20093 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFTLMIT NO.
"°idagAddress, 20093
2 12.5 WAUL,*-I'
mcea 2va' CITY OF CUPERTINO-BUILDING DIVISION
Contncias's Name: Lle.N APPLICATION I PERMIT - .
1 -L42 4
BURINNC-ELD'IRICALPLUMBINGMWHANICAL CATEGORY CON]ROLY5 yfl
Amchtleci/En neer L .Na •7 {"�
QrY ELECTRIC PERMIT FEE -BUILDING PERMIT INFO
Address qqo e du7
I'FRh9TI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION rg
Thereby affirm that ofDh m3afheunder Rosprovisions df apter9(mnmen AIs1eI.IANCESRESIDENIIAl JOBD ON
Ing.Isi ctlon 7000)ofd effeen3afthe BuYnmand Pmo/eeUonuCade,and
Iimve ainfuB!orae and ,,0 PANELSLic �-
Dat Cam Lia T \OOO•..aaa\a 1` \ \��)
� Date Comnctor UP TO 200AMPS
ARCHITECT'S DECLARATION 201-1000A.MP5
m �7 and�tab b sM1al be used u�ub�c OVERIWOAMPS 5Q.Fr.FLOOR AREA $/SQ.FT.
O 11i7�1/�ina� Giles.
Lf¢l ons � SIGNSELEC-RICAL
�«<
OWNER-BUILDER DECLARATION SPECIALCIiCU1T/MLSC ��6D
F, Iherebyaflrmthatlameaempt(mn eCnmractor'a LL¢n iAwfmthe
�gfollowing reason.(Section 7a3l5,BuafnmandProfessions Code:Any eftyor TFMP.ME7FRORPOLEINST.
muntywh requimaprm wmrutruct,alter,Impm ,dermlbhormpUr
alanystru mpbrtolbbesa ,al.orequbestbeapplantfaochpmmtlto POWER DEVICES
a algned statement that he Is Bamaed punuunt to the pro Isloru of the
Ou, Comranola license Law(Cha er9(eemme ,[n with Section 7000 of DlvSWIMMING POOL ELECTRICELECTRICVALUATION
l- I
Yon3ofthe Busamand Prc(embnu Code)orthrtheae d ihemfmmarJ
h- So 5 the bub for the allegedesemptfon. Any vlc1;mon of SeetIo 70315 by any 'l a-a,n,.l
Q appU.t for a permit.ubjeets theappliad
nt too vil penalty d not more than OUTLETSSWITCHES /� J C CX)
�, uuuu fiv.�wndred ddlua Q500). NEw RlswwriALEI.=
GGG777 �n Lf I,u owner of the property,or my employees with wages a their sok `''Q STORIES TYPE CONSTRUCTION
t
samlemp(Seence70Ksv111doth.MrParonedthe C.d,:Th.Co d doesllm er Uw
dnouapplyw. nerdppe,ty Wlds.,i.pestherenand
whodmuhwotseBorthougM1h. wnemplgm,poiddtM1atuch
OCCGROUP RES UNITS
tmprwemew art red intended aro/lend(m vk.IL however,the bullding a TOT
lmpmvemcmboldwXMnoneyearofcompldib thewvner-bullderw Tuve
try�p .ofpmW re
ngthAhedldnotbuildorlmproforpurpoenfaale.). QTY. UMBI IT FEE
LJ L u owner of the property,am exelwhrely mntraedeg with licensed FLOOD ZONE APN
..to construct the proles(Sec 7061,Businm and Professions Code: PERMIT to
` The Contractor's L rune Taw does not apply to an owner of property who
builds or Improvers thereon,and who menus for such pt,ojects with a 'M-TER-D -WA
ryntra mor(s)parsed pursuant to the Ccotrana.License Law. FEE SUMMARY
U I am exempt under Sec B 4 P C for this renin BACK .D
*W OUTSIDE FEES
ORNNS RRCOF, GOND. SANITARY Y_ N_
Avner Date RECEPT
( WORrot the COMPENSATION DECLARATION FIXTI FS SCH0 TAX Y_ N_
hereby affbm that 1 have a ardente m consent d cel thxneo (S a
late of Worke 'Comeerwtlonl ¢ora¢rtifled ropy thereof pec. AECE7I'TI
Tab CJ /� (�/s ��)n GAA EA. -1 IJGI OUTLETS PARKFEE Y_ N
Polley I -- RECEIPT a
�
Com GAS EA.SYSTEM-OVER 1(EA) .�`
ny ��� u BUILDING DIVISION CCn edcepy k ed. GREASE/INDUSFL WASTE INTFRCEPTOR PLANCHECKFEE
relied ropy Is filedfiled with
N the city lospenlon dlvlelan. I�
CERTIFICATE OF EXEMPTION FROM WORKERS' GRELSCTRAP PAID SSM 1L�
COMPENSATION INSURANCE SEWERRSANTTARYSIORM EA 200171. Date Revel t#
(Tens senior need notbe completed B the permit a forom hundred dollar
�00)Q1that WATER BEATER W/VENT/ELEM ENL•RGY FEE Y N
1¢rtly that lo the perfomnwa o(the woh forwMch teds permitis issued,
I shall not employ any person lo any manner o to to become usb)M to the WATQI SYSTEM/TREATING � L����
Worlerl Compeneatlon]awsof California. Date PAID.T'L'lLJ
O Z Applicant - tJE1'.'RFSIDEN717AL PLMB. 9Q}T. Date
Z O NOTICE TO APPLICANT.ILaNer making this CertBiate of Exemption,you
should become sub)"to the Worten'Compemati n pnovlaives of the Labor TOTAL:
N Cade,you most forthwith complywlth such pnrvlslaos ortha permit shYl be
deemed rtwked. BUILDING FEE
W ' CONSTRUCTION LENDwG AGENCY SE15MIC FEE
CL I hereby affirm that then ba mrswalon kMing agency for the perform ELECTRIC FEE
m
M Z arof the work for which this permit b issued Qee.3097,CW.C.) TOTAL
02 I,nder.Name PLUMBING FEE
I,dar.Addees QTY. MECHANICAL PERMIT. FEE
O W Iortlfy Al have read thisapplatlon and statethatthe above information - MECHANICAL FEE
IL bmmet.T agreeto comply with al city and county ordLsnasad state lawn PERMIT ISSUANCE FEES PAID:
r IA Maing to building mrotmuction,and hereby allorir representatives ofthb t
F- U) city toenterupon the abovsmentloned property for bnlorR
upen purposes. ALTORADDTOMECH. Date ReCCI [#
_ (We)agree to save,Indemnify an d keep harmlm the City of Cupertino
agame WbWtles,/rdgmerds,nista and expenses which may In anywayacvue AIR HANDLING(TMT CIO 10,000 CFM) SUBTOTAL:
against said city In mnaeqmm¢dthe gnmag of this permit. AIR HANDLING UNIT(OVER 10,000CF.M) CONSTRUCTION TAX
Signature of Applant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applam or future build ln omrpart Yore or handle%a rdouEA
s HEATING UNIT CTO 100,000 BTU) Dale Raef 1#
t materalasdefirod by the Cupertirohlumdpl Cade,Ch.pmr9.IZzuvIthe
HeYthand Safety Code Scalon2 32W7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
JYes No
Wll the app"m or tura building oavpant use Nulpment or civ VENTILATION FAN(SINGLE RESID) ISSUA4DATE
which emit harardous air contaminants as defined by the Bay Arca Mr ,QT
Quality M exgemem Diad? BOMER{OMP OHPOR Iffy"BTU) /,'(1
4 Y. No
have radtheh sass matedaa rcqulremcna under Chapter 695 of BOILER-COMP(OVQi 100,000 BTU) U/l^
the Caldoma Health 4 Safety Code,Senlom 2SS05,75533 and 25536.1 10/1
0
undrrstaM that lithe bullding dm not cumntly have a tenant,that it e,my NE1VR®DEIIIALMEIN. SQ.FI' aha
roponsmRity, en
to notify the aav m of the requiremt.whld at be met /�re
hot to daCertl a Onvpaocy. r0 9A'F'
Ow cr thorlud jg,ant Date ISSUED BYyyk rV �'k'�^�-""`'eV
TOTAL:
OFFICE COPY