22636 (2) APPLICANT TO FILL IN INFORMATION_ WITHIN RED LINES — USE BALL POINT PEN ONLY
eulmin Pro en Identlfknlon PE]UATNO.
Building Ad ma,: 22636
2 2 G qR en V1�w =�
ners me:
L -736 5) a CITY OF CUPERTINO-BUILDINGDIVISION �/ l
C tneor'.N.. Lie,No APPLICATION / PERMIT
fQ SlleermarA BUIIDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL
Amhften/Fsglrcer. Lia,N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adarcu TRPERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
IM1ereby. rMOD).M titan,edurderpessand dfeest.r9(mmmeno- APIrLIANCESRF3DPNTIAl JOB N
lim.M1 StIan form and
effecn3ofNeBuJrca.rod RofesslaruCode,.nd
Ls,e 1,1.full tome rod effect. PANELS
Date Class LIC K
Date Contractor
ARCHITECTS DECLARATION 201-1000"PS
re0 Z I unaerraM my plans shall be used an public remrda OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ECD ;—MA-LED IN
Liminsed Professional SIGNS ELECTRICAL
6 OWNER-BLRLDER DECLARATION
7F.�6 Ihertbya(Rrmtlutlsmnempt/rmntheContr,eor.Ll¢nselawforthe 9'ECULCIRMT/MISCp U T R
folbMng reason.6tlan 7m15,Business aM Pro(ubru Code:My city or
O i=. TEh1P.METpt OR POLE INSf.
emnry which mryWapemdemmruwR,iltn,Impmve,derroLLsh,orrepalr
any,wRu¢prbrtoltsbwarce,alwrryulmtheapp8ant forwehpumftto POWER DEVICES �O /
HNe a signed statement the he Is licensed pursuant to the provbbru of the DAM
a Contnnor'a Lice.Law(Chapter 9(mmmenctngwith Seabn700D)ofDivi-
Fdl Jon3ofthe Buelnmwd ProferlomCode)orthnhebesmptthemfromare SWH.Th9NG POOL ELECTRIC
Y.'•„] tho bash for the alleged e¢mptbn. My WWLLbn of Stbn 7fU15 by any
I;IG� ,pp8antfor.permit mbjnb theappBcanttaadvll pevlty drat mo.than OVD.ETSSWIICFIFSFD(IURES
c.Yy 9 five and red doils.(5500).
.e w
I,as owner of the Property,or memployee,y eploy ,with wages u their sole NEW RFSIDENIIAL ELFCTR SQFT. S[OW6 TYPECONSIRUCIION
t=7Q comperoLLlon,wwdothework,andmeJmu mLsn WeMedoroffe¢ for
5 ❑ tole(ScC 7014,Boeln tes and Prdeasbv Cade:The eoMnaors LIcen e,Law
I7jS$ don rctapply to an owner of property,who builds or improves thereaq and OCG GROUIs RES.UNITS0. wm
hodwchworkhIrmeiforthwgh hisow.employees,provided thusuch
Improvemew are not Intended oroffered!creole.If,however,thebu lding. TOTAL'
bnproverrcnt i.wld wLLhNoneyearafcornpletbn,thewvnerbuBdrrwill have
tkLkn rdenofpm ngtheheabml Wudorimprr,vefarparpoaeofa,le.). QTY. PLUMBING PERMIT FEE
LJ L.s owner of the Property,am ex .twly oomracting with lbmsed FI.00D7D T APN
rontne,i .to mmtrua the pro)rct(Sm 7061,Business are Profmbu Code: PERMIT ISSUANCE
The Con". n no',Lianas Law don.apply to an owner d property who ALTER-DRAIN 6 VENT-WATER(EA)
builds or Imves prothereon, and who mntrsd,for such pP)to with a
ceW[aetort.)li¢nxa pa.u,nt to the Cont.nor's Limits lave. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ f.m exempt order See B k P C for this renin
y� Owner pee DRAINS-FTODR ROOK AREA,COND. SANITARY Y_ N=
WORKMAN CO
MPOVSATION DECI.ARATION RFCFLR a
❑1 hereby affirm the I haw a Consentova
rtl0ate,of Consent to self-L ,or a S'PER TRAP `SCIlOOL TA% Y N
oertite of Worke.'Comperoatlmu Insurance¢a¢ruffed ropy thereof(See. �
fia
3500,LabC) CAS FA.SYSTEM.1 ING4 OUTIE PARK FEE Y_ N
Polley GAS EA.SYSI'F7.1-0VER1(EA) RE EPI'a
CRY .BUILDING DIVISION FEES
Certified ropy b hertbyth the dry GREASEANDUSTILL WASTE INTERCEPTOR PLANCHECK FEE
�CertlBed ropy b filed with the city Iropectbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS CRFASETRAP PAID
COMPENSATION Ipeb f¢orc hundSEWERSANITARYSIORMFAZXFT Date Remi til
OTl..ertbn need sat be completed Bthe INSURANCE
red dolls.
at W)arin.� ENERGYFEE Y N
• I¢rtifythe Nthe pedomun¢o(the work(or which W.permRisbmxL WATER F�ATFR W/VFM/EIKTR
I shag not employ any person b any manner w ss to Isemme nub)en to the
Waken'Compewtbn laws of Ca Womb: Date WATER'SYSTIM/TREATING PAID
Applicant
Z 0 NOTICE TO APPLICANT:U,after nuking this Ccruff"te of Fxamptbn,you NEWRESDEN1IALP[1dB. sQ. . Date Recei tH
Amid become subject to the Worm'Comperoatlmn provision,of the Labor TOTAL
~ y Code,you ncowm
ustforthwith comply with welt provisions or this peJt shill be
W > dnmed.voked. — WILDING FEE
CONSTRCTION LENDING AGENCY S MIC FEE
CL IM1erebyaMrmthat them Ub a eorutwdlon lending agency for the pedon ELECTRIC FEE
Z ance of the work for whmh this permbm
it Lamed(Sec TOTAL.C .C.) TOTA
U O lender'.N.me PLUMBING FEE
LL f IeMer:Aaartas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1¢rtlrythatl have mad tM1ls applhuonaM gateth,ttheabovelnformLLien Q
emnea.I:greetocomplywN Ali cfty.M muiryordirar...d sate laws Pk7N11TISSUANCE �6/(/ FEE$PAID-.
} 6 rel.toentrulpontheea oarnundhe.bpwthorinspection
rtproenteWnofthfa
FZ dty We)armtoue.boecfyandpropeh for imps Kyof(Doss. AL'hRORADD TOMFCFi. Date Recdtit
V — (We),gr¢to Tres Inaemdry.n d keep h.rMer the CNy of Cupertbu
agalrotllsbWtles,(.udgmees,mstraM expeun whkA may In anyway acrnre Nft HANDLING UNIT 8010,000 CFT1) SUBTOTAL:
Against.LLd City in consequence of the g.eing of this pemdt.
AIR HANDLING UNIT(OVER 10,000 CFM) - CONSTRUCTION TAX
Sigwtum of Applicant/Contractor Date ExHAusr HcDD(W/DUCT CONSTRUCTION TAX PAID:
HAl2ARDOUS MATERIALS DISCLOSURE
Will the appllaM¢future budding omrpantnone or M1arele havnlms HFA TING UNITED 10DA0 BTU) �•DDate Recei tit
nadedal u defined by the Cupertino Municipal Code,Chapter 9.12,and the
Fle❑alth are Safety code Section=(a)l HEATING UNIT(OVER 100,OW 8TU) TOTAL: I
W Ys �No
01 the haran];pPileas titm bel...oaup.ntuby the Day n,or devices - VENTILATION FAN 6INGLE RESID) ISSUANCE DATE
which emit age rd¢u alit contaminuu.u defircd by the Bay Arta M PAID
Quality klarugeme. QNo - BOR.ER COMP OHPDRIW,ODO BTU)
Yes ❑No
have read lealthra&dou.nwtilarcqulrtme5,under Clupte46.954 BOILER-COMP(OVER1W,0008111)
StheUlRornlalislth6SafetyCode,Stloro75505,2557and7553/.i i„511 14 !� laal
roi
underuste that if the building does t currently have a tenant,that It b my NEWRESIDFN'DALMECH. SQ-FT
►5 n
responsibility to really the onvped d the requitements which trust be met
prior to leatan,e of a CertRlate ofO pa ncy. �E /IrsaseR/sM
Owner or autharU dagent Date p ISSUED BY:,
JA
TOTAL: i
OFFICE COPY