20552 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pm Idend(katl.n PFRMIT NO.
BuiWirng o o 10 OF , . � 20552
Owner's amt: one: _ A A
licAlim CITY OF CUPERTINO-BUILDING DIVISION
"• m APPLICATION /PERMIT �—tvq I�t�
BLUDINGELECTRICA PLLWINGMECHANICAL CATFCARY CONTROL#
AtehRM Bike. No:
1 I Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre /� ' PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION
I hereby dfrem that l am licensed under provisions of Chapter 9(commmc APPLIANCESRFSIDEM"IAL JOB DESCRIPTIO
Ingwlth Sedion (Dldelon3oftheBusiwaandPmfndona Code,and my
Lenz le in fu0 fa and d(M. 711J-24PANELS
LlcerucC Lk.a
Dale_ /// Comr.dor
b / ARCHITECTS D I AMPS
p�p�uu02 I understand ny plaru+hall be Vend as publicrecorde. OVERIOOOAI P SQ.Fr.FLOOR AREA $/SQ.FT.
- Fio Lkxneod Prdeve.rad SIGNSELECTIICAL
<X OWNER-BUILDER DECLARATION 9rECIAL(TRCllrf/MLSC -
Thereby i(Brm thatI am exempt from the Coranetorb License law for
0Z. ppp following reemr.(SMimn 7MIS,Bueo.arAPm(,sbnn Code:Myd[ym
F,/ duntywbicbrequl apem wmro Malter,lmpr ,demolbh,orrepalr TEMP.MEIIX OR W
ESr
�M �Q anymmdure prbrto ib fssu.nce,.bo requrenthe.ppEnnt f«such pemdtto r
cyL U file a agnea saternent the he b harmed an
pwwt to the provbro ioof the POWER DEVICES
Contractor's Li ntu,Law(Chapter 9(Mmmencing with Section 7000)or Dld-
sisubro SWa1.MING IFoamFoam - C i`
on 3 of the BuelneandProfCode)or that he b exempt therefrom and IT
the read•for the alleged exemption. Any dolatbn of Section 70315 by any ` I A'h/A
LSy Q� aPPN.a tt.r.pemdtsubject•theapp"nttoaddlpemhyofnmmore than GVfI'E'7SSWITCTaS � " L
C flv hundred ddlan(Svf10).
"1,a+ownm of the my employees B NEW RESIDENTIAL ELFf7R SQ STORIES TYPLCONSTRUCTION
p^, Property,d a wflhen d r their
coledk.atlm,will Bothew«k,+ndthe Codurebktlmerded oroffered ct.Lfor
p dale ISee 7014,Buelroa.rd I'rdamry Code:The Comndore I. Law
. S don rnat+pply to N owner d property wed bullae or Irtrprovn thereon,and OCC.GROUP RES UNITS
whodoowchwon not
ughhisors e.If,h.,proddedslut gor
Improverrew+rt no[Intended oro.ftne tones].,tLhowever,theeri ifi]aur TOTAL:
' Improverramt beoid wlthlnokyorofcamplelbn,the wvnerbulldnwllihave
t rd..or pmdrg the M did not build or improv.for purpose ofnleJ. QTY. PLUMBING PERMIT FEE FLOODyONE ApN
LJ L a•vomer of the pmpeny,•m ercWlvely contracting with licensed
�i contncton to wmlmd the pm)M(See 7DK Buelnete and Profesmom Cade: PF]t),1R ISSUANCE
The Comndm.Llceme I.w don not apply to an ownn of property who ALTER-DRAIN&VENT-WATER ff.V
Wilda Improve thereon,Improthereon, and who mntnm («such plIects with+ .,
+dor(.)linked pumunt to the Contradde Llceme Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec B&P C for thio re..
•
DRAINS FLOOR ROOF,AREA,COND. , SANITARY Y_ N_OUTS]OF FEES I
Owner Date REOFR'Ca
WORKMAN COMPFWSATION DECLARATION
❑I hereby affirm that 1 hive a cerdBate of cansnt to self-iwn,m(Sec+ VIVRE&PER TRAP S BOOL TA% Y N
certificate Workm'Compewuonlnwnn««.certified copy thereof . REC=
GAS E.A.SYSTEM-]WG4 OUILES PARKFEE Y N
I,ul C.I
Try s GAS EA.SYSTEM-0VER 4(EA) RF�E�f'a
coCy BUILDING DIVISION FEES
edified copy b hereby fuml hed.
❑Certified copy b filed with the thy ImpMlon dMalmt. GREASE/INDUSIILL,WASTE INTERCEPTOR PLANC14ECK FEE
CERTLFICAIR OF FXW PTLON FROM WOR KERS GREASE TRAP PAID
COMPENSATIONINSt1RANCE SEr.FR SpNTTARY STORM E.A.21XFr. Date Rcoel t#
(rbb raatbn need fid be compided lithe pemat b(more hundred dollam
($100)«IaJ 1
WATERT-ffATERW/VExr/ELECTR ENERGY FEE Y N
hall
thato they pe.I any manner/a as tobthioesubjle bared,
I .rk fiat employ any Laws f any runner at..to become subjM to the wATFRSYSTEM/TREATING
Wopli.ComperuaHon l.we of Glif«nb.Dae PAID
O Z NDTICnt u NEW RIDDENnALP[.MB. SQFI'. Date Recei t#
Z � thruld TO APPL),t to
a Sher malong thio CertBlp.1slons.fth.Lyou
� y ebd,la],!throe subject to m.worker;eompeasrtbn provbbro firth.Labor TOTAL:
Cade,yw rtwY fadhwith comply with wch peovbbro orthb permLL+hal be
W j dnrred revoked. IN t
W —p CONSTRII(. mn LLENDING AGENCY SEI IC FEE
CG
CL ]hereby.(BrmthatthenbammtrtidlonkMingagenry(or the pedomf ELECTRIC FEE
= anceo/rbcwork(orwhlchthispermitbbled(Src3097,CN.C.) TOTALU O e aer.wn. PLUMBING FEE
LL t- Lender.Add. CITY I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imni(ytlut I h.v nradthb+ppllatbn•"sieetha the above infomaidm
bcorrM.Iagreetoeomplyw aBdty.Mcountyordiru dltelaw. PERMIT ISSUANCE FEES PAID:
} IL relating to building mrotruNoq•nd hereby+utborlae reprnantatNn of this
F N cty to enter upon the abov nnantbrcd property for ikpedion purpose. ALTTRORADDTOMECFL
(We)agree to five,indemnify an d keep huMes the City of Cupertino Date Reeei t#
U +gainer llebWt ,jadgmew,maa.id espen.n whkh mayN anyway.mve AIR HANDLING UNIT CFO 10,000CFM) SUBTOTAL:
agabM ill wmneequ oft +ming dthb permR.
GIf AIR HANDLING uNrr LOVER tD,DaocE.%D CONSTRUCTION TAX
g ren AppRcan/Cre�� tallE)a-wusr rroDD(w/DLrn CONSI'RUCfION TAX PAID:
HAZARDOUSMA LSDLSCLO REf
WdI the+pplicam«future building oaup+nt store or ha M te h.rdous HEATING UNIT(TO 100,000 BTU) Date RLCCI t#
maeriA a dellmd by the Cupertl no Municipal Coad,Chapter 9.12 and the
Iirahh and Safety Code SMlon 25532(a)i HEATING UNIT(OVER 100,00)BM TOTAL:
E Yn No�VBltheappBorLLor mrebuildingouupantusecyuipmentmdevkce VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
whicheMthamdb airmnUa mmemdefin byted Bay Arta Mr
Quality Managcmcnt Dieu ? BOILER-COMP OFm OR 100,OOD BTU) ,
17 Yn Q No
r have resit the harar7we matertea refulrementa a nder Cha pier 6.95 of BOILER-COAIP(OVER 1 W,Om Bun
the California Health&Safety Cad,Sediore 25505,5533 and 255M. I
undentaM that if the building does run orrrently have.terunt,that it is my NEW RESIDENTIAL MECH. SQJT.
mspoklbility,to notify the o cupam of the requirement+which must be met Vi
prim to beuance da CsN!{nte ofOavpanry. — J�
Owner authorized agent Dae D BY:
TOTAL ISSUE
OFFICE COPY