20047 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro et Id.ndfkatlws PERMIT NO.
R.Id -L3,wio vWLTS I 3a � 2��47
rcr• . me.� - CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Ix.Nm 'APPLICATION I PERMIT l� CCJJ
Ancht / BUILDINGELECTRICA4I'LI7hSBINGMCCI]ANICAL CATFLORY CONTROLa
�7�cc yc.No:
y/ y� (\ QiY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address �ji Q l.RJ LJ S PEN4TISbUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONN
I hereby elm,that l an,llcmaed under provolone of Chapter9(mmmrn APPI.IANCESRESIDENHAL BDE9CR�f10
ingwithSmb.700Mforce afd efeon3dthegudnessand ProfeWonuCode,and / ,.��_ F PUP L+a
license Is In foil force and effect. PANELS I�eGfJJ1 r1--F'`(
Lianas C�aq Llea 227562 -
Date72 cnntraaKalman Mechanical LV
ARCHITECTS DECLARATION Ml-000
W07 lureardand mypbroaBh
shuednpublicrecords OVER1000AMPS .FT.FLOOR AREA S/SQ.FT.
y Licensed mlonal SIGNSE.FCTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT[WK
Iherebyafflren that l am exempt frontheCordrator'sLiceruelawforthe
7 '❑a following reason.0dtcri 7MI.S Buelnm and Pmfero c
ubCok My city or
K�~� c ntywhlkhrequbeapem wmmtruct,altrr,4npmv demo h,ormpalr T12AP'MERRORIOLEINST. .
SS� anydmturepdamin baunce.aborryulrcacheappBont(oraucM1 pemJtto
t5 G file.slgned mb statement the he Ilanxd pursuant to the provbro bof the ]OWER DEVICE' '
O Cterraao/s Lle.Taw(Chapter 9(commencing wah Settle.700W of DIA- SWpdhgNG POOL ELECTRIC do.3 of the Budnea and Prof�bru Code)or that he b exempt therefrom and VALUATION
. the barb for the alleged exemption. My vloldbn of Section 70315 by any
Q'g �.� C}� � -
appRant fora permit subjnta the appliced too civil penalty d ivot more than
Mrvndred dollen(fv0ll). NFW RF ENTIAL ELFC7R SQJ-7. SNR16 TYI'F CONSTRIICTIOt.'
Lf L u owner of the property,or my employee with wages u theU sole
Cmpewtfon,will do the wakand the structure band Wended or offered for
5 O msale(Sec70K Ruercxard Pmfeaslom Code:The Cortlntols Weare Law
wh.d aPP .,kh lfo th ghhy obu,Wporlmpravnth th,t and OCCCROIIP RFS,UMTS
Tu wprovemu is aren tInte dad r ffa doe k.If,heq pmvWedthatuch
improvements are not Intended rarofced(a sob,If,however,thebullding a TOTAL '
improvden nitof baking than prey exat buildorI p,ne for puuBderwWlove
LlL_j Las ofprovingtephat oedmnot exclurlmprwnlmpurpoeu chain.), QTY, PLUMBING PERMIT FEE
Ute 1 er Done of the property,am exclusively Boo .ant!
essi U—nacdCode: FLOOD 7DNE APN
Th.Ctontommicar.L Ned (Sec7 apply
Romeo and Pm(eebro Code: T'FRMII'155UANCE 'l c+{/
The Conrtncip Litmus IAw don not apply c f owner d property v who ALTER-DRAIN k VENT-WATER(&V '•l
build.tc Improve thereon, and wC menta fol such w. whh
gp�afor(eexemptdp.nder Setrotheeontntor'a Llarue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
c L,J 1 am exempt under Sec B k P C for this rtuon
® Owner pat DRAINS FLOOR,ROOF,AREA,COND. - SANITARY. Y_ N_
RX WORKMAN COMPENSATION DECLARATION RECEIPT a
FIXhereby affirm the I have a arelBote of constant to saf-lore,m a N�$�T SO100L A% Y_ N_
arWlate of Worknn'Comparaw lon]uurance ora certified copy themof(Sec. RECFBf a
38 W,Tab C) GAS EA.SYSTEM-1 WC4OUT= PARK FEE Y_ N_
policy 0610040779 ctis FA ss7EdovFR4(FA) Rl�rfa
Co ^Y waists _ O- BUILDING DIVISION FEES
Catlfleampy b hereby rumlehed, eREASE/)TNDusrtu.wnsTEIMFRCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS CREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM E.A. Date Reed t#
(fhb eenbn need nt h completed I(th permit b/or orae M1undred doBan
(ST rUfess3 WATFRI-ffiYTERW/VENT/E.ECTR LNERGYFEE Y_ N
I mwy that b the performance dthe work for wWch this permit is bund, —
1.hafl nos employ any person Warfrrat u to become object to tin WATER SYSTEM/TREATING
ken'Compewtbn l,w.d California.nia.la. Data_ PAID.
PP NEW RESIDENTIAL PLMB. 9Q.FT. Date Recxi t#
2 AIlam NOTICE TO APPLICANT:If,after maid this Certificate of Exv I
becomen.,you
H N should seb)ect to the Workeri C.mro
pealum probm The vbhe Labor TOTAL
CC Code,you wstInd hwhh comply velth such provploro or this pemdt shall be I BUILDING
deemed revoked.
W CONSTRUCnON LESIDING AGENCY SEISMIC FEE
CL I hereby affirm the there It a construction herding agency for the perform- ELECTRIC FEE
7 Z once olthc work(or which this permltbtmued f$ee 309/,CIv.CJ TOTAL
U O I<Mer'.Nena PLUMBING FEE
LL H ]e.dar'.Md. QTY. MECHANICAL PERMIT - FEE MECHANICAL FEE
OW ]artlfythelhave read this applfatbnard danthat the above lnlormelm
a iecormt.lagreetocmnplywfthailttyardoountyordln anddatelawe PFRMITISSUANCE FEES PAID:
relatingto WlWingmrutrutimr,anal hrebyeathosi ampresenteivesoftht
F = etyto enter upon thesbvve-mentioned property faiupetbn purposes. ALTERORADDTOMECH. -V Date Recti t#_ (We)age reto save,Indemnify an d keep harndm the City of Cu partW
ago NellabWtln,judgmew,mesaM ezparm which nvy In any wayacaue AIRHAN NGUNIT(TOI0,ODOCFM) SUBTOTAL:
agairotsald Cbyimmnsequenceof hegnIV ming dthls pemdt.
MR HANDUNG UNIT(OVER 10.000CFT.n CONSTRUCTIONTAX
Signature.!Appgant/ .n D,te EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATAR SMATERIALS DISCLOSURE
Will the applicant or future building.cmpantstora or hamile havedcus HEATING UNIT(TO 100,000 BTU) Date 'Recti t#
material as deflated by the Cupertino Municipal Code,Chapter 9.17,and the 77�Y
Hmhh oral Safety Code Section 25533(07 HEATING UMT(OVER 100,000 BTU) TOTAL:
❑ Ye Nn
Will theappBoM or tum building occupant use equipment or device VENTILATION FAN tSINGLE RFSID) ISSU/�j�aATE
which emit hmrdous air connMnanta as d.flrcd by the Bay Area Air r//'�U��Y/
• Ihy Management District? BOMER-COMP OHI'OR 100,0(09T))) '
Yae �
Thove reed the heir sort nutedab recto lrereents under Chapter 6.95 of BOILER-COMP(OVER 1(0,000 Z .1 STU) JUN 6 �U
tln OBfomla Heald k Safety Code,Sections E.505,25533 and 2S534. V .
urderstand that if the building does ent currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.Ff
responsibility to notify the occupant of the requirements which nue be met
tAvn etroohrn+uatnnc.rtdmda CcBennlPvte.f�fyfry ' VI/V O�f].cI�umu�nY tt�`02
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Data p
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ISSUED
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OFFICE COPY