23903 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proled Identification 11-. PERMIT NO.
Address Building Adds: l sT' 23903
hers ame: Phme ,
CITY OF CUPERTINO-BUILDING D ISION
e redo/. me: L .Na APPLICATION /P IT L
BUTIIDINGELECTRICALPL H''
MFCPANLCAL CATDRY c
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Are,t/Fnglrser. Lie.No:
QTY ELE ERMIT .EE BUILDING PERMIT INFO
Add. CE
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LICENSED CONTRACTORS DECLARATION
Thereby affirm n7D that I D).(Di .3.fhn BuirovWonsv(fP w.r9( CFSRE9D pB DESCRIfT10N
fie,ingmeh Sinful7o eandeffect (thegusinimeand Pro(esdmsCode,and
1 � Ilarue V N(u and effect PANELS
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ARCHITECTS nON '�-
0Z IurdeMandmypI..mhallbeueedaapub cmmrda 7:P
00 SQ.FT.FLOOR AREyyA{{�, S/SQ.FT.
j Licensed Professional ��c/`L 107-Lt
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OWNER-BUILDER DECLARATION CIRCUIT/MIK4I hbyaNrmthatlamexempt frornlheContractrsLlnruelawfmNe
following morn.(5eNm 70315,Bualnes and Professions Cade:Any dry orEITR OA IDLE INSI.
K� musty which requires apermit tomroWd,alter,lmpmve,demolish,orrepalr
1 any structure prier to its leaurue,also requires theappBant for much permit to POWER DEVICES
C n file a signed statement that he Is 1 reed pursuant to the prm,mlos of the
Ow
Contractor'.
ustroce Law(C)u,xdo.cemmsndng with Section 7000)of D1W- SWIMMING POOL ELECTRIC VALUATION
� 1 abbasis for
Premption.Any violation
emmpt 703IS by and _
y1 ...777 the Want for the alleged exemption. Any vto atbn of BMbn no,m by any
y<.E
applicant form permit sbjMsthe appllunt tom dWlpmaltydnat more than O OITILEISSY.77CIIESFIXIVRES
F.a 02 2 fine hundred dollars MN. NEW R®FNfIAL EIFLTR �tT. STORIES
❑ m
1,as owner or the property,or my epkryees with wages a a their mo le TYPE OD\SiRUCTIO\
C comIsewtlon,will do the work,and the sUutlum b not Wended or offered for
p sale ogee 701 Busmen and Professions Cade:The Contmdo's Untrue law
S� dm ret apply to an,owner of property who builds or Improves thereory and OCGGROUP RES UNITS
who domauch work himseUmthrough Mee°,s own employprovided that srN
Improvements am not Intended.',offered format.If,however,the building or
improvement band with-nonayearofcompldbn,theawnerbullderwW have
the burden of pmving that hedid out build or improve for purpose masts.). QTX PLUMBING PERMIT FEE
I,as owner of the property,am eacWsivcly mntraeung with lie need FLOOD ZONE APN
contractus to mrutred the project(Sec.7D76,Bushes and Pmfesiona Code: IT ISSUANCE
The Commdari Limns Law don not apply to an owner of property who N WATER(FA)
Wilds or Improves thereon,and who centrads for such ptofeets with a
etur(.)Ilreneed pursuant to the Contnda/.Laamme Law. DEVICE #SANITARY
FEE SUMMARY
LJI am easmpt order Sec B k P C for thin mann 60T91 DE FEES ND. Y— N_
• Oweer Date RFLEIIrf
WORKMAN COMPENSATION DECLARATION FDCrURES.PER Y— N—
❑1 hereby aBbm that I have a nrtlrfam or consent to seB-Lorre,or• RFLE�I.s
mrtNmte of Workers Compensatlm Insurance ma oenifled copy thereof f5ec. GAS EA.SYSTEM-I Y NLab CJ —
RECERT stIwky�y ('�EA'��-0 s(EA I LDING DIVES ION FE FS
rtNed spy b hertbytuniWted. GREASE/ WASTE EPTORI CertlBed spy b riled with the dty Inpedbn divWm.CERTIFICATE OF EXEMPTION FROM WORKERS' CREASEaP COMPENSATION INSURANCE(Thbsectbn needndbecompletedBthepcnM fmomhundnddollan Sll F Y- RMSEA.20067. \ I- a Rccci
(f100)m1esJWATER I-ffArFRw C'Iit' ) ly
1 1 dNew
FEE
I eertify that In the performance ofthe work for which permitbl
s permit is ed, /F7E �I �� l� —
1 shall not employ any perm In any manner n ae to become sb)M to the '-- �•^ �5
Workers'Compersatlon L...[Cabbarnla. Date WATER SYSIIDA/,TRFAIING
0 Z Appllard NEW RFSID .I pI.MBD 1 Va1C Rc ifs' tN
Z O NOTICETO AITI.IGM:lf,after making thin Certnlote of Ezemptbn,you
FN should become subFct to the Worker-Compersatlon provbbru of the labor TOT
CC _ Code,you mrn(orthwYh amply with ach provbbro.',thin permN dull be BUILDING
W > deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.flihat them Is.construction lerdingagency for the perform TOTAL ELECTRIC FEE
7 Z anmof the work!.',whish thinermit is Issued(See.309'7,CW.CJ
0 O Lander-Name PLUMBING FEE
LL H lender',Address TY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 W 1 Adyth,tt l have read this application and etatethat the abo elnfomutlm
IL bcornva.Iagree to complywlthW cityandcounty.nd and atete Tawe IT65l1ANCE FEES PAID:
} N relating to Wllding mrolructlm,and hereby authorlri repmsxrdm=tLilhb
F- dty to enter upon the mbmve-mentbrcd property for irspedton purposes. Al, RADDTOMECH.
Z (We)agree m save,bdemrdfy and keep harmless the City of Cupenlw Date Recel t#
agaWtllablBtb,jodgmenb,m[saM ezpenxa which may In anywayaawe AIRHAND ' UNTT(T010, CFM) SUBTOTAL•
aga Lutuld Chyinccrosequerreof gamof this pemW.
AIRLTANDLI Tr(OV D,000c6M) CONSTRUCTIONTAX
signs re tractor Date ' EXHAUST HOOD IW CONSTRUCTION TAX PAID:
DDUS MATERIALS DISCLOSURE
Will the applicant or future Wilding oceupant mom or handle hazardous HEATING UNIT(TO ,WO
material asdefined by the Cupertino Munetpal Code,Chapter 9.12,and the Date RCCCI Ib
Ik.hh and Soddy Code SS,toloo 25532(.°)? KHEATINGUNITER IOD,000B TOTAL:
❑WWheappBantor fuNrebuudmgw pantuseryuipmentwdevim l$AGI.E RE9D) ISSUANCE DATE
which cot hazardous air mntamirs us ma deBrad bythe Bay Area AUQuality Marugerrcnt District? OR 100,IXDYn No
IhavemailtheM1 smaterial.mquiremenbunderChapter6.9Sof Qt1W,OWLI ) PqIp
the Califomla Hembh kSa@ly Cade,Sections 255505,2SS33 and 2534.I MPA-. SQ ��
responsibility tondreich
lfy the pod qutremeom whmust be mer L1
pr�mml>eua�w.ceniflamodomnp,�ny. ?-� �FI
Qvnercrauthorfad a gent Date 1S6'UE BYa \�'C��
TOTAL:
OFFICE COPY