21766 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentlfkaBon a.�_r-/_ _� fRJRa _'►"� PF�ihflT h'O. \
BuOding Addw: � al—`/-+R`�](� 1�.K7V U�� 21766
1 C 1-115- 72 �2z2 SIR 2
r. CITY OF CUPERTINO-BUILDING DIVISION
cunt" 'sNatne �I ek.Nv. APPLICATION / PERMIT
Y"C BUILDINGRWELDC PLUMBINGMDCHANKCM, CATEGORY CONTROL Y
Arth m/Engineers Lk.Na
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aaarac PERMIT ISSUANCE Is ❑ ,❑ ❑
LICENSED CON uR erSDECLARATION
withS alflnn3)ofamM 30fe eB provhndPmfhapter9( c APPLIANCESRF9DF.MTAL PBD RIPDON
IngwlthSMbn force of Dldsbn3 ofineBuW�sand PmleWwuCod d
11¢Ne b In full forte and effect. PANELS 1
Lianx Cllas LILY �2 Q G' rE soRow—
ate Contractor Y.,JJ�� v�0` v
ARCHITECT E RATj 201,10DOAMPS
mzC IundentaMnyplavalu0beueedaspubllcre®des OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.Ff.
00
`j Licensed Prdmbvl SIGNSEL2C7RICAL �..
OWNER-BUILDER DECLARATION SPECIALCIRCUITIM13C
p I hereby affirm that l am exempt from the C.m,M:tor'n Lice.Law for the
p fcWwing reason.(Scdsan 901 S,Business.mi ProfmloN Code:My city or
O] e TEMP.MET79t OR POLE INST.
F� mystm lchrequHeaapemmt alco mmqu dtheaprove,derml&orrtpto
flky any atnnureptementahar he,is licepursuant t the forauch,of to POWER DEVICES
K Co a Ngnrd statement the he h licensedl)( pursuant it the pmvhbN of the
CnmradLhe Licenselaw(Clmp 9(mnvnndng ek Seaton900))d ard! SWIMMING POOL ELECTRIC
+m0� sbn3olthe Rusbmand Prdmbn. Ary orthdhof ScoU tthnrefu by and VALUATION
�n the hash for the dleged exempteap Any vlalatd n of Scab"n" by any
OSA applcandred Pela.($5 jedn theapplkanttos ddl penalty dna mon thin 0[IfLETSo'TVI'ICEQSFlXNRES
r� (Wc Hunan,ddlan he pr.
F1 1,an owner of the Property,or my employees with wages astheir sok NEW RISDENTULEI.Ff7R SQFI'. STORIES TYPECONSIRIXTION
compeNatlon,wllldothe wmk,and thewuaun b wt IMeMed or o(fenM far
do,,ts not
O xk(Sec 7011,to an owner
w and Pmlmbv Cade:The CoMnctves IJreve law
property
1$$$ who..Achy rkhw lfdth=gh s hemplyuilils or l ,p Wt that=chen,,and OCC.GROIIP RES.UNRS
0.0. whouvemorh wm nm Intendedawgh hl so sak.IC never,thebulhat gor
Improvemenb an nm Intended orolferN faille.IL However,the WlWinga TOTAL: 1 '
Improv menu inewi g th t o did nes build r Impro a for purpose
u poserwW love
try9,j Lr owner of the pMatdmwarlortmprwelarwgwith licensed
QTY. PLUMBING PERMIT FLE
Ltr L or owner of the Propoty,( 70K Buss mntn i n owXn s,Code, FT'ODD ZINE AI'N
mntndastomvtNnse Law doe outapplyt stn nand PmfmbN Godo: PERMIT ISSUANCE
The a or Imprl Ulnae law dart out apply to an owner p property who ALTER-DRAIN&VENT-WATER(FA)
Wilda or Improves thereon,and who madnda for such p.ojeav w0) a
qL3jador(emeeptunder Sec.
the Cm�tndaiLf¢nz law. BALK FLOW PROTECT DEVICE FEE SUMMARY
LJ f am e.emp[order Sec B k P C for this reason
e Owner Dace
DRAINS FLOOR,ROOF,AREA,OOND. SANITARY Y— N_
WORK MAN COMPENSATION DECLARATION RECEIPT Y
❑I herby affirm that 1 love
certificate d o not to ydneae, FDCNRFS PER TRAP SCHOOL TAC N
certificate ofWorm'CompeNauo Ivunnamaatrtifed copy thrreof(See. RECR'I
Y
]800,Lab
CJ GAS F.A.SYSTEM-1 INCL OIIlI.E15 PARK PEE 'Y_ N—
Policy 1 RECEIPT Y
GAS EA.SYSTEM-OVER l(EA) BUILDING DIVISION FEES
Com +
�IOed copy is hereby turNdnd. GREASE/INDUSrRI,WA57E wrERC=R PLANCHECK FEE
❑CenBied ropy h filed with the city Inspection dlWYmn.
CERTIFICATE OF IXEMPTION FROM WORKERS GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER SANITARY STORM EA 700FT Date RC i t#
(Thor lesson neM not be complded tithe pemat h fmorc hundred dollen
LYI IIB mI®J WATER HEATER W/VENT/ELILTR ENERGY FEE Y N
Ianetify mployat In an person
manynce of the work sores to ich
pemdthhothe
I What not empty any penin f any Hunner at as to become erb)ea to the WATER SYSTEM/TREATING
wmken•compen.amnlaw,are.uranh. Date - PAID
O = Applicant NEW RL4DFN71ALP MB. �FT, Date Rroei tb
Z NOTICE TO APPLICANT:If,after making this Cenlflnte of Exemption,you
N should become subject to the Worl,en'Compevatlon pmvlsbv ofthe Lbor TOTAL
Q j Code,you mrrtforthwith comply with such prmbdoN or this permit shall he
deemed revoked. U •E
CLC CONSTRUCTION LENDING AGENCY SEISMICFTE
I Hcrebyaffirmthat there Is.construction knding.ge for ttspeform ELECTRIC FEE
= arta of the work for which this permit is homed Sec 3099,Civ.C.) TOTAL, t
U O Lander'.Name PLUMBING FEE
LL H Lndcr'.Aadrm QTY. MECHANICAL PERMIT . FEE, MECHANICALFEE
W
O Iai"
nt l have read thhBca
apptbnarci Yatethatthe above lnfomudan
0. feco, .lagreetocomplyw audtyaMa ntyordiNnmandetatelaws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authodam representathres of this
F Z city to enter upon the above-mentlored property for hopedbn purpmm. MTFRORADDTOMECFl Date ReCel t#
_ (We)agree to alae,IMemNfy.n d keep harmless the City of Cu peniro
agaWt liabilities,y dgmentn,coda and expenses which may In any way accrue AIR HANDLING UNIT CTO 10,ODO CFM) SUBTOTAL:
against Bald City In consequence,of the granting d W permit.s pedt.
. AIR i-FANDurrc UNIT rovEn lo,DaocE,n CONSTRUCTION TAX
Signature of Applicant/Contrattor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX-PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplica rd arfuture W ldbg occupant Mom or hand le haaandoua HEATING UNIT CFO 100,070 RM Date Recel tic
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
liealt h and Ssfety Cad a Section 755370)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑yes No
Will the appilodm m Wilding oaapant use a ipmen mdnvim VENTIATION FAN(SINGLE REED) - ISSUANCE DATE
wnich eMt hazvaous atr con?Mvme 1a definN by lM Ray Area Alr
Quality Management IXarfct7 BORER-NMP QI-I'DRlfl(I,0(q B71p
40 Yve n ❑his
loread the na Nwu materials cpdmme.tsunder Chapm,6.95 of BOILER-NMProvp210],000BTU) ��� ����
the California Health&Safety Code,SeabN 25505,25S33 and 755M.1
understand that if the building dm not currently h.vea tenant that it h my NEW RESIDENTIAL MECIi SQ.FT
.poNlbil,y to notify the omupart of the nequlremenn which corn Ix met
prim to Issuance da Certificate ofOavpavy.
Ownerm authorlscd agent Date ISSUEDBY:�V-U�PTI ••+�� `"'eaV
TOTAL:
OFFICE COPY