22629 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY '
Rulldln Procct ldentlfkatlon' PER EITNO.
BuOding Addmas: ; �� 2.2629
Owner one: - A
C D /( •?,� CITYOFCUPERTINO-BUILDINGDIVISION
Contracusm (y(� LIc,N'o: APPLICATION / PERMIT
BUILDING ELECTRICAL-PLUMBINGMECHANICAL CATFfORY - CONTRO M/'
Archn./En r. Lk.No: eU
M, QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address n.iL
PERM171SSUANCE a_CX1:1 �r
LICENSED CONTRACTOR'S DECLARATION elX�I
!hereby ion7M that lamg.30funder provWoneolmionsC(mmmenc APPLIANCESRESIDENT1AL JOB DESCRIP71UN
Ingwlth Seaton 7,100)AnDlvlalm3o(1he0udneaand ProlealoneCade,and
limns.le In fuB( and J(act z+ PANELS
Limner Clan Contractor
Date = Contnaar_, l ®aJv
ARCHITECTS DECLARATION w fit-1000 AMTS
rcz , I understand my plana shag be used public records OVER 1000 AMPS
00 . Pu SQ.Fr.FLOOR AREA $
//SQ.FT.
Licensed Profembnal 9GNSE v`��� {•I^
92F< OWNER-B UILDER DECLARATION / (Ill'/
Z.�4 I herebya(firmthat l am exempt tram lh.Conl..es Limnw Uw fmthe SPECLILC CUL
0@ following reason.(Section7mIS,B..hussand Pro(eame.Cade:Mytltyor TEMPM
rm .a countywhich requRraa petrol reconstruct,alter,bnpowe,demolish,ormpalr
.<� any atrutlurc pdortelts Wuance,cels.mprlmtheappBant f.rmch per to
log U ale a Jgn d wtement that he V Bmnaed pursuant to the proal io u of the � R DE 7CFn5 A
BE6G Contnct.rs LlceveLw(CM1apter9(mmnendng with Sectbn 700D)of Dlvl• gWpdAgNGI IID.
p.,IS S J.n3o(the Buslneaand Profeal.ro Code)orthJ bebexem)gtherc(rom+nd VALUATION
yyyy Q the basis(or tM1e alleged eaemptbn. Any Woatbn of 'an
70715 by any s OVILETSSWITCHFSFIXTURES �.. 2� ( /' l Owl
0 appOonlf.ra permit aubjeM the appBc-at'--d
nt tea tivll perubyo(nat morcthan + V 3p CC//
00 fib
dollar(f.+OO), - NEW RESIDENTIAL ELECTR
U�n ❑I,as owner of'
f the property,or my employees wlih wage as Ihek e.4 —SRT. SIORIFS TYPECONSTRUCTION
mmpewtion,wllldothe wmk+nd thestruaure boot Intended or offered(or
O tale(Secaton,Bu.Rma and Pre(eeeI tyiCode TMC'cipecare he. Law
�$ does not apply,.en.weer of property who Wilde orimprwethercory and
whodoeeuchworkhboar"mthr.ugh E, wnemplw.provided that
tush OCC-GROUP - RES UNITS
Improvements are not Intended orolfercd(orale.l4 however,the Wading or TOTAL:
improvementteeold withinoneyearolcomplabn,theowner-W 0derw111 have
t rdeno(pmving that he did not build or improve fmpurposeof.k.). FBACKFLOW
ING PERMIT FEE
Lj 1.ere owner of the property,am exclusively cooncting with licensed FEOOD ZONE APN
contractors to construct the project(Sec.7066,Businea end Profesaimu Code: E ,
The Contractor's License Law does not Apply to+n owner of property who
WGde or imp
rove thereon,and who contracts for such piojects with AENT-WATER(EA)
ret.�actor(.)BcensM Pursuant to the Contnam'e License Law. I,FLT DEVICE FEE SUMMARY
LJ 1 am exempt under Sec B&P C far this reason
Ownar Dale ROOP,AREA,COND. SAMTARY
WORIOsxA COMPENSATION DECLARATION, RECEB'fN
❑I hereby affirm that I have A certificate of concent to self-Inwn,or A FIXTURES PER TRAP SCHOOL FA—X -
-2=m
AX Y - N .
3800,Lab ofWorkers'C.mpematimin mnmmamdtfiedcopythemo(6m. RECEEPrM
3800,Lab CJ GAS EA.SYS'TEM.I LNG OUTLETS PARKFEE Y N
Poll k GS EA.SYSTEM-0OVER ry("
kREGV
ISIONFEES
Crtfled copy b hereby
h d. UILDN
Certified copy la filed with
hthe city inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECAF
G
CERTIFICATE OF EXEMPTION FR OM WORKERS' GREASETRAP _ P I
. COMPENSATION INSURANCE
(Thts need not be completed if the permittsSEWER-SANITARYEA,2FP, Date 'RCCi(�rone hundred dollars Wet#
"
($100)or Iea..)J.
I certify that lhthe performance ofthewark forwhlch this permit is boxed, WATER HF.ATERW/VENT/ELFGTR E ERGY FEE' Y N—
I shall not employ any person In any manner so As to become subject to the
Workers'Compensation Laws of C+lifuse, Date WATER SYSTEM/TREATING
O Z Applicant -P
�.
ZO NOTICE 10 APPLICANT:[f,afternuking,laic Certlflmleo(Exem)Rl.n,you NEW RESIDENTIAL PLMB.__SQ,FF, Date Recti t# ��.
Hshould become subject to the Warkere-Compeuatlon provisions ofthe Labor
M N Code,you must forthwith comply with such provisions orlhb perms shall be TOTAL:
W > rimmed revoked. - B N E e ev
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
Ihereby affirm that there k a construction lending agency for the perform TOTAL: ELECTRIC FEE (�
O ance of the work for which this permit ishsued(Sec.30r?,Civ,CO t
V _ Lcrder's Name - PLUMBING FEE
LL,F LendersAddrea. QTY. MECHANICAL PERMIT FEE. MECHANICALIGFEE E .W
O W Imrtlfythall have read thisapplkatl....d statethattheaboveln(omutlon rr
IL bconect.I agrmto comply with all city and county ordinances and gate lawn I PERMITISSUANCE TjC.01 FEES PAID:
ID relating to building construction,and herebyauthorlu reptessetJlveaoftM1la
1— Z tlty to enter upon the above-mentioned property for inspection Purposes. ALTIERORADDTOMECH,
z (We)agree t.save,IMemnify and keep harmless the City of Cupertino a Date R ei t#
agalvthabiliticaj, melds. sandexpett.whlchmayln Anywayactrue AIR HANDLING UNIT(To 10,000 CFM))n $UBT TAI;
galyta In coe r gnnnn .(thispermit AIR HANDLING UNIT(OVER IO,,DOCFM) CONSTRUCTION TA -
` a-
Signs reofAppO t/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUSMATERIA ISCLOSURE
WIIlthe"Plica ntm(uWrobullding oavpant store or handle hazardous HEATING UNIT(TO 100,000 BTU) r
mrterlal a Date defined by the Cupertino Municipal Code,Chapter 9.1Z and the Rem
Health aannd Safety e,SeRi0on 25532(+)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL e2
WIIlthe applicant or❑famine Wilding Occupant use equipment or device VENTILATION FAN(SINGLE RFSID) I$$ ATE
hich emit hAradoua air contandents A.cleaned by the Bay Area At, - •
lily Management Dktrlat BOILER-COMP(3HPOR 100,000
�i J Yes he n No OCT .7711
Thave read ealth&Safet Code,Sedio irem.nte under Chapter G95of BOILER-COMP(OVER 100,0(0 BTII L�1
the California Health&Safety Code,SMloas 25505,2S533 and 25536.1 w�n
understand that if the building does not currently have a tenant,that It k my NEW RESIDENTIAL MECH.
res $Q.FI' O..h111�
poruibflity to nalfymnt
the opaof the requirements which rrvrat be met T.[�y ,rim"=•
prior to Issuance of a Comfimte o(Oacupancy. - }L\+iia__ _.s
Ownerorauthoriva agent Date lan/CL• �7
TOTAL: L.�'. ISSUEDBYQ YYdd LLE/r�//+,
OFFICE COPY