20533 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT.PEN ONLY
B.M1.9 Project Identification 7 rERA9TNO.
Building Addrtn: 20533
c �O
� APPLICATIPN gUBMII IM,DA IL
rJ 1 nt��� CITY OF CUPERTINO-BUILDING DIVISION c,
Cm trsd6r'a N.m: k.No APPLICATION / PERMIT
14- BUILDINGELDCTRICALPLUMBINGMFLHANICAL CATEGORY ONTf�L
rrhh.a/ ,gltaer k.LNo:
e tj QTY ELECTRICPERMIT FEE BUILDING PER INFO
Add.
LICNEDCONTRACTOR'S DECATION
PERMITISSUANCE El _
1-1
11Ihrtby latlmlr roWmsolaper9( nc APPGANCESRF3DFMNL JOB DESCRIPTION
InSn7ODafDl .3.flheB.dvndPro/mnsCade,and
IbanselbinfiflIformanddffect. PANELS
L ���
kem. cuss Lk.e
Date Cowanar UP TO 2DO AINIPS
ARCHITECTS DECLARATION 201-1(IX) I
ce rQ7- I uMeratand my pbroshall he used as public amrds. OVFR1000AMPS SQ.FT.FLOOR AREA
E f" Llaved Pr f.,storm SIGNS ELECTRICAL j
<�a OWNER-BUILDER DECLARATION SPECIALCIRCUIT/hiLSL
I hereby alr (5emthat lam exempt from the Contractor's License law f¢the W'��
ppppfoBwinga . m7(D15,Busine aMW fesel Coda:Anydtyor Fit -1 muntywhi requU apem tommimMt ter,Impm ,demolbhormpLr TQ P.MEfFR OR MME WSI.anystruaurt prW to its t aarcgsbo requdresthe applicant lara,a&permit tofile a signed statement,that he b licensed pursuant to the provisions of the POWER DEVICES
3"G Cmtnim'aLkenselaw(Chapk,9(...ctngwdh Seaan7(Xe.f Dlvl- SWHMMING POOL ELECTRIC
X05 sbn3 ofthe Ruslneaand Professions Code)orthrt he b e pt therefromasd .
<5 the basis for the alleged exemption. Any viotabon of Section 7015 by any OUTLETSSWI.ICHESFIXTURTS
applicant for a permit eubjeas the applicant to a avll penalty of no mart than
�
flv hundred dolWs($.AO). NEW RESIDENTIAL E.ECITt SQFI, TYPE CONSTRUCTION
I,as owner of the property,or my employees wish wages as their sob
t mmperwtlmt,will do the work and the structure as not UdeMM or offend for
5 p
I.bee 7014,Buslrcss aM Pmfeabns Code:The Contnaots G¢me Law
� $ dm notapply town owrcr of prop aywho builds.,improves thereon,and OCC.CRO RESUNITS
whodoosuchwork himself orthrough hbownemplaycu,Provided that such
lmprovement,are rot Intended oroHered torsade.If,however,the building or TOT
improvement bsdd withinoneyearo(campletbn,theowner-W Ilderw8l have
t n.fprovingthathndtd rotmAdmimprmeeraparpa,eaf.1,.). QTY. PLUMBING PERMIT E
I,as aurae,of the property,am e.W.ively con racting with licensed FLOOD ZONE
contractm.to ronswcttk projM CSoc-7OµBualnese and Proferbro Cade: PERMIT LSSUANCE
The Contractor's Llocre law does not apply to an owner of property who ALTELDRAIN4 VENT'-WATER(FA)
Witch;s or Impcovthereon,and who contracts for such ptajecta with• FEE SUMMARY
cgW(+ctor(s)B¢nseA parsasm to the Coeractda Lkeroe Law. BACK FLOW PROTECT.DEVICE U I am exempt under Sec. B k P C for this renin
DRAINS FLOOR ROOF,AREA,RIND. SANITARY ' Y_ N_
e Owner Date RBCFdT'I's
WORIONAN COMPENSATION DECLARATION FDO`URFS PER TRAP SCHOOL TAX Y_ N_
¢ - I hereby aHbm that I have a certificate of consent to aeB-iwn,m• RDCElFrr s
t rtB .of Worken'Compensrtlmlroursn¢¢•¢rtHled copythaeo((Sec. GAS EA.SYSTEM-1 WC4 OUMEIS PARK FEE Y N
pock Lab CJ —
RING DI R
Tiley a GAS FA.SYSITM-0VFR 4(FA)
Company BUILDING DIVISION FF.E9
I ICemNed copy b hembyth the cis. GREASE/WDUSTEL WASTE INTFRCPrroR PLANCHECKFEE
Certltled espy b filed with the mY Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY S[OIL1f EA-W()FT Date RCCDI tH
(rhissectionne nabecomplde lithepe bfamahundreddoBan
($100)¢1,,:.) WATER HEATER W/VFN7/ELFCTR ENERGY FEE Y N
I¢rtlfythatNthepedor naoftheworkforwhichthiopemdtbI ed,
I shall not employ any person in any manner m an to become subject to the WATER SYSTEM/TREATING
Workers'Coroperaatlon Laws of California.Date PAID
O Z Applicant NEW RFS]DFTrl7AL PLLfB._BEET'. Date Reeel t41
Z O
NOTICE M APPLICANT:If,ager rnadng this CertHlute of Exemption,you
N should become subject to the Workers'Compersatbn provbbns of the Labor TOTAL:
Code,you must tmthwhh amply with such provisionsw this pemdt.hall be
- W > deemed revoked. BUILDING FEE
CONSTRICTION LENDING AGENCY SEISM19 FE
CLE
IberehyafHrm that then b a amtmctimi leMing agency lir the perform ELECTRIC FEC
7 Z anaofthewo,ktorwhkhthbpemdtbL (5ee3097,Clv.CJ TOTAL:
00 Lerder'sName PLUMBING FEE
LL F- Ledee.Addras QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OIU 1¢duy WHhavertMtAbappl tbnaMstatethat the above in(ormwim
fl bcormct.Inneeb Iywhh.Ucdtyard countyordlnanmandnntelaws PERMIT ISSUANCE FEES PAID
} N mlatl tobulldin ruction,and hereby authmine representatives of this,
F Z atyt m ru rat a tlorad property for Lapection pu,posn. ALTERORADDTOMECH.
e), e, y:Zde narml®the city of Cupertlro Date Reeei tH
V a IIabW ,}t g v aaMe which may In an weyamue AIR HANDLING UNIT ITO 10,0DO CFM) SUBTOTAL:
d his pe
AIR HANDLING UNIT(OVER IO,000CFTD CONSTRUCTION TAX i
s- bort ApR¢ t/Contr.aor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wil applicant or Imam Wilding occupant mart or handle huardnus HEATING UNIT OD I(0,"BTU) Date Rccci Iq
.1 defined by the Cupemd.Municipal Cade,Chapter 9.12,and the
Safferty Codjjvfdim 7SS32(a)r HEATING UNIT(OVER 100,000 BTU) TOTAL:
Eli
ee appRcantorr rebuildingaroefired by equipment Bay A mdevke. VENTILATION FAN(SINGLE RF9D) ISSUANCE DATE
-wtflch emit has rdous air contaminants n de0rcd by the Bay Arta Air
MvI
Qct IIty, agement t } BOBFRCOMP OHP BTU) �ryI JD
4 sir N.
.read heM1 a fode'alerequlmmenbunderrd per.I of BOILER-COMP OVERt00,000BM
tis. �i.."idt ea fary and ptM.1 i u;i 971990
1\ u old that if ding does not �1�Ply have•tenant,that ltbmy NEW RESIDENTIAL LfE(]L SQdT.
ill fty to 1fJ-.��tF oar 11h r"immentswhic mM /�, a�ar�a�
p bsuari¢ fklt 'a ri / IIT YupeINIW
Owuc out ' seg,, t e D
TOTAL:
OFFICE COPY