned bye S ct1.2 eo MuMdpal Code,Chapter 9.1;end the
Fleahh and Safety Cade SOilon]5537W7 HEATING UNIT(OVER IW,WO B'ITJ) TOT L:
Rill
No
Wdlthe app0canto�turt WBdingecapantuu the Buy mordeWms VENTILATION FANSWGIB RESID) ISSUANCE DATE
whichemithaement airrontamWntsas deflmd bythe Bey Area A4 p�
Quailry Management Dbtdn7 BOILFR{OMP131E'DR 1W,IX9 BTU) 1�
4 Yn —I No
havervdthe haw ous materials requirements under Chapter 6,95 of BOILER.COMP(OVER 100,000 BTU)
the CalBornla Health h Safety Code,Sections E505,75533 and 75534.1 U►t,fj aF
understand that ifth.Wlldlngdoea not currently haw&tenant,that It is my NEWRESIDPN7IALMECH. SQFf /B 30 1A
mponsbWty to notify the occupant of the requlrementswh"most be met ^
pnbr b n isauanufa Certiflatc of Oceup ncy. ' /J
/r
Ut-
c-, , I,, ) � J-WsA . �( Ler �
Owoerorauthcri agent Date Is ISSUED BY:
OFFICE COPY YG