23617 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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Building ProM Identification IT NO. —
Buda Addrts:
o S-S' -r-Js a 236 :7
n Name,: e: APFUICAr
f .� >La's1 Ll�-�4y1� CITY OF CUPERTINO-BUILDING DIVISION _G 2
AlaContncta.Name: ( Lk.No: APPLICATION / PERMIT
n b S�6l Lk BUILDINGELDCTRrALPLUMBINGMECHAMCAL CATEGORY CONTROL
Llc N. N
ArchUea/Engleeer.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. SCGh
PERMIT I56UANCE El ❑ 1:1LICENSED CONERACIO 'S DECLARATION
Ihereby.Htrm that amiv Brn3ofthunder
uaneasWonaof Chapter9(commmc AI'I'[.IANCFSRESIDFMIAL JOB DFSCRIIPIION
i.gwitLomas
form l d effeen3athe Btudnesand PtelemlonsCade,.'nd my S LTJ
Hans 1'In ' force.'nd dfect. 61xA PANELS
Dance Clam Lk.I I-�'1�1��N
Date Contactor 7 0 �+ iC 1
ARCHITECTS DECLARATION 201-1 AMPS
9Z IundsretaM OVER IWO AMPS �.ET.� I 5/SQ.Fr.
rnY Phns aWUbe uxd upublic escort• 11`V1
E o Licensed!PdnalLnsl SIGNSEMCIRICM,
<<� OWNER-BUILDER DECLARATION 9'ECIALCDtCUIT/AQSC T � �
Ihereby afflrerthat l am ram exempt Tthe Ccmta .r\Lia 'e nlamw for the
'yZ OO following rcaaon.(Section 70315,Bushes and Profubns Code:Any city or n
F]^ TEMP.MLTFRORPOLER.'ST. t q
��� munywhW rcqubeapemttbmnstruct,alar,bnprovq demoWh,orrtpalr V / I
rgfl6 anya"Pcdtalortolrohat he a aborend pursmmtothe faauchperm the POWER DEVICES DATE C
IIIc a signed fatetrcnt that W b Uoensed purw.'nt to the provleloro of the
9$µII-- evemp<therefromW ('l Contattor's Llceroe Iaw(C W pter 9(commencing with SUne a 7f1(p)of Dri, ELECELECTRICVALU�IIIXJ
F, O;} slon3ofthell dn.mnd Pmf.Imv Code)mthat hebp
hES ..•7777 the balls for the alleged exemption. Any vld'Hon of SeRbn 70315 by any «mETs-SWITCHES-F.I)MIRFS !1 4!O
+ appU.ntf.r.pemdt.bjectathcapp]LcnttoadWlpenakyofnm=mthan
X61,a.ed owner of be%pro NEW RESIDENTIAL ELECTR
�n Lff 4 d owner of the property,or rtry empbyen with wages an their axle gQyr. STOW M'E CONSfitLCDON
C pavatlon,wBl do the work and the atructua Is not intended or offered for
Y 0 eaL(Se,70K Buelnmsand Pmtessic.Code:The Cordadoes I.Imme Law
� $ dm not apply to an owner of property who builds or Improve thereo,and
S^ who dcea'uch work hbmeUathmugh his own employee,provided that eh OCCGROUP RIS.UNITS
Improvement'are not Intended moffered fneale.IS however,thebullding or TOTAL:
Improvement hsokl withinomyearofcompletbn,the owner-0ullderwlB have
try"aNen of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE -
U 4 as owner of the property,am exchaivey contracting with Ilmnsed MOOD ZONE AI'N
mntracN'b mrotruct the p.jsd CSec7041,Buelnesand Prdesdoro Cod. PERMIT ISSUANCE .
The Cont.d.r.Lice.Lw dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER lE/0
WUd'or improve thereon, and who mntratl' fee s udi p," wW a FEE SUMMARY
�ST�c1a(il Nonmed purau'nt to the Contracts Lim.Law. BAER FLOW PROTECT.DEVICE
U I am exempt under Sec B&P C for this renin
Owner Date DRAINS FLOOR ROOF,ARPA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECRATION N
LA
❑I hereby aRlrm that I have a mrtiBate of oameal to ft)M uurc,or• FIXTURE-PER TRAP SCHOOL TAX Y N_
mrWlote of Workers'Comprro.tion Insurance a.'amfled ropy,thereof(Sec. RECmPT a
3800,Lab C) GAS F.A.SYSTEM-1 INCAOUl1.EfS PARK FEE Y_ N_
RECEIPT N
Policy/'C[ GAS EA.SYSTEM_OVER 4(EA)
Ca ny ' BUILDING DIVISION EYES I
CertNed copy b hertbytumWed. GREASEANDUSIRI,WASTE INTERCEPTOR PLANCHECK FEE
CertNed copy Is filed with tins,city IropMbn dfvWm. r I Q
CMTHTCATE OF EXEMPTION FROM WORKERS' GRFASE'IRAP PAID
COMPENSATION INSURANCE SETyppgANITARY-STORM EA 20U7. Date Recei t#
(Thlaaeclbnneednotbecompleted Rtheper bfaonehundreddoUan
($10Worlea') WATER FIERIER W/VENT/ETFi'IR ENERGYFEE Y N
I mrdfythrt N h W
the performanceoftheweakforwhics p mrdt is blued,
I shall not employ any person ban rtunnerp{s�0 b y�rc�t�pj d to the WATER SYSTEM/TREATING
worlicancompen i f.wa of epyf tilJafe/Y' I(/ �-- PAID
C' Z Applicant v O ` \ OI aaC[/� NEW RESIDENTIAL PLMB. SQ}T.
Z O NOTICE TO APPLICANT:If,.Rer making this Certificate of Excmptbn,you Date Recel t#
should beeome'ubjcd to the Workeri Corrperoatlon prov[tlons of the I.abor TOTAL-
Code,
OTALCode,you must forthwith comply with wch provblom orthis pemJt"I be O
deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY - SEISMIC FEE
CL a Ihemby.fflrm that them Is a comamtlbn lending agemy for the perform TOTAL ELECTRIC FEE
:) Z arta of the work for whish thh permtt Ynned
le (Sm 309'1,Clv.G)
02 Iender'.N.me - PLUMBING FEE
LL H Lenci&.Addrtsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mdlythatl have mad this application and statethelthe above lnfamvtlm
IL Iscomort.Iagme whh'Ucity and county ordlruncs and elate laws I'FRlsflT ISSUANCE FEES PAID:
} N relating to hWldingco hereby auth reprexnmNn o(thb
toenteru the.'bovs . bn ALTERORADDIOMECH.
~ Z (W1).gas io 14 . tnc Ity.(Co rtbto Date Receipt#
V agaWt WblUt a b, may m.ny wayp cvue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL-
agaWtealdC b n mdt.
AIR HANDLING unTr(OVER lo,000cFM) CONSTRUCTION TAX
SIP, .. AppUant/Contnctm Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllt eapplicant mfitWm building oaupant atom or handle havrdous HEATING UNIT(TO IM,(00 BTU) Date Rttei [#
metcrlal 'deflnM by the Cupertino Mu Ncipal Code,Chapter 9.1 2,and the
Health.' SafetyCode Sectlon25532(a)7 IffWM
ATG UNIT(OVER 100,000 BTU) TOTAL:
F1 Y. M No
Wllltheappliant orfuturebulldingoaupantumcquiprrent adev{ms VENTILATION FAN(SINGLE RESB7) ISSUANCE DATE
whirb emit heardoue air omaMtunteas defined bytM Bay Area Alr 1F �a
Qaalty Management Wtrict7 BOI1AR-COMP(3HFOR 100,0(q BTI) Q Ji
Ye No
1have read the haa.m.smae rcq lrcrenbunderChapter&95af BOILER-COMP(OVER IMM BTU)e MAY
Ay -
the CaUf.0 Health&Safety Cod,Sections 75505,25533 and 25534. I 'IWUUJ`%
unclersUnd that if the bu0cLeg doTrot cvrtently have a tenant,that It is my N RESIDENTIAL MSQ17
responsibility to notify the oaupant of the requlmments wh"overt be met
prig to Bauana a.cenlflate nr Otnnpaary. CITY Ur ,jet;11d1YU
Owners aethorlaed agent Date ISSUEDBY: a h V
TOTAL,-
OFFICE
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