20007 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Butwin Praen Idention flaatiI'IJftAT Np,
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r�VAJ 60cup CITY OF CUPERTINO-BUILDING DIVISION �2 h
• c da .N Lk.No APPLICATION I PERMIT U
/ ' 3 BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL.
sphalw,IV Archil /Englme } ,�,_ • G— 53Lk.p1a:
S3/ r. QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrees: �Q ,� ST', S F.
PFRIA'T ISSUANCE ❑ ❑ ❑
ENSED LIC that Ia CONTRACTOR'S Diziors RATION
• ]hereby ofMndut lam lknaed urderpuvMvna of CFupter9(mmmmc APPIlANCESRISIDENML JOB DCSC
Ingwlth Sedbn70W)ofDiAdm3ofthe Budoe„and PmresI.Code,and ...�C'7 i x�
FSI !"'
1kmse 1•In full and effect' PANELS 1 K- 1_��"/
LI¢rua Llc 0
Drte Conal 0 ,P/Vs 4D
J ARCHDECI•S DECLARATION 211-1000A.MPS
K Z I underdurd my pI ro,hal be used u publl,reo rd> OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
DD N
�Fj LI¢nsed Profesbml SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPFL1ALCpiCU1T/M6L L E D
F- 3 Ih...by affirm that l am exempt from the Contranor's Lio,e law forth, 1.
L 9 qq following reason.$wilco 70015,Bu ea aM Profabm Code Myty dor ITE R
OLE.�y TFh1P.MEll7t OR POLE WST. UMP
Ky�y3 muntywhkh rtqubnapemdtto mmwd,alter,bnpmve,demall,h,or rtpdr _
�[ 3 Ilk.zined prbrto itshat he
llomradi pursuant to the r tonsemdho �yypR DEVICES Q,
K��
Ilk•dgned,utement that he b uocnaed pursuant to the provbbm of theDATE
Oj4 Contrvdori Lkeme Law(Chapter 9(commenting wish Sadbn 71100)of DIN- -SWE'('ONG IA70L ELECTRIC
pth On don3ofthe Budnu dPrormbm Code)ortlutheiscumpttherefmmarul VALUATI
L Q` the bub for the alleged exemption. Any vidatbn or Semon 70315 by any
Ian ippu¢ntfor.permlt,ubJ"thrappkant to a dell penalty of no mon than 01.71-11 MSWITC}ESH)ITURIS
E Bve hundred dollars(5,500).
❑I,a,owmr of the pmperty,or my employee wkh wagn n theb wle NEW RDlDFN11A1"E['F-CIR SQ-Fr. STORIES TYPE CON57AUCf10N
]�O cortw1do work, ndtheWdmb WdeoroHendror
EScab=and!
Prof®bm Code:The Comnd.e.LI¢ma Law
$$ don cot apply to an owner o(property who wilds or Imp.thereon and OCC.GROUP RES.UNITS
whodoesu&h mrkhlm,efforthmugh hla w employee,provided that.&
Impmvemenla are ut intended oroffered fork.If,however,thebulldIng¢ TOTAL:
Impmwe nt IssoldwkhlnomyerofcompleU thewvner-bullderw hart
tryr_parden of pmwng that he did not wild arlmprwe for purpose ofule.). QTY, PLUMBING PERMIT FEE
LJ h�
L u owner or the property,am exchuely contracting wXh lloend¢ FLOOD ZONE APN
mntradon to ronorud the prupd(See 704/,B.ffi.and Pretensions Code: PERMITISSUANCE
The CoMndori Lkenae Law doe not apply to an owns or property who ALTER-DRAW&VENT-WATER If NN
cauda or Improve thereon, and who mhura a for uch pkojecta wish . FEE SUMMARY
cgpypdor(,)B¢ rauan
naetl pul to the License Lw. FEE
FLAW PROTECT.DEVICE
LI I am exempt uar Sec B &P C for this rescan
DRAINS FLOOILROOF,AREA,COND. SANITARY Y N
Owner Dee gyCpS.f 5
WOR KMAN NMPENBATION DECLARATION MIURES.PER HEV' SCITOOL TAX Y - N
Fertby af/lrm that I love•¢rtlBmte of aon,ant to self-Inure,or
oe IBweof Worker'Com Ina pIca n ¢rtBkd copythercof$ec. �•
38 ,LabC OI OIuI T'00 GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE RECEIPT
Pdryl T
Co N� ISS f.A GAS EA.S1^T'SYSTEM-OVER BUILDING DIV]SION FRES
�Cedl dmpyV hereby furiLL,he / aC GREASE/WDUSRL WASTE INTERCQ'fOR PLANCHECK FEE
rf iBN copy is filed with the dty inspection division.
+� CERTIFICATE OF O(EMPTION FROM WORKERS GREASE TRAP PND
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA.FOOFT. Date RCC21 f#
(TMsaedbncoedn¢becv ylded Bthepcmdtb!Dronehundreddollars
61 W)J Ina.) WATER HEATER w/vENr/EI.FcrR ENERGYFEE Y N
I¢dlfy thd 1n the pedorman¢orthe wek forwMa thio pemdt le Wiled;
l. U not empby any penin In any manner n u to become ubjr t to lee
WATER SYSTEM/TREATING
w«kere'CompemaHon lrws of GllfarMa.Date PAID
PP NEW RE&IDENTIAL PLMB. SQFf.
A horst
Z 2 .onCEronPPLIGwr:eWor making Cornpeneut iprmis Exemption,you Date Recei t#
should become subject b the Worken'Compematbn provhbna of the Labor TOTAL
CC UI Code,you nnut fonhw h comply with uN provisions or this pemaB shall be QUILDING FEE
> deemed revoked.
LLI CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyafflrm twhhat there b a mrutmMm Lending agency for the perform
M Z uue of me work mr kn thio permitvl,9,ea(Ser.3os/,Ci,c) TOTAL: ELECTRIC FEE
V O Icnder'a Name PLUMBING FEE
LL F- I. nd&.Address QTY. MECHANICAL PERMIT FEE
O w l¢A"Alh vemadtwappinatlonanddalethattneamvemf.m ion MECHANICAL FEE O
Ismnen.lagnaemmmplywithaudtyand aountyordlnancesund datelaws PERMIT ISSUANCE <,M FEFSPAI D.
} a relating to wilding Cor rtirxr,and hereby uthadr reprnentativn of thN ,
ZN city to enter upon the above-mentioned property for Wpenlon purpoaea ALTERORADDIOMECH.
(We)agree to yKJ LdemN keep harml the City of Cupertino Date Recci t#
V a,metllabilit 11 =cl saexpemn, chnuymanyw.yamue AIR HANDLING UNIT(IU10,000CFM) SUBTOTAL:
agobot ill y ,¢of fififieee g.ntln w.per,rdL ,erg HANDUNG=(OVER lo,".CFNI) CONSTRUCTION TAX
SI natu !App Iradm pit, IX}IA135f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA
FIZA RIRrU5 MATERIALS DISCLOSURE
WBl the
a.dpfl applicant or C pedudbgomupant Wore or haMkM1avrdom HEATING UNTC(Io 100,000 BL1)) Date Recei tIt
I kalth ass definedbythe Cu-255 MuMdpal Code,CM1aper 9.]Z and the
I Leann and sandy cod:Sedion zs3z(.)7 HEATING 17MT(OVER 1000ao Rrlq TOTAL: 190 1-30,
❑Ye
WUltheapplicant tune wilding occupant u,e equipment or devim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whlch emit hanrdw connmWnt,a,deRmd bythe Bay Are.Al,
Qualuy hlanagemant a tdn7 BOr,FR-COMP OFIP OR 100,000 BTU) 7'\
Yn F+
have read the M1 ou,matedab requirements under Chapter 6.95 of BOILERCbMP(OVER 1W,000 BTU) JUL
the Cald.Ulieanh&Bafdy Code,Sedbna E505, 3and795U.I u 31 1990
urdendard tti tl a Ildingd =11y ha atenant,riot lthnry NEW RF9 DFNTIAL kfE(Ii SOFT
rnponalbillty t all thee requirerdawhkhmud be metpa ncy.
CI�''17�^,<�cnn..nil-f�hRl)1-{.�,
ne authorized agent V Date TOTAL 3 Q ISSUED BY: x.l V G- /rk E'-'
OFFICE COPY