21093 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEPS ONLY
BUMI.8 Pro ed IdeetlRmdrn PERWT NO.
B i"lig �/®,- � ` I � 21093
a b44&Ir-H,P-, -Q5-9_/4797 CLTYOFCUPERTINO-BUILDINGDIVISION
C. a amz �� Tee. = APPLICATION l PERMIT
IMAMBIA DING-EISC1RICALPLUMPING-MECHANICAL CA=RY CONTROL
ArrhBed/Engivme: Lie.Na _
QTYELECTRIC PERMIT EE BUILDING PERMIT INFO
Addnac PFRh(ITIMANCE ❑ ❑ ❑ B
LICENSED CONTRACTORS DECLARATION
I hereby aBirmtbat I am Oomsed ander provklone of Chaptar9(conmfteoe APPITANCE&RESMENITAL TOB DESCRIPTION
/ngwlthSed1on7000)ofDlvlelon3 theBuefoesammdProfees(omCode,end
Iicenmtete rmnnd e(fed. ! ��
PANELS
Llmnm�Lk.B 6J
Date Contractor
CIDPECTS DECLARATION 271-IMO AMPS
8z Iundeutaod pry plansshallbe used as public ramda OVFR1000AbM SQ.PT.NMRAREA S/SQ.FT.
o
Llmnced Professional 9IGNSmwr-rmrer
owwt-BOILDEa DECLARATION spEcinr crSt=
zp, Ihambyar&mthatlamexenytfromtheCoNrutor'sLirnnmiawforUu
[ollowlvg nmaay.(5etlton 7mis,Business avd PraFeesbns Cede:Any
city or TEILE,milmoitp4zw.
randy which requhm a pervtlt to mmtruc;altrr,lmpnova,demola4 m repair
q�
anyetrudurepdmtofmlanuanalaerequirntheappllmnt(oreuchperndtto POWER DEVI
15 O Bis a algded etntearnt thffi he la Ilceeaed pumuant m the provEaione of ttu
[y tt�� Contmdor'eLiceme Law(Chapter9(mmmmmdngwBh Becton 7000)of Owl- swwmGy6DLEL=C
"A
by
VALUATION
w'•77 the lveia far the aueged exasptfon. Any vlclatlm M seRlan 7mis by anyFIXTURE4
Ger epplltmifora perm[taubjeCatheappllmvtmacWl petultyofnat morethan
81 Bve,_}undred dollam fS`,0�. NEW ENTW.ELECTR—SQ yr. STORIES TYPECDNSTRUCITON
L m owner of the properly,as my employees wlih wage mm Urea'eoo
compensaaarywllldathewmkmmdtheetrudure lsmkhdendedar oSered fm
OLAW
don wtapplytoan owner afpropenywhobulldsorimprovnthereon,mmd OCC-GROUP RFS UNITS
whado®aurhworkbimcelfmthmughhisownamplayme'PAN edthateuch
Impmvemenmare not Wendedoroffered fmsale.Ithowwet tbebulklln9 or TOTAL:
ivtprovemerd lasoldwhhinareyearefc®rpkHmytheowner-buEderwW have
en ofpnWingthet be dM mtfiuLLd orimptova tmpurpmaofData QTY. PLUMBING PERMIT FLOOD ZONE AFN
mm owner of the property,am eadiue(vely coca acBng with licensed PERMTrISSUANCE
mntrxtoretommhud:Bre project(Sets 70K Business and Professions Code:
The Commoma L)mnse Law does not apply to an owan of property who ALTER-DRAIN&VENT-WATER(EQ
builds or Improves thenen,and who mu ado for each ptolee s%th a FEE SUMMARY
mtheContredor'e Limrua Law. BACRFIDWPRC/TECT.DEVICE
771`1210== B&P C for this reason
Owner Gate DRAIN&FLOOR RODF,AREA,GOND. SANITARY RECEIPT 6
ii�AWORKMAN 00MPIINSATION DECLARATION FDOUM&PERTRAP SCWMTAX Y_ N_
FV
y�a7�y ef9rvt that I have a cetUBcate d trouser to aeR-kmtre,m• RECmrT 6
6AMmwofWarkers'cempons tumlrsuranm mamtyled mpythereaf(Sec. GAS EA.SYSTEM-1 IN r-4 CUM76 PARKER Y_ N
Ca OZ ZJfs l "PJ GAS.EA.SYSTEM-OVElta
Pol 0 RECEIPT'B
may BImD>rrcolVlstoNFEes
b the GREASE/)NOUSTRLW INTERCEPTOR
cCertified opy with
herbyth fised.hed.cay inspection diWdton. PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANTA RM EA.OEM Date Recei t#
(Thie seNon need not be completed I the pemdt fafar oro hundred dollam
tsle)mlew WATER HFA W/vENT/ELECTR ENERGYFEE Y_ N_
I mrBfy nut In tha pwformaam of the work for whish this permft is isared,
I shall eat empty my pereon le any manner so as to became subjeG to the WATERSY /TREATING
Wmkera'Compmsatton Lawsof CdiImN Date PAID
Applicant y P1M . SQgr, Date Reoel t#
Z 0 NOTICE TO APPLICANT:I,after we"this Certificate of Exemption,you
should became subject to the Workera'CompemaBmt provisbn7 the labor TOTAL'
tqCode,yea vwet fatthwkhcamplywithwchp wisiom or"p.m d.Ube BUILDING FEE
Ic III7 d CONSTRUCTIONLENDING AGENCY SEISMIC FEE
CL IherebydE=thattbere isacmutrueSon)ndmgagemy fortbe pm.-.-. TT)TALt ELECTRIC FEE
z mmmofthe work forwhlchthis permit la hoard Oce 3097,CN.Q
() O LenderaName PLUMBING FEE
LL I- Lendees Address QTY. MECHANICAL PERMIT EEE MECHANICAL FEE
U lmrtifyoh Ihawreadthisappliwd= ndmahethattbeeboveWormaOon
O W la correct.lagreet000mplywBhaadtyandcuuatyerdhunomsodatatelzws PMM ISSUANCE 12 J56 FEES PAID:
IL relatingtoballdiagmnsbudion,ard herehy AutMrize repreauttaBvesofthis
H U) etymentnupontheabovcmmgonedpropedyfor Ira pedbnpurpMM ALTERORADDTOMIEFI. Date Receipt#
(We)agree to save,ivdevu+ify an d keep harmless the City of Cupedhia
agaimtllablildoo,(udgmade.msteandeapermawMehmayinan wayaonue AIRIIANDUNGUDIT CrOlLUMOCF4 SUBTOTAL:
a d f�Cofthe��
t /C�u/y�, CO"8Bm'� �xa11° p ATR IIANDLIVG UNIT(OVER 10,000 CFM CONSTRUCTIONTAX
y.0/r e� oftfile �/ /O
StgnaturereadAppumrc/ContraMor Date DMAUSTHOOD MIDUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC7.0SURE
Will the appllmtd mfuWre buildingouatpantatom orhandle hazardous HEATING UNIT(TO 1mm0 BTI) 9,0Date Recei t#
material m deftned by the OtperRno Mutddpal Cade,Chapter 912,and the
ffeatthard Safety CodSecioa25532(a)2 HEATING UNIT(OVER 100,000 BTU) I,; rt e1�
❑Yes Np
Willtheapp0mnt or futurebai)dingoaupmmtueeegatpment ordevkas VENTIIATIONFAN(SINGLERESID) 15516,1 - TE
I. which emithaardousairomfaulambeedeflned Whalley Ams Air
Qua Mamga�M No
BOILER{OMP OiHPORIm,000 BTU) t
EYNOV � �
4es No h amsdhefia wevaedemry4emeaeundnCbapeGASof BOILER-COMP(OVEt100,0WIITU)
e
the Ca Ve ea Healtb&Ssfety Cod4&dton87s.505,25533 and 25934.I
undeeetand that iftha buBding does not currently have a tmord,that it la my NEW RESIDENTIAL MECi. SQ.FT. Al of '_i TFrlfl�
reaponsl6Bhytonoilfytheocoaperdafthe requireaertswhiehmostberne, L` ffts �t
prlorto Issuarw of a CertiBcateof(kxupamy. -µJ
Ownercambarizedagaat Date LSSIIED BY:v VI"� 1'TtN Int" ��
TOTAL:
OFFICE COPY