21980 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proeet Identification 7 PFRWT NO.
Building Address: n 9n 0
0 +i- _ 2£E�J D 2 G
�rala"ame
f-PPL- - IJP L CITY OF CUPERTINO-BUILDINGDIVISION
, TION / PERMIT� CVPeenJ kNm APPLICA
G 7 Y .T BUILDINC-ELE=CAL-PLUMBINGMFGHAMCAL CATEGORY CONTROL 0
AmIthed/Engineer U.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISS'UANCE ��n00 N 0 a
LICENSED CONTRACTORS DECLARATION
Thereby n7OW) MAsiI am c 3ofthderprwf dPm(eWp r9(mmn�mc APPI]ANCESRESIDENCIAL JOB
lngMtlice.h.^nfull f1m,and efelon3ottM1eBuelrwmand Pmleaderu Code,and '
Ilaroe is U(uB roe and s,# PANELS
Lim ��-�Q LIc. I. 7 Yb 37
Date 4/ Contractor [rJ Ti w/D EC CC .
ARCHITECTS DECLARATION AMPS
µppµ!!aO Z2$� 1 ur est my plan shag be used as pubUC rermda OVER IODO AMPS SQ.Fr.FLOOR AREA S/S.FI.
Cd,
Llamxl professional SIGNS ELECTRICAL
<<�< OWNEReBUILDER the Co RATION SPECIALCIRCUIT/MLSC
I.,iYd�3 IM1ereby affirm slutI II exempfrom the DECLARATION
Llar�Iaw(m the
following reason.(Sedlae 6 7!015,[h ones and Prefesbn e.CodAny dry or F. TEMP.METER OR POLE INS(.
�4 muntywhldt requlreapemdt tomrowd,ilter,Improve,demnWh,orrepalr
,� any.trudum primto ltsisaane,abo requlmthe appltantfm.uch pemdt to pOlyF-R DEVICES
ya0. file a alined swerrent that he,is partied pursuant to the provision of the
O n.1. Contndor'.Lu,s.Law(Chapter 9(commencing with Section 7DDD)of DM-
30J don3ofthe Buelneeandl'rolesloroCde)ortha heisexempttherefromand SWP1h9NG 1l70L Fl.EC17iIC GUATION
t
M basis for the alleged exemption. Any violation of Socilon 70115 by any
�,s.•, appb.ntfor.permit subjects the applicant to a civil penalty d not more than OU77-Ef5SN7'ICFffSFlXIVRFS G''.��
u I,W.
n �n B6L as owner of the property,or my employees with wagm an their mIe NEW RESIDENTIAL ELECTR SQFf. y06 TYPECONSIRUCTION
rompcnadon,willdothe work and thesUumn,is nat Wended or offered for
Osalo($r70141,Builneae and Pmfesbn Cade:The CoMaa.e.Llaroe Law -
$ doe rwt apply to an owner of property who builds or improves,thereon,and Ow�G
c+3" who dceaauchworkhlmuelfmrauwid
thgh hison employees,proved thetacla 'I RES.ANTIS
Improvernentsare not Intended uroffcmd forsale.If,however,the Wddinga TOTAL:
Improve bwMwlthinonyearofcompl&bRtheowner- MerwWhave
tlA_tInrdenofpmvingthan has did not Wild or bnprow for purpcaeotsals.). QTY. PLUMBING PERMIT FEE
"L u owner of the property,am a Iuaively contracting with llan.e! FLOOD ZONE APN
contractmn to mmunud the projed(Sm 7DH,Bushes and Prof®loro Code: PERMIT ISSUANCE
The C.m.emes Line.Iew doe fiat apply to an owner of property who
Wilda or Improve therm., and who mrdnde for aeh pPFm with• ALTER-DRAW 4 VEM-WATER IFN
o�E+darts)Iloeneed puramt to the Cm Was'.Llan Law. FEE SUMMARY
LJ I am exempt under Sec B 4 P C for this resat BACK FLOW PROTECT.DEVICE OUTSIDE Frrq
• Ownm Dae
DRAINS.F1,00KROOF,ARFA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT 0
❑I hereby !Bron Wt I have a certificate of consent to sellAruure,or a FDCrURFS-PEER TRAP SCI1001,TAX Y_ N_
anlBmteofwork Cmnper im InurenaaaaNf mpythert f45ec. RECEITTa
N'W,LbC CAS rA.SYSTEM-1 INCA OUfLEIS PARK FEE Y_ N_
RECEBTI
Iblloy. GAS EA:SYSTET1dVQi4(EA) BUILDING DIVISION FEES
CenNd spyis M1ereby(uml.hd.' GREASE/WDUSRLWASIEWTERCEPfOR - PLANCHECK FEE
CenlBd spy V filed Mth th dty Inpectbn dWiaon. -
CERTIFICATE OF F7(IMPTION FROM WORKERS GRFA.SETRAP PAID
COMPENSATION WSU tisfo SEWER-SANITARY-STOW EA,x)�T Date RCcci tit
(Thiseectbn need fiat becanplTI Btk SLX isfa on hundrM doBaa
WWI or lex) WATER HFATFRW/VENT/ELETTR ENERGY FEE Y N
I anifytfut lo the performance of thewerk forwhdch this permit is
Jt Isued, —
1.hall not employ any pesos In any manner m u to beeome sub)rd to the WATERSYS IMI /TRFA11
Workers'Compensation Iowa or CaWo nia.Dae PAID
PP Date Rccel to
Z Q n BostjQMP
NEW RF
NOTICE TO APPLICANT.If,after rtaking this Certificate of Exemption,you SIDENTfAl PLMB.
Nshould become sub)trt to the Workers'Comperaatlon provisbm ofthe Labor TOTAL:
_ Code,you must fathwhh morply with such provlsbnorthis Permi.htilhe
LU > deemad rewked. -BUILDING FEE
W — CONSTRUCTION LENDING AGENCY hla�-+-� SEISMIC FEE
CL IhembyaW=that there ba wromcion lendingageruy for the perform. -Tow ELECTRIC FEE l
D Z ana of the work for which this permit b Lswd(See 3097,CI,.G7 ��-
U O lender.Name PLUMBING FEE
IL I- lenders Add rea QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Iartifythatl have mad thisappllotbnand sate thathe above information
M b sant.l agree to comply wh .11,Ky.nd countyordWunm and state Is. PERMITISSUANCE :
ISSUANCE FEES PAID
T N relating to Wilding mrotrodlon,and hereby authorlae representative ofthis
city to entmupon the above-mentbried property for Wpe lcm perp. ALTER OR ADD TO MECH.
H Z Date ReCDI iN
e)agree to save,Indeko
d kap hamNes the %of Cupertiw SUBTOTAL:
V agalro said City In dcvmequthe gn thlhs .n wayamue AIR HANDLING UNIT CIO 10,M CFMI
AIR HANDLING UNIT(OVER ID,DDO CFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
tore o(Appgont/GDOUSa OM"/
ate IXHAl15T HOOD(W/DIRT)
HAZARDOUS building
part LOSURE
Wia the appBcaby theurertilo Murldpan c,drc hM1ad93Z and
HEATING UNIT(TO 100,000 B'IU) Date RCCDI Ill
material a as Sid dyd by the Cupertino Murdtlpal Code,Chapter 9.17,and the
IIeallh and SiletyCde Section 75e32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: l
Ye No
❑
Will the appllard a tore Wilding oaupantux equipment or devl VENTILATION FAN(SINGLE RESID) 1551LATE
whkh emit havrdoua W contaminants,as deRned by the Bay Area Air
Quality Marogemmt District] BORFR-0DMP(1FB'GR100,IXD BTI. Gq1
4Yn `Z 1?T
luwe read the hanp ou.rraterials mqulrementa under Chapter 6.95 of BOILER-COMP IOD,ODO BTII) MAR & s
the GIff. la Hsahh 4 Safety Code,Sedbn BSM,2553]and 75534. 1
undersand that if the building does notmmintly have a tenant that It N my NEW RESIDENTIAL MECH. SQFT.
mporoibillty to notify the occnpard of the requirements which sun be met n Fyl
primto Lsuaocxda CertirkatcorOa pancy. '
Owner or athai dagmt Date TOTAL ISSUED BY:
OFFICE COPY