23762 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Suildirg Pro ad Ide.i/kation PERMIT NO. /lit 7 Cee //�/
Building Address jb�S � / 2 V 1 V 2
rcro ams'{ 11hone: ^ p
LL �6 CITY OF CUPERTINO-BUILDING DIVISION
Lie.No APPLICATION / PERMIT
Arehlted/Engineer. Ik o BUIIAINGQ.BCTRICAL PLUY.BING-MECHAMCAL CATEGORY CO
019-
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PFRh9TISSUANCE 1� El ❑
LICENSED CONTRAROR'SDECLAChaI/j
Thereby aRlRn Wwm oof that licensed order pnnvf Chaper
ter9(mmmenc APPLIANCES RFSIDFNTIAL JOB DESCRITHON
Ingwith to 00)of � /theguelwand Pm(eaeluCode, nd PANELSlice.b 1.full70� � /
censLb Y
Data Contractor .1 AMPS
TO ANIPS
ARCHILECTSDECLARATION
p�p�uu0Z IundereUM my ph.sha8 be uad upubec remsda OVER 1000 AMPS SQ.FT.FLOOR AREA I 5/SQ.F7.
y O SIGNS ELECTRICAL D
<< E Lkxnxd Prdeeelorul ^ p
OWNEReBUILDER DECLARATION $frECULCIRCN7/MISC �V a�
,I„ Iving Rafflrmthatlamexemptfmosea Codfeselos License law fat he ^ rI L� p..
FgIRSq followingream.healon7 W B and Ot r,upebm Code:My mpor a L\V,' 1Y, {Z
F � ovntywhkhrequkeapemdtromvtrua[,altcr,Imprwe.demolish.orrcpalr TEMr.METERORroLEINSf. 1YJ
a4 qZ
any structure prior to its bauinee,also nequireatheappllant forsuch permit to POWER DEVICFS 7
wIlk a signed statement that to Is licensed pursuant to the pre vhlone o/ the
Cootncto/s Lkeeue LAW(Clui er9(mmd
menn with Section 2000)of Divi- E
elon3ofthe Budnw dPrd mCade)ort htbe niptthercfmmaM '`Y'R'f�NC POOL EIFCIRIC VALUATION
�5ap+ Q the brsb for the alleged exemption. My vldatlon of SaYbn MIS by any
FLXTUR
appliantfora pemJtsubjetlatheappBcanitos Wil pe.ltydnat morethan "�" �� ES 20 00
five hundred dollars(S500). NEW RESIDENTIAL ELDCTR
�
F-1 1,as owner of the property,or my employee with wages as their Role SQFT. STORIES TYPE CONSTRUCTION
mmpewtloe,will do the work and the structure b ret intended or offered for
Osok 1$ce 20K Bwbcut and Prdmla.Cad,..The Conlrsctals Uarme Law
dm not apply to an owner d property who Wilds or improves t hemer,atd OCC.GROIII' RES.UNITS
EE who doaauch work himself athrwgh his own employee,provided that ouch
Improvemerb,im non intended oroffered for sok.If,however,the WBding or
Improvementbaold within oneyarofcompidmn,the ownerbullderwlll have
LfAjZurdea of proving that he did not build or improve for purpose of sak.l QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am esshmhely mstnu:ling with licensed FLOOD ZINE APN
PERMIT ISSUANCE
eentrietotorestruct the pmjed(See70K Busmemand Prdesbne Code:
nro
Lite Contractor's Limns Law don not apply to an owner of property who A1,1711-DRAW k VEM-WATER(FA)
Wilds or lmprw.thereon, and who mrrtracea for ouch IRV"with a FEE SUMMARY
-mllactada)Bcerued pursuantm
to the Clrademi License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B &P C for this realm
OUTSIDEFEES
DRAINS FLOOR,ROOF,AREA,CONI. SANITARY Y_ N_
• Owner Date RECEIVE Y
fie
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCIEOOL TAX Y_ N_
f ❑I Fereby a(fkm that I love a certificate of consent to sell-Inaurt,m a
oete,ofwarCmnpermatiawn ¢
n Inn¢ a certified copy themaflSee. RECFFIPfY
rtNae
S FS
3900,Lab C) GAA. YSTE(-1INC/OULLEIS PARK FEE - Y_ N_
RECEIPT
Policy Yy $45TF�1-(I`JFR ) BUILDING DIVISION FEES
rtNed mpybhereby(umlahed. /Iivouslilt, psIE WIIiRC ! PLANCHECK1yE
Certlfledmpy b fllcdwithtbe dty l.pectlon division. t (�
CERTIFICATE OF"EMPTION FROM WORKERS' PAID
d COMPENSATION INSURANCE ARY SNRM FA 7fpF7 /R��Vf
(Thlssectbn need not be completed lithe permit b far one hundreddollars
a100)mlea) WATFRHFATFRW/VENT/EJFCIR EN Y
I certify that
mthe pedon.n¢olehewmk/or wMch fids parent Issued,
1 shall not employ any person in any manner.as to become subject to the WATER SYSTEM/TREATING
Workers'Campensatlonlaws of UlBomb. Date PAID
rP mDate R 1 tit
Z NOTICE TO APPLICANT:If,after miring this Certifiate of Exemption,you NEWRFSIDFNTLkL PIMB. FT.
P N shwldbemmeubjedtothe Workeri Cornpermationprovbio.ofthe Labor TOTAL:
_ Code,you most farthwhh®nply With such pmvb{om or this permit a hall be
cc W > deemed rewohed. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE �e
a E5 lherebysfl thatthercba m.tmetionkedingageruyfortheperformF TOTAL: ELECTRIC FEE
7 Z anaoftheworkforwh1ehthb permdbbved lSee 3092,Clv.CJ
02 IandaraName PLUMBING FEE
LL
F Lenders Add. QTY. MECHANICAL PERMIT FEE
martion MECHANICAL FEE
O W Irmet.lhatlhave rcedthis ywUhandtyaaM ntyhatthaa a dfitf telws
M Damned.I ildlnoco mdibhand mbyauntyondmpn ntata ofawa I'FdtMTf]$[JANCD FEES PAID:
rclat oent Wildinge amdlon,aMhereby property
or I rcprexntatNn of thio
U) dtymenleee upon
to the abovo-mntbn d lumperryf¢IropeCit purpose. ALTER OR ADD TO MECH.
? (We)agree to ave,Indemnify an d keep harMu the City of Cupertino Date RCCCI t#
V agatrut Eiihietb,judgment,miss and expenses which may in any,way amus AIR HANDLING UNIT CN 10,000 CFM) SUBTOTAL:
ago bM said City in con sequence of the grinding of this permit. AIR HA NDLING UNIT(OVER I O,ODO CFM) CONSTRUCTION TAX
raaf AppBant/Contractor Dale EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future,building occupant store or handk hazardous HEATING UNIT(TO 100,ODO BTMn RLtiel ted
material as defired by the Cupertim Municipal Cade,Chapter 9.1 2,and the
Ekalth.nd avly Cadge,SSedIm25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
11 Ye I No
0ltheappllard or Wrcbulldmg omupanl use equlpmd adevlm VFNTIIATION FAN LSWGLD RESID) ISSUANCE DATE
which emit havrdoue ab mntamWrde as defined bythe Bay Arca AIr pp I7
Quality Management District? B011.12-COMP DIEP OR 100,0(D BTIp Pa
Ye QNo
have red the h ,...materials regWmerents under Chapter 6.95 of BOILER-COMP(OVER 101),"BTU) _g 1992
the California Health&Safety Code,Sectio.25505,25M and 25531.I .�11A
understand that if the W Bding dm not currently have a tenant,that it is my NEW RESIDENTIAL M,FCi SQFT. V
repo.ibBlty to notify the oaupant of the requlmmnts which Rata be met l lave
prior to lwnane d a Certificate of Oceupn.y. G11I sur QQr, �
Owner m authodad agent Data TOTAL ISSUED BY.—
OFFICE COPY
J