20000 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pro'ca WrntlfloHon " •''� �•f. LE M[ITNO.
BuidirgAddm.v leF-cVuk4 6-am�e t' CITY OFCUPERTINO-BUILDING DIVISION
® Centnder'aName: Lk.Na APPLICATION / PERMIT
BUILDINGELECTR ALPLUMBINGMWIiAMCAL CATEGORY CONTROL
A ea/Engineer. k.Na
Z ` r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— _ ad �F. PFRMTISgUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lfeen Led under provisions ofChapter9(mmmmc APPI.IANCESRF9DENIA1. J()g ON
fngwith Sa1bn7000)of Dlvlslon3ofthe Buelrresand I1nfeuuunj Code,and '�I P ((—�lX,
B¢nm b In(uBy-(fyorx'y¢and dteR. - PANELS L—
LkeR+eCy.2a-/J. s 2 V
Dale CoMncioKA ma
r n Mat^ anicd
LA
ARCHITECTS DECRATION 101-1
G Iurderstexi myplamekBbeued upubllcretad� OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
}i [j Lkensed Profenlonal SIGNS ELECTRICAL
fn 6a OWNER-BUILDER DECLARATION SPECIAL CECIJIT/MUSIC
Ihenbyaf@mthallrmexemptfmmthe CeMTWeri Llc Uwfmtk
O pp:i,
a TEMP.METER OR POLE INST.
K� �` countywhlchpe miap amm a r regt,a theaprwe,de m6 ornpt.
any strudun prisme ItsheheI,abonqu pursuant to the
f¢evch pemdt to
(ha a signed abatement that k b Boenaed pursuant to tkprovbbm of the LOWER DEVICES v
OS
Contractor's Lcenae Law(Cha 9(mmrrencin withSeWan70M)ofDlvl-
ebn3oflhe Business and l'rdmbnsCadel orlhat Fels enmpttherclmmandSY''0`fMING IDOL ELECTRIC VALUATION
y.' tk basis for the alleged exemption- My ,violation d Section 7!315 by any
yon applicant for a permit subjents the applicant to a civil penalty of not mon than OUTI.EISSWITCF@SFI%NRES
dollee,MM.
n,I as owner oft NEW RESIDENTIAL EECTR SQ.FT. STORIES =CONSTRUCTION
G72 property,or eseumne it with r their
mmpmuallon,w111dotkwaeKandthe WuadeRhe C.e ceded or offered for
5 O vale Sec.apply
to an owner
Profmlons Code:Wild.CoMnctors U¢nse law -
$$ don does
apply roan owrcr dthroug his own
nemporimpmovidedthatsnw,thereon, nd
such OCC GROIII' RFS UNTIB
who doeaweh m not mxBmt ore ugh haorf em p,howepmvd ver,the buiWiarch
improvement It seLd Intended
one earofrtd!merle.If,hoover-bu Ilderwill have TOTAL;
improvement bsdd within eneyearafcampldbn,tkownerbullderwW have
tll9kundm of proving the he did not build or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE
U Las owner of the property,am exclusively mntraetrg with ILLensed FLOOD LONE AI'N
PERMIT�IIANCE
ntrectto construct the project(Sec 70K Buelneseami Prefubna Cade:
moe e'3
The s or Improves
es the Law don no apply ct an r. d prop"who ALTER-DRAIN VENT-WA=(EM
Wilds or improve thereon,and who mMntla for weh p�e)eas with a
19114aetor(s)Iircrued pursuant to the Contnd¢i Lf¢nse Law. BAC:FLOW PROTECT.DEVICE FEE SUMMARY
L_j I am exempt under Sec B k P C for the uawnOUTSI DE FEES
IXUINS FLOOR ROOF,AREA,CONTI. SANITARY Y N_
• Owner Date RECEIPT If
WORen IANthe COMPENSATION DECLARATION FDnIJRFS PER TRAP Sa3O0I.TAK Y_ N_
®1 hereby effrorkem that I Frac• Inau ate d crosent to nlf-Wurc,(Sa RECEIPT I
3800,mniftabte o/Workeri Compewllonlnaunn¢ova¢rtlfled copythemN(Sec. GAS F.A.SYSTEM-1 INC OUTLETS PARK FEE Y N
3800,lab CJ
Policy If 0610040779 RECEIPTI
Com ray Wancdu nE:_ _[)_ GAS'EA.SYSTEhfOVER°(FA) BUILDING DIVISION FEES
Certlfied copy b hereby tomished.
FCenRled ropy b filed'Mth the city impeedoo division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EfO,IPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEVER-SANTTARYSTORM EA.X(IT. Date RCQII t# .
(Ihseedbn nevi eat tr completed R tk pemdt b!snore hundmd dollen
MOO)arfyt WATER BEATER W/VFNT/E3ECTR ENERGYFEE Y_ N_
I¢Am CmPbthe perxor many manner
forwhichoospesub Ielto the
1 shall nm empty any peramr N any manner n n to become subject to the WATQt SYSHI.f/TRFATWG
Applin campenaatmn Lw.of aurmw.Dale PAID
O Z Appllant NFW RESDFNIIAL I'I.MB. FT. Date Rene[ t#
Z O NOTICETO APPLICANT:IL after nuking thio CeMfiate of Exemption,you
should becoe msobkcl to the WorMen'Compereatlon provisions of the Labor TOTAL:
Uj~ H Cade,you mueafmthwhh romply with wch provisions orthb pemJt shall be OIN
> deemed revoked.
dCONSTRUCTION LFADWG AGENCY SEISM19 FEE
Lkrabyefirm thattkrcbamwmcianlendingageny(ortkpedorm TOTAL 4Q ELECTRIC FEE
Z ante of the workfor whkh this permit b iasued LSee 3097,CN.C.) L
O O 'Mer'.Name PLUMBING FEE
LL ~ Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O U l¢rllfythatl havereadthe,appuatonand steemattheanowinfomunion
bmrrro.lagreetoconplywdh alldtyand oountyordWnmand statelaws PERMIT ISSUANCE FEES PAI D:
} N relating to Wilding mnsimttlon,and kreby aulhorb mpresentativei ofthia -
F Z dty to enterupon the aboaommntbrcd Property for Inspection purpose. ALT13t ORADDMMFLH..9. Date Recel t#-
— (We)agto aaw,Indemnify an d keep harmless the City of Cupertino -
agalnst Bab Wties,judgmenls,mated expesne whkh may in any wayacxxue AIR HANDLING UNIT(PO 10,000 CFM)
.gainer Bald City In consequenoe o tk granting dthbpemdt. SUBTOTAL
AIRHANDUNGUNIT(OVFR10,000CFM) CONSTRUCTION TAX
igreunotAppllun t a D,te ID(HAUSTHOOD(% /DUCT) CONSTRUCTION TAX PAID:
\
HA7ARD6IJS MATERIALS DISCLOSURE
Will thcappllant orfuture bullding.pantetoreorhardle hazardous HEATING UNIT(TO 100,000 BTU) .Date Recei f#.
material as defined by the Go PcAiw Murddpal Code,Chapter 9.11,and the
Iltnealth and Safety Code Section 1553I(a)7 HEATING UNIT(OVER IM000 BTU) TOTAL:
_IYn No
ferret appliaMm tun Wilding oavpanl ubythe yA mdevtm VENTIIATTON FAN(SWGLE RF9D) I$$ NCaF�ATE
whkh emit ha:,rdws air�tamLunts as defined bythe Bay A.Air _0�]�,�}
®
Quality Management DisuicU pt BOILER-COMP DFB'OR 100,IX0 IHU) _.W
4halfeonnHeaLLhkSuua(etyCodee,lsrcq ementaunderChapter695of BO RCVMP(OVfR100,0006N7 JUN 2 61990
the 2SS05,25D3 and 2S534.I
undmtand that lithe Wilding does rot currently have a tenant,that It le my NTW RESIDENTIAL MECH.—SQ—FT,
roponslbd8y,to rally the oaupant of the requirements which must be met
prim to ivvance ole Cer00ate of panty. Co of Cupwri"
nerm 6-�S-9d ���4CC 6
authortu a e Data TOTAL ISSUED BY:
OFFICE COPY