19861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bui]dLng Projert Idenefkrtlm PERMIT NO.
Building Add.: 19861
one: A
H y _d CITY OF CUPERTINO-BUILDING DIVISION
Ct or'.Name: I�w,sw�s Lk.N¢ APPLICATION / PERMIT
II m BUILDINr—ELW7RICALML BINGWJCIAMCAL CATEGORY CONTROL
Archltem/Engineer. r Lie N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑
LIm that ED CONTRACTORS DECLARATION
I hereby o 7Ot ofD BcevedheBur rovmm Pm Chap C(comma, AIs1eLIANC6RESIDEMTAL BDE9�tIPT1ION
Ingwtthicerwisin 9(10(8 se leffect v/the BuYrusard ProfeWovCodc,and
Ller.C sac L Tsai. ' PANELS
DaContractor
te - UP TO 2DOMAPS
ADEC K3N
.1000 AMPS `y
Po+{NWy CZ ]arderwnd my Ebro.s1u."ll B ATused n pubfic nerds OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
F Ly tj Lkxn:d Role eWvl SIGNS ELECTRICAL
6pa OWNER-EUILDER DECLIRATION SPECIAL CIRCUIT/MISC
Z E"rG71(Ka Ilurebyafflrrn that 1.m exmpt from the Cuntranor'.License Law f«the
following reason.(Section 70315,Basins and Prefessbu Code:Any city«
O � TEMP.METER OAIPOIR WSI.
F� cauntywhkh requhnaperntlt tomvtsue,alter,lmprwe,demolbh,orrepalr
y a nyrtruciureprbrtolblavarcgaborequU theappb=tf«euchpem w POWER DEVICES
C 1 file a Ygned statement than he b lkeved pursuant to the provisions of the
Oyu Contraearb Litems law(Chapter 9(mmmendng with Section 9IX9)of Divi-
Y�O� Alenle on3 of the Business and Professions Code)ortbat Fexempt therefrom and SWIhAING R')0(.ELECTRICVALUATION
Qy y.'.•--tt the hula for the alleged eumptlon. Any violation of Section 7m1S by any ,
.ppileart for a pemJt subjecta the applicant to a dm
Nl penalty a not ore than OlTDRTSSWIICEES-FD(TURES
$ fi undyed dollars WML
.. I,u a r of the pmperty,or ny emeesploywtth wages a thetr sob NEW RESIDENTIAL EI,FLTR SQFT. STORIES TYXCONSTRUCTION
mmp«srtlon,wfildothe w«k,and Ne Yroeure b rot hderded or offered for
D sale Sec.701.1,Busirusard Prdenbu Cole:The Comrsctoh U«rue law
SZg doanotapplywoa rofpropertywh WlWsorlmprovnthe mo d OCC.GROUP RESUJHS
whodomsuchwmh himself«thrwgh Msownemployees,provdN that arch
Imp..art not Intended crolfertd f«sale.If,howewr,thebufidingorTILDRMN&VENT-WATER(EM
� TOTAL
Improvemem b sold within oneyearofc«npletbM the wvner-bullder wBl have
ben of proving than k did not bund or improve for purpose of sale.). PLUMBING PERMIT FEE FLOOD ZONE
APN
L u owner of the pmpady,am es W.iwly contracting whh Ikenard
mntnetms to mveuct the projen(See 701q B..lnesard Prolesbv Code: R ISSUANCE
The Contractor'.License Raw does tad apply to an owner d property who WBds or imprwn thereon, and who-nursers fee such III" with ac9olpet«(.)hoev punuant to the Contnctor•.Lice.Law. FIDWPROTECT.DEV ICE FEE SUMMARY
LJ I am eumpt under Sec B h P C for this reninSANITARY Y N_OUTSIDFFFrS
Qvncr D.ra NS FLOOR ROOF,AREA,COND. RECEIPT If
WORKMAN COMPENSATION DECLARATION❑ FD(Tt ES PER TRAP S IUOLTAX Y_ N 1 Fereby affirm than I hive•«rtiftah o!eovent to self-.sure,«a
m'Lae orworken•eompevatfon Tvuranm or.«nBbi copy thertnr�ec. RECEIPT'I
m
3g W,LbC.) GAS FA.SYSIFTI.I INCA 0[JTLFIS PARKFEE Y N_
Polley. RECEUIT I
GAPA.SYSI'FAE-0FA)VER 4(
C°m nY S BUILDING DIVISION FEES
I I CeaWed copy b hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCFIECKFEE
iL�JI Certified copy h filed with the my hapectbn dlvWm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
PAID
Cm bererom
COMPENSATION INSURANCE SEWFR-SAMTARYSTORMFA7:8�' Date Recef [#
(1'hlssectbn need na tr pleted If the permit b fm ore dollars hundred dalia
(S)W)«Im.) WATER HFATERW/VENT/ELECTR ENERGYFEE Y N
Ill e t than employ
p person in any ew«k/or wMch oo p sub a(tared, —
1 hall not c y person b my manner.o n tR nem-.a,' i 1 D the WATER SYSTvd/.TREAnsac PAID
W«ken•C conlaws
of Ia.YB,LuA//
O Z W_ eant .Nwn. /'C LIQ NEly RF9DINI7AL PLN B. FI'. Date ReCEI I#
ZO NOTICE TO .0 ICANT ,after making thio Cert to of 1w, aIn,you
.heuldbem b}ctta Wori,eri Compersrtlonprov:lunso Lhe Labor TOTAL:
CCN r
Code,you mY forthwhh comply wBhsuch provbbruorthbm
pedt.hslbe
CC j deed revoEed. UVILDING FEE
CL me
E CONSTRUCTION LENDING AGENCY SEISMIC FE
CL Z
Z Iherebyaffire,that them I,a mvtructfon lending agency for the perform, ELECTRIC FEE
ane,ofthe wort,for which thio b permit Lov097
ed Sec 3 ,CW.C.) TOTAL
0 O I,Mer'e Name PLUMBING FEE
U. t— Lender.Addren MECHANICAL PERMITMECHANICAL FEE
U 1«nBythat l havemad Lids appliatlonand nabove Information that the aboInformation
OS IsmrnH.Rag ee Wcomply wtthallcityaM countyom en«s and Yatelaws ISSUANCE AID.
} N relating to WIMLng coratruelm,and hereby authorees repmentaevn ofthb Ul_
F Z efty to enter upon the above-meneored property for leapeetbn purposes. ALTER OR ADDTO MECH. weo
m. Date Retel I#
— (We)erg«to a.vq Ldonud fy.n d keep harmless,the city of Cu pertlno
.g.net liabilities,judgments, ts and e.,..which may in any w.y..e AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
against lid CRY in consequence of the gamey of thes permit.
AIR HANDLING UNIT(OVER l Stns CFM) CONSTRUCTION TAX
Signature of AppBont/Contract« Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAIAR DOLS MATERIALS DISCLOSURE
Will the.ppleam«futum bufidingo pant Yore or handle h...ndou. / HEATING UNIT(TO 100,000 BTS)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recei t#
I kahh a AdSafety Code Ion 75533:)? HEATING UNIT(OVER 100,000 BTI) TOTAL:
Ye
B)the upplia Iding occupant use equipment ordevims VEMILATIONFANSINGLE RESID) I DATE
whkhemithaardousabmnuaM nbadefinedbytMBay Area Ab
QoalitYn ragemem De �tu? BOILER-COMPOHPORIW,0(DBTU)
k1'MK f O
I haw read the�ar oubmanr,ab requimmenta under Chapter 6.95 of BOLLER-COMP(OVER 100,0(10 BTU) T` V 199
the Califomia Health A Safety Co,!,Scat lona 75505,75533 and 75531. 1
urdentaM that lithe bulldingdoes oat mnensly haven tenant that ltb my
NEW R®DENTIAL MECH. SQ.FF.
rrs � s�(,11ponsibfitty to notify the o pant of the requirements whicb must be A T ?`Gr"rm
�, �
laCertlflolid agent to
TOTAL ISSUED BY:
OFFICE COPY