20466 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN OMLY
e�uai�a Fm�n ia.���n�,��o� f�t� ��.^� sQ U I�({!LL G� retu,urno.
ev1d�'°°re=° —� � 2 0 4 6 6
�: one: , . A A •
t��M�'S l �'ft'� ."�.��4� CITYOFCUPERTINO-6UILDINGDIVISION
Cantneor'eNure: ����Na APPLICATION I PERMIT 0 '� Z" �
' I� 'YLT 0 P`UM � 2�I'�Z gUfLDINGQ,E7C7RICAL['LUMBI\GMFfHAMCAL CA'IEGORY N7itOL X
Archi /Engirecr Llc.No:
Q'n' ELECTRIC PERMIT FEH BUILDWG PERMIT INFO
na�� g R —S�Mf! 0 LE'RD. S',S r�,wnssunNce � ❑ � ❑
LICENSEDCONTRAGTO SOECLANATION
IAembyaf(Irmthat1am11cmudunderpmvulonaofChap�er9(mmmmc MPLIANCLSRFS7DCM'IAL JpgDFSCRR'I70N
ingwitA5eR1on90W)o(Dlvidon3o(tFeBuslnesaandProfesUomCode,andmy �
liunu le In full force and d(M. ? PANpS /
LlcenseCh.o��llc.p ��� �' �J T`� V� �
oate eontnctor 'l� L C
ARCHITECTSUECLAMTION p�-����
�QOC ]undersbndmyphresMllbeusedaspubliereroede. OVER1000AMP$ SQ.FI'.FL R FA S/�.FT.
�u ��cenud I'rolesiovl SIGNS ELEC7RICql
�L
y.,�6� OWNER-BUILDERDECLARATION . $�+��pLCIItCUI'f/MLSC
� Ihercbyaf(IrmthatlameMemptfmmtheConlractor'eLlcenael�w(orthe -
�O., following reawn.(Sepion 7Q315,9uainem aM P'vlmbns Cude:My tlty or .
F �"� countywhichrequlresapermltrocoriatrvtt,alter,impmve,demolbh,orrcpalr T��''MEI'HRORPOI,EINST.
�'��.� anystructurepriorroibLuuanre,aLwrcquimatheappllantforsuchpemutro
O 0.U file a signed tatement that hc le Ilremed pursuant m tFe provislo�a( tM1e ��R DEVICFS
�30�^ y�v3of heB vinesalndPro(e.�niowCod orMatF,etco�iemptth�from�nd ��M�NGI'OOLELGCIRIC LUA770N
a�y3 g the basV(or the a11egM erempHon. Any WolaHon o(Se Hon 9Qf1S by any
�u�I 0¢i OUILE7SSW[TCHESF7%TURFS
applicant(on perMt aubjecb the applicant m a Avll pevlty Mnat morc than
c.��� five hundred dollan(f500).
7,aaowneroflM �H'RFSIDEN77ALELECIR �'.
�.7 j�n ❑ pmperty,or my employem with wages as their soie —�� S TYI'ECON57RUCTION
��Q c pensaHon,willdolhewwk+�dtheat�vcturcbnotintend�doro(femdlor
$ 0 vle(Sec.7044,BuelnessandPm(esslovCode:7heContraaotsLlmweLaw l
�j5� docenaapplytoanowmrdpropertywhoWild�orimpravnthercoqand
�- whodocssuchworkhimselforlhraughhleownemployeea,providedthatevch ��CC ROI1P �5.[M�
ImprovemenU are na Intended orolteredlorea4.It,howeveq thebuiWing or TOTAL:
Improvement Lrsold within oneyearofcompictlon,thevwmr-builderwlll have
�n�ra.�orp��i„g��„�neam�awuaari,,,pro�.rwp„rpo,�or��.�. QTy, pLUMBINGPEAMIT i�EE � ApH
I,ae avner of tAe Pmpeny,am exduelvely mnhacHng wllh Ilcensed Y p�MR ISSUANCE
mntnctonmmreWRlhepmjecc(Sec.9D14,guslnemaMl'ro(mWreCode: { �
lTe Contnclor's Wcenae Iaw dces na apply ro an owner ot Property who �.�.D��&y�.�,-WAlEit(FA)
huilda or Improvee thereon,�nd who mnfncta !m euch p�ojeab wltA a
,�(anrn(e)IlrensdpunuantlolheContnRm'eLlrenxLaw. gpp�}7pqrpBOrpLT.DEl7CE FEESUMMARY
LJ[am exempt uMer Sec. B h P C for ehV rcaaon
Owner Date DRAINSFl.00RROOF,ARFA,C79ND. SAMTARY Y N_
WORKMAN COMPENSATION DECWRATION RECE�'!'M
•'�'�1 Acrcby a((Irm that I hrv<a oeni(Irite of conxnt to�e141neurc,w a I� ��FS����' z'Z��+ �{�L TAX Y N
ce Iln�eo(Worke'e'CompevaHonl�uuranmrna¢rtif4dmpyfhemof(Sec. RECEI[''fk
3800.IabC.) ��/� Cy CASFA.SYy7pN-IINC40UlLEfS PARKFEE Y N
1'oliry M_ �TT /d "' `� RECID'f p
Comany COM N G���51"SfEM-0VE[td(FA) 9UILOINCDIVISIONFf;LS
�Cenu� �pymhemby(umish . CAEASE/WDUSIRLWASTfIN7'QtCp�7pp PLANCHECKFLE
Cetllfled mpy 6(iled wlth tM tlty Wpecclon dlvialon.
CENi1FlGTCOFIXET1Pf10N1'NOMWORK[RS' GR�ET�r PAI�
COMPENSATIONINSUBANCE
(ThlsxctionneednaMcompleMdifthepermitls(orarehundeNdolian S�wEA"�MTaaY�sroR.Hen.pper. Date RCCei [!!
(Stao)or�rn.) "
Imnifythatln�hepeAormanmofthework(orwLlch�hlspefmiclsluued, WAT�}�T�W�VENT/p,Ff7'R HNERCYFEE Y N
1 shall not employ any person In any manner ro u to become eubjec[to the
Workern'CompensatlonlaweofGll(arnla. Dure WAT�25YS7LM/7RFq7INC PAtD
Q Z Applivnt
Z � NOIICETOMPLICAM:If,aNermakingtlJaCertifi�ateofFsempHon,you H�RFSIDFNiIqLPLMB._$Q,}�', �ate $eCei [N
� nhwldbemme�ubjMto�heWorken'CompewHwpmvisio�ao(tAeLabor TOTAL:
� N Code,youmustfonFwlthmmplywlthsucApmvlsioroortFuperMtshailbe
W > a:�med re�okee. 6U1 ING FGE
a p CONSTROCI'ION LENDING ACFNCY SEISMIC PEE
I hcrebyaffirmtlut them b a m�utrutllon knding agenry(or tAe per(orm�
� Z anceoftFeworkforwhlchthbperMlislesued(Sec.3097,CIv.C.) TOiAL: 3� pU' ELHCTRICFLE
U 0 i<w«aN�m` PLUMBINGFEE qy
�y F �<na�.sndamss QTv. MECHAN[CAL PEAMIT
O w �"��'�hatlhavereadthbappticaHonandshtethauFcabovelnlomuHon �E MECHANICALPEE
a IsmrreR.legreerocomplywlthe11c11yandmuntyoMinanresandstatelaws I'FRMRLSSUANCE FEESPAID:
} N rclaHngmbulldingrorohunlon,�ndMrebyaut6orizerepresentativeeo(thb
�— Z citytoenterupon�heabwc-menllonedpropertyforWpe¢lonpurposea. ALTEItORADD7pMECH.
� — (We)agrec lo save,IndemN(y an d kcep harMea�Fe City of Cupenlno Date Receipt#
aqalns�Ilabillties.j.Ydgments.meteandexpenxswhlchrtuylnanywayacrne AIRFWNDLINGUMfROl0,000CFM)
aga����a�ac�trm n«orehe �;ngortM.pen,Ne SUBTOTAL: @�
` �",�'"���t fd 2q_� IvxHnH�uHcun�rrovaeia,000eFu� CONSTRUCTIONTAX
SlgnammofAppilcan! onva�mr p,�te—" IX}iAUS'fHOOD(W/DUCl7 CONSTRUCTIONTAXPAID:
HAZARIXlUS MAiERIALS UISCLOSUNE
WilltheappOcantor(umrcbulldingoccvpantsmreorlundleFvzrdom �IINCUMT(IOIW,pppg7l])
rtutcrialasdc0�udbytheCupertlnoMuNdpalCode,Chapter9.12,andthe Date $CC21 IM
��o nn.,,a s,r�y cm.s�a;o�zvazfal> HEA7IKC UI�7T(OVFR 100,000 9TN TOTAL:
p v� . Ho
Willtheapplicanto�mrcbuildingoccvpantuseequipmentardevices VFN77LqTIONFAN(SINGLERFSID) �$�JA(}j�pAT$
whlch eMt IauNow alr mntaM'ums as de0ned by the Bay Area Nr
Qu IityManagement c11 tl0[LFA-COMPOM'OR100.IXp8ilA Bm�
41'ca No
lwvcread�hchaza ouemaicrialsreqWre�rcnbunderChapter6.95o! 90fLGR-CONP(OVIX100,OOOBN) (�.� � y �g9Q
� IheGil(omlaHealiF&SafclyCodGSectio'u75505.2i537and25534. I (1, U
undcrsmndthati(thebuildingdoesnolarrcnllyhaveatemnt,thatitkmy NEWRESIDFMIALMLCIi. SQ.FI', ��
rgponaibllity m noilfy the accvpanc of tAe requlmmentc wAicM1 mus�be mec
priortolssuancco(aCcrtlficat o(Occupan . ��(���nef�lnp
SNt.p�]a
�—l' ,�
Owner or awhonnd agent Dne ( ��� y���, �y� �
7UTAL: ISSUED BY:�l'R1W\v NV-'�-l'•
OFFICE COPY