22633 J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building ProIdentification PEIMTNO.
Building Address:
22633
L�1'• o'11 CITY OF CUPERTINO-BUILDING DIVISION
cm °e N. APPLICATION I PERMIT
� S BUILDINGFI,ECIRICALI'LUMBINGMECIIANICAL CATEGORY CONTROL I
ArdXed/Englrcer. Lk Na
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
Add. / ✓J/7 v.L APERMTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby Wkmnslut lam BcmeedunderpmwMau'f Chapter9(mmmenc APPIIANCESRESIDFMIAL J BDESCaN
ingwith Smc .7000)'!Dlvlebn3ofthe BuM.n dProfeael Code,andrny
Ike ns ICis fuN d mn
dfart PANELSLiee
Date Codor p
�� UP TO 2000AMRS
ARCHITECTS DECIARATION 1-1 AMPS
µppµ!!04 QQZ I understand my plan shaube used n pubBcremrd> OVERI000AMPS $/SQ.FT.
?i X, Lkxrucd Pro/mbvl SIGNS ELECTRICAL FM
p U T E R
6 OWNER-BUImn
LDER DECLIRATION
Ion SPECIAL CIRCUIT/MLSC
t.., 9 Thereby sfOrm that lam exempt lrom the Cocmrb Lkrnse lAwfor the I ,
7.9 following reason.5,d 9(315,Buslneas and lhofeeeWv Code.Any dty or
OG TEMP.MLTTRORI'OLE INSf.
'p 4 muntywhkh pequlrna Permit to rout,uc;alter,lmpmvet forsch,orreperomttoDAT
any at Jaxazzee,afsortgWrtsntant the t t he (msuchpermitto
file•signed mtemmt thrt he b Benaed punuent b the prvvbbv of the I'OWF.R DEVICES
00 Contndor's Lkevelrtw(Chapter9(mmmendng with Sedbn 7(11X)of DM-
0
SWAM
NG POOL ELECTRIC
don 3 olthe Budne.md Prdembv Cade)orthrt he 6 exempt NexfromaM VALUATION
K'g the Web for the sikged eaemptbn. My violation of Sectbn 90315 by any -�
�pr5I applicant fora permit abject/the the applicant to a dull penalty of not mom than OU71.E'ISSW17CFff3FlXTl1AES
�� lit/�ndndl owne,r ars ofthe Pro �Ft', STORIES TYPE CONSTRUCTION
LJ'•a ower of the property,or my ermrybym wXh wages u their sole NEW RESIDPNDAI.ELECIR
mmpovation,willdothe work,and thestadure is not bdeMeci or offered for
Oale(See 70K Rueruv aM Proleabv Cade:The Comractore Gave Law ..
({ g don rat apply toan ower of property who W ibis or improv.there',and OCG GROUT' RFS UNfi5
E whod..a h.khlmxlfo th.gh M...n npl ye ,pr WMttut.ch
onprovemeMe art nextIntended oroffered forsale.If,havever,the W L;Bding or TOTAL'
improvement beold wkhinarcyearofcompldbo,the wvner-bullderwW Wve
t relen of proving that he did not Wild or improve for purpose of safe.). QTY, PLUMBING PERMIT FEE
1,as owner of the property,am excWaively :m%n,ting with Ilrenaed FLOOD 7L1NE APN
mntndms to mMruct the pmjed(See 70K Bush®and Professions Cade PERMIT ISSUANCE
Ile Contractor:Lkemue Law don not apply to an,owner of pmperty who
WIMa or Improves Hereon, and who mmncts for such ptojecv with a ALTER-DRANI&VENT-WATER
c,)ypdorW tkeroxd pursuant to the conaadw:Llnnx taw. FEE SUMMARY
LJ I am nempt under Sec B k P C for this reason BACK FLOW PROTECT DEVICE QMSIQFFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Ow^er RECEIPT I
• WOhCOMPENSATION DEE CLARATION
QI hereby dofirmrm that
I have•rtdinnte of Covent to self-Iwrt,or• NQS lRAIs SCHOOL TAX Y_ N_
srtNxw.o(Warken'Compensstlm�Iwnnax a a mtNled mpytherto((Sec.
RECEIPT g
,LabC.) GAS FA.SYSTEM-1 ING�OUIT.EIS. PARK FEE Y_ N
porky g umlened. RECEIPT
T d
ray GAS EA.SYSTM-0VER 4(FA) BUILDING DIV
ISION FEE
pdbn division bb nhror.thewGREASE/NDUSIRL WASTE 24TERCEPTUR PLANCHECK ES
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA �T Date Reed tit
(Thi-aectbn need not he completed if the permit b intone hundred doBara
(91aWorlsJ WATER HEATER W/VENT'/ELELTR ENERGYFEE Y N
I rtrnfythrt U the pedonanm of the wait/or wMch this permit b lsued,
I-hall not employ any person In any manner so as to become subjed to the WATER SYSTEM/TREATINGWmIo ra'Compevatbn taws of California.Date PAID
OZ Applin"t NEW RESIDENTIAL I'LMB. SOFT. Date Recei tit
Z O mmeNOTICE TO APPLICANT.If,after making this CertBkate of Exemption,you
shld becosub)ed to the Worken'Compentanon provbbnsof the Labor TOTAL
P U) CMe,y'urruatfathwkh=ply hath chprovblovorthlapemdtahallbe
dee n d revoked. U
W CONSTRUCTION ILENDNG AGENCY 5EISMIC FEE
d Iherebyaffi hattheme, mvtructionlendingagerryforthepedorm ELECTRIC FEE
Z anm of the work(',which thfsa=b baued(Sec 3097,Civ.Q TOTAL
00 Lendee.N.
PLUMBING FEE
LL F LeMcrb Addre. QTY. MECHANICAL PERMIT FEE
O LU Imrt"at l have read thb.ppBatbn.M mtethattheabove information MECHANICAL FEE
a nromel.IagreetoeanplywkhaBdtyardmuntyordlrun md-tatelaw- PERMIT ISSUANCE FEES PAID:
>_ relating to building mvtruchre,and hereby authorise representative ofthb -
F Z city to enter upon the abovc-mentbrcd property for Wpedbn purpose. ALTER ORADDTO MECH. Date ,MCI t#
_ (We)agree to save,IMemoly an d keep harmless the City of Cupertino
agaWt WbiNtin,W gl�ienb,mrtaaM es pen hkhmaylnanywayamue AIR HANDLING UNIT CN 10,000 CFM)
galatt c� uenceofogram Ms pemdt SUBTOTAL-
- /J / ane 91171 AIR IT NDUNG UNIT(OVER IQ"CM CONSTRUCTION TAX
Slay{ re or Applicant/Contractor d' / EkTUUSTHOOD(W/DUCE CONSTRUCTION TAX PAID:
HAZARDOUS MATERULS DISCLOSURE
Will the-pplkant or future building art/pant.t.r,.,handle hanrdoua HEATING UNIT(TO IM,W0 RTU) Date RCCCI t#
matembl as defirud by the CuNrtiw MuNdpal CMe,Chapter 9.1Z and the
Ikahh and Safety C'd!,Sjndlon 75537(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
n Yn I�1 No
dl the apperamm tune Wilding oaup.nt use equipment or devims VENTILATION FAN(SINGLE RMD) ISSUANCE DATE
I whkh emit havrdous air mntarnamsu denrcd hythe Bay Area Air
Qua Wy Maagem`mot Dk!pd? BOILER-NMP QFN'OR 100,,1(3 BTU)
4Yn 1QNo
Wvertad the h oetrt ode,St re gW25505, underChapter.1 of BOILER COMP(OVER 100,000 RT(n A,�r(
. unthe Ca mtaM to bath dinfety d noctbv755 lx 7,e.3end,that it
PILY
uM.s.smahati(tha dingd�es not currently have atenant.thatkLs my NEW RESIDENTIAL MECH. SQFT A�
mnp'vbllNybn thewcupam ofthe tenants whkh must be met
pro"t )'C fkateof C�upa (1r
Own authorised agent to I V U N /
rornL 04 gall ffn F
OFFICE COPY