20157 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed ldentulanlm Ta 1pN PL m A G SS PLWATNO.
Building Address:
L 20157
LD N. N rA ` s j2t 1)903 1_17Y LAB.
r, amn: - one
7E_ urOeS CITY OF CUPERTINO-BUILDING DWISION D
ee 9dee,"'n _ A ( e: APPLICATION / PERMIT —
N . rN C "i / BURAWGKCELEC(RBNTLUlI MDCHAMCAL CA RY CONTROL a
aaddexr/Fagtver. ,' L o
NtICy9EL /�1 m ILL Qty ELECTRIC PERMIT FEE BUILDING PERMIT INFO
l os mnx�u� T� Pr
Add./1"MDq PERMITISSUANCE Z ❑ El 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcensed under provWmt,of Chapter 9(oarrunm APPLIANCESRESIDEMTAL JOB DESCRIpHON
ingwithgedbn 7000)of DWision3ofthe Budiessand ProfeWonsCodeand my a.
Ilan,e b In full 7 If Afed. -3 /9 73 PANELS j^ p
Date antador C,-=N C. UP TO 200 ANTS LAYS
ARCHITECTS DECLARATION 20q.jffl0AMPS - .
O Z I understand ery plan shallbe used as public records OVER IODD AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
Llanaed Prolmbvl _ i SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFZLALCIRCUIT/NUK I N A L E D N
I hereby affirm that las exempt fromthe Contractor's Llarue Law for the � R
Z Q3 foWwMg reason.(SeWoh 70715Wa
,Bueand Professions Cade:An �(
Arty city or P,METER OR POLE INST.
d ry c ntywhkhrequ4 aperm wmro Malter,4nprove,de lbh,wmpalr `-n
) MPU 7 any�udure prlwblb leuarcSaleo requlrutheappBunt(er seal,pemJt to POWER DEVICPS/Sb ICA/A-rn[41,45.
C O d 5 Ne a dgned cote rant that he b Ilmnwd pursuant to the proalbro of the /
Contrador's License Law(Chapter 9(mmmendng with Seed r7000)of Die]- SVIMMLNG POOL ELECTRIC
O don3ofihe BuWaa dPdmlov CWd)orthrthei.exempttherefmm&M
Sn 5 the basis for the alleged exemption. Any violation of Se Ica 7015 by any OUTLETS-SWITCHES-FIXTURES
{� �� •ppBentforapenmltsubjedntheapplkanttoadvilpeahyofno=mthan
E B�:Qtundrtd dollars(S5M. NEW RESIDENTIAL ELE1Ctit
�, u I,an owrcr of the Property,ar my empbyav wBh wage a their wk 9Q-Fr. 5701U6 TYPE CONSTRUCTION
mmpensatton,willdothewal and the structure Is not Intended or offered for'7O /�� L L✓ ` �D
5 0 sale IS,,70K Boameas and PrefmdGme
ions Cude:The C.Maots alaw
2 does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RFS.UNTIS
E who detach work himself wthrough his own employee,provided that such
Improvement are noHntcnded proffered fm We.I(huwever,thebuildh g w TOTAL
bnpmvemem is Wwithin one ye...(completbow
n,the ner-Wilderwill have
Imro
urde..fpvingthat hedid tbu0dorlmprove(arpurposeofele). QTY. PLUMBING PERMIT FEE
L v owner of the property,am ex l atvely contracting with limned FLOOD PANE Al'N
contractor to coronad the project(!1ec.7094,Businmard Pdeabm Cade: PERMIT ISSUANCE
The Contada/.License law doe not apply to an owner of property who
bullets or Improve Norton,and who contacts for such plojac.with a ALTER-DRAW&VENT-WATER(EN
etor(.)]iansed pwsuant to the Cwuadei.Lim.law. FEE SUMMARY
U I am exempt under Sm B k P C for this recon BACK FLAW PROTDCT.DEVICE
Qvvr Date DRAINS FLOOR ROOF,AREA.COND. SANITARY Y_ N_
REC,. WOR KMAN COMPENSATION DECLARATION
k81'a
❑I hereby affirm that I have•certificate a consent to self-Insure,or• �TTTRS'PER TRAP SCHOOL TAX Y N_
artlRate of Worker ComperaMk n Iguana or a artified copy thereof(Sec. RRCEIFT 4
3800,Lab CJ GAS FA.SYSI'FM-]INCA 0IIILEIS PARK FEE Y_ N_
Pollq# WP SO4�8333 _ _ R��''"
Com N. U R t- t GAS I%,.SYSTEhf-0VFR4(PA) BUILDING DIVISION FEES
ed copy b heed with the
GREASE/WDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
rtNed copy b fled with the dty Wpectlon div W m.
CERTIFICATE OF EXEMPTION MOM WORKERS CRukSETRAP PAID
COMPENSATION INSURANCE SEWFR-SANR'ARY-STORM p�20wr Date Repel t#
(rhb section wed not be completed lithe Fermin I.for one hundred dollars
m
(Smorl .) WATER I-ffATFR W/VFNf/ELWTR ENERGY FEE Y_ N_
I artily that in the pe,dormana of the week for which this permit Is issued,
I shag not empty any P.In any manner so as to become subject to the WATER SYSLFM/TRrATING
weeken Compens.tiun lawa of Ca B.U.late
Z PAID
z Z Appliant NEW RE�IOFNTIAL PLMg. SQA.. Date Recti t#
O NOTICE TOAI'I'LICANT:H,aBermaking tMa Certl(iute of Exemption,you
ix N .held become abject to the Worked'Compcaatbn provisbv of the labor TOTAL
Code,you at forthwith comply with such provisions orthb permit shall be 13UILDING FEL
W > deemed revoked.
Fn CONSTRUCTION LENDING AGENCY SEISMIC FEE
d l hereby affirm that there Is a mvtmdlon lerdingagcrcy for the perf., TOTAL ELECTRIC FEE .(�Q
Z anceo(theworkforwhkhthp permB blsued(Sec309'/,CW.CJ
02 Ierdar.N ret r , /n PLUMBING FEE
LL r ]enders Address QTY. MECHANICAL PERMIT FEE MECHANICAL PGE
OW I ceNlythat l have read this appllatlonud statethat theabosre Information
a barred.Iagrteta comply wlthWcityaed munryerdlnanmand ante law. PERMIT ISSUANCE FEES PAID:
r N relating to bullding mnswctlon,and hereby authorlu representative of thio
F dtytuenteruponthe abov mentlonedpropertyfw Wpe npurp—. ALIERORADDTOMECH.
? to.ave,indemnify an d keep form] .the City of Cupertino Date Receipt#
V againathab les,ydgmenb, as whkhrayinanyw.y..e AIR HANDLING UNIT(TO 10,000CFTp SUBTOTAL:
a inateid by lam w e Qtingeltnl B. CONSTRUCTION TAX
/ Al/") AIR HANDLING UNIT(OVQt 10,000 CEN)
b (V
Slgature o(AppOont nt act r Date EXHAUST n000(w/DUCD CONSTRUCTION TAX PAID:
I I CtlStC1ATERIALSDISCLOSURE
Will the applicant afuture building occupant Moa or han,llehavrdau NETTING UNIT(TO 100,ODO B'Ti) Date Recei t#
material as deflsed by the Cupertino Murldpal Cade,Chapter 9.1Z and the HEATING UNIT(OVER 100,000 RTU)
Health and Safety Code 5i cyi mr7nW](a)7 TOTAL: _Q
Ye o
B1 the appliant or future building omupant use equipment or dedm VENTILATION FAN(SINCI.E RE_%D) IS!PP"ATE
whkh emit hanrdoos air cbntamirunts as dellnel by the Bay Area Alr
Quality Management MMrkt OOB,FRCOMP 079'OR IM,oR1 BTUs
YesIfello
ubUz t�.yu
Ihavereadthehavrdmmateriaaqulament,underChapteG95of BOR.rRCOMP(OVER100,000M) JUL
the li'Ah&Safety Code,Seetluns 25505,75513 and 75534. 1
erMardI t ifthebuildingdoesnot r0y have•tenant that It b my NEW RESIDENTAL MECH. SQFT
mepovibiiity nalfythe pa t Irene hkL rtwM be met
to Lsua da Cart
Own or authorludagent 6ute TOTAL- ISSUED
njLD� , �72m, T
20631OFFICE COPY ME ff )44 8