20554 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
11.11,11M Pmiel IdeMl( n Utotl ^b �O PERMIT NO.
Building Aa3 ,t] e'IILVQ� \ '•I 20554
3
Mone:
u-P-` p- CITYOF CUPERTINO-BUILDING DIVISION
. Ga �d '•N Lk.Na APPLICATION / PERMIT
BI1If1NNGELEY'IWCALI'LUMBINGMEICFIANICAL CATEGORY CONTROL#
ArchRect/Engineer. Lie Non
QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Aaaresa C - PFRHf1i IE6l1AN'CE ❑ ' ❑ K} ❑
LICENSED CONTRACTORS DECLARATION y—Y�
Thereby aHlmntlutlam llrmaeduMerprovslons of Chapter9(mmmenc APPLIANCESRESIDEMTAL b�1�NppDESC
N
Ingwlth Sed n7")o/DMMm3ofthe Buel and Pmfe .Codgandmy - -
Ikavc Is In full form and effect. PANELS
License Clam_ LION ' _
Date_6 I ontrsdorKa roan MP^ anical '
ARCHITECTS DECLARATION' 1- AMPS
�2 I understsod my plans ehall be used as public remrdA - OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
Licensed Porf.lovl jSIGNSELECTRICAL,
�<
Ihertby a/flrmtlutlam:/ OWNER-BUILDER DECLARATION SPECIALCIRCUI.I./MIS
6 .
7 .•oexempt fromlh#CoMrxtori Licerm Lew for the
Zc. lolb
anty whuhrequiSnnlafopnemdI,to mBunsalcnvectct,aanitderP,vimprmee,de=l:eh,o r drepairtypair
TEMP.METER OR
POLE INST.
x4 mystvhrtpbtOimMe,abrequbtheappllatf«suhppW POWER DEVICES
Om a signed statement that he b licensed pursuant to the pomistoro of the
Pi uO, Contractor's LkerseLaw(Chupter9(mmmencing with Section 7000)of DIN-
tlSWE.frANG POOL ELECTRICC
on3 of the Butlnmand ProferobnsCade)orthat he b exempt therefromand VALUATION
the hiss for the allegedexemption. My vlofatlon of Section 70115 by any
�L app0ant(ora permit eubJecstheappllcantto•Wil pevity ofnof mortthan OUTLEISSYITCFffSF1X'TURFS _
five M.
1,as
droftheellars pro NEW RESIDENTIAL Ej�R 9QFr. S-rog(6 TYPECONSIRUCTION
I,as ower l the property,or my employees W with wages u their sole
mmpcnsatim,B.dothc work and theatncturt b rot bdendedor offenaa/or
O sok(Sec 7fR4,Bwbras and Professions Code:The Contndoe.Llaroe Law
docs not aPPly to an owner of property who builds or imimmea theater,and OCC.GROUp IUNnS
E who does•uchworkhlmecU«through Meownemplo/m,provided that such
Improvemcnbanenotintendedoroffrz fmsale.Il,however the buildln8 or TOTAL -
Improvement brokl whhlnoreye.rofc«npldbn,thecwner-bulklerwi]I W,
t4LllArdenofpmvirgth,d hedm renbuudorimprovef«purposeo/sale.). QTY. PLUMBING PERMIT FEE
11 L as owner of the Property,am exchulvely mntranting with Ikerued FLOOD ZONE APN
contractors to rovtmd the Project(Set 70K Bu.lnm.nd Pra(mbro Code. PERMIT ISSUANCE
TM Contndoes Liana Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER TA)
or Improv.thereon,and who mMrada for such p4aFm with a
B¢naed purwant to the Comrades'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec B &P C for this rt
uon
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N WORKMAN COMPENSATION DECLARATION RECEIPT#
}®1 hereby aHlrm that I lura•¢rtumo of consent to opytrunrt,(S• F1X717RF4 PER]AAP SCIi00L FAX Y N—
¢dNab o/Warken'Comperuatbn Imran¢«a¢rlHled copytheneof(sec. AFLFTPr a
3900,Lab CJ GAS EA.SYSI'EM-]INCA OUTLETS PARI(FEE Y— N_
Pokyle 061004077 - RECEIrr.
C. �ray usall�IS —1.. GAS EA.SYSIEAf-OVFRTfFit> BUILDING DIVISION FEES
XXICedif exiort ropy b hertby furNshed. GREASE/INDUSIRL WASTE INLIIKErroR PLANCHECK FEE
CvtNed ropy bfiled with the dtylropectbn dWWm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINSURANCE SEWERSANITARYSTORM EA.30QT. Date Recel t#
(Thee Ims) need not be mmplded Htha permit b/«ons hundrtd do0ara
(51 W)«fa..) WATER HEATER W/VENT/ELECTR ENERGYFFE Y N
IoenHy Nat in oy he any Performanceof
runnerhe work for to
omm,suJts Issued, —
I shill not employ any person b any manner at u to become sub)eei to the WATFRSYSITM/TRFAIING
w«kers compevatbn L.ws of California.Dam PAID
—
z
Appllant
Z Q NOTICE TO APPLICANT:It.fter making this Certificate of Exempttre,you NEWRESIDENfIALPLMB. SQ.FT. Date Recti t#
N should become subject to the Worxem'Comperuatlon provbbro of the mbar TOTAL:
_ Code,yw rtuat(arlhwkh comply with such provsmns orths pemJt#lull4
Uj ] deemed revoked. 13UILDING FEE
'a G CONSTRUCTION LENDING AGENCY SEISMIC TTE
Z Iherebya/lirmthMtherebamvv
tctlon kMingagency for the pedomm -1 ELECTRIC FEE
ante olthe work for which thispermit b bnes a (See 30Y7,CIv.C.) TOTAL 4Z5
f,) O Lender'.Nana PLUMBING FEE L
IL Lendee.Addrts. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtlfythatl have readtMs appBatbnand tlatethat theabove ln(onrutl«�
scoceree
.]agtocomplyw aDdtyandrountyardlnanmmdtlatelaws PERMIT ISSUANCE FEES PAI D:
>_ N nrelating to building mnstroetlan,and hembyauthorbe mpremtauvn of the
Z city to enter upon the above-mentlered properly for inspection purposes. ALTER OR ADD TO MECH. Date Recei f#
_ (We)agree to save,Indm
eNkeep fy an d p harmless the City of Cu pert W
.,mot WbWtln,)odgmenm,maband.pen.which may In snywayacerue AIR HANDLING UNIT(TO 10,OD0 CEM) SUBTOTAL:
aga Inst aald City, m
im n.aryce enof the gra Miry of this permit.
AIR HANDLING UNIT(OVER 10,000 CFAU CONSTRUCTIONTAX
el 3gvtme of Appuant/ or Dam FntAUSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAL] DOUSMATERIALSDISCLOSURE
Wilrthe applicant or future butdingonupant stoat orhandle h...rdous HEATINGUNIT(IO100,"BTU) Date Rttei t#
rvtarlal as defired by ted Cupertiw M.Mdpal Code,Chapter 9.17,and the
Idealth and Safety Code Stolon 25533(.)? HEATING UNIT(OVER IDO,OW Bit!) - TOTAL: '
F-1YeaNo
Will theappliaM or tumbuilding oceuNnt use equipment or devlas VENTILATION FAN ISMLERFSID) ISRALRDATE
whkh emit havrdous air defined by the Bay Area Ab
• IRy M.vgemeM District?No BOIIER{OMP OFW OR lOD,O(O BTU) JUN 2 C 1�IJ
Ya ❑No V
a have read the havraousmaerl requime nmunder Chapter&95of BOILER-COMP(OVER I00,0W BTU)
the California Health&Safety Code,Sections 25505,75533 and 25534.1
understand that if the building does not currently have a tenant that it is my NEW RESIDENTIAL MECH SQFT. City of Conertno
responsibility to notify the omM met of the requirements which Trust be et YI la
prior to bsuanca of.Centifk to qjOcc.Ieey. .
Yid••
'Owner«author? ages Date ISSUED BY:
TOTAL:
OFFICE COPY