24090 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Projeei Idemifkatlon 7 PFILMITNa 4 0 9 0
Rudding Address:
one
Z assa CITY OF CUPERTINO-BUILDING DIVISION
Con ct sN; : Lie.Na APPLICATION I PERMIT
RUfLD ELECTRICALML lNGMECHAMCAL CATEGORY CONTROL
ANsXect/Englnen:' IJr.No:
QTY ELECTRIC PERMIT - FEE BUILDING PERMIT INFO
' Address PENM]TISSUANCE ❑ A El LICENSED CONTRACTORS DECLARATION
Ihereby Secdss70lhat I am fDivid n3 ofthderpeastannsof Clupler9(ccanmm AI7'[lANCFSRESmENTUL , r ' — FY
Ing with Sectlollfomeofd effd 3ofthe Buelneaand Prolealaru Cod<,and
II¢n.c b In lou for¢and effeA. PANELS �
LI¢ns<Claa Lk./
Date Contractor
ARCHITECTS DECLARATION 201-I0OOAMPS
quq�aa W�2: I understand my phm shall be used aspublic m0n7da OVER IWO AMPS SQ.Fr.FLOOR AREA $1SQ.FT.
k L(/ LI¢ved Pmlewbnal 9GNSEIKfRICA1. -
«<< OWNER-BUILDER DECLARATION /1
7� a Iheeby.f .th tlamexemptfromtha C.Mr.cior'e Lkena Ua f¢the SI'FLUL CIRCUI7/MLSC �l r� n A L E D I
p followingre,m�.f5e lon 70115,Busmen and Prefeabro Code:M d or LL CV�I
07`� Y tY MIR INST.
F��y muntywhkhrequl apermklomvmMalter,lmpmv de=o kormpalr d �I
anystmu mpA tolbtambo
a ¢qulrntheappu¢ntf¢s &permitto PO E DEVICES
I. /1 p I�
Of le a signed statement that he 6lkmsed pursuant to the provisions of the ✓0 1� tl
µ Contractor'.Lkerae LAW(Chapter 9(commencingwith Stt[bn700D)ofDivi_
s„30 sum3ofthe Beaineaeand Prvfeaebro Code)orthat he b exempt therefromand MING 7\70L ELECTRICV ON
the besb for the alleged exemption. My vldatbn d Seetlon 7(315 by any TE
�« appu¢et for a permit.ubjeM the applicant to a civil penalty,d net more than OUfLEMSWITZHESr XTURES
Ove ndnd ddFC
la+.Mile). NUINFESIDE-MALELIR
?¢ U 1,as owner of the property,or my employees with wages u their sole �'�' STORIES TYPE CONSTRUCTION
aa mmpensatlon, W
wdothe work,andthe Armeture b rot iMerded or offered for
r(❑ ale bee 7Ot4,Buslneve and Professions Code..The Contractors License law
F�F$2 don not apply to m owner of property who Wild.or Improves thereon and
who doessuch work himself or through hismen employee,provided that such OCC.GROUP RIS LINITIS
Improvements a¢rmt Intended oroff red forale.H,however,the W llding or i0
Improvement bsod within oneyearafcomplatbn,tk owner-buldcrwW have
rden ofprodng that he dtl net Wud or Improve f«purpose orale.). QTY, PLUMBING PERMIT FEE
a.owner of the property,am eshnsively contracting with Boned FLOOD IDNE APN
tractors to comuuct the p.Iod(Se,70K Bu.Iwr and prostration Code: PERMIT ISSUANCE
Contnctori Lberse,law does net apply to an owner of property who ALTER-DRAW k VFM-WATER IFA)
Wilds or Improve thereon and who contracts f¢such plojm,,with a
offdor(s)Bcensed pursuant to the Contran¢i Lamese law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_f I am exempt under Sec B h P C for thh reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Dns RECEU'Ta
WORKMAN COh1eaN9ATeam aEuxurot to ant FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm Nn 1 have a¢rtlfi¢te d cmiet to alf-Inure,a a RECEIPT a
ortifleateo(Workers'C¢nperr.atlm lnsuran¢¢a¢rtBled¢pythered f5m. GAS EA.SYSTEM-1 INC4 OUTLETS PARR FIT Y N
pwi0 Tab CJ
If
Com a GAS EA.SYSTEM-OVER 4(EA) DING DIVISION
I1'
Y BUILDING DI V ISION FEES
CertBied copy,b hereby famished. CREASE/INDl1SIRL WASTE INTERCEPTOR
PEE. .
Effied copy is filed with the edy Irupeetlon divirlon.
CERTIFICATE OF EXEMPTION FROM WORKERS CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTIARY-STORM Ea 2o0FT Date Revel IA
crw:eemn nee.eat ne eomplatea u the pcmM b r¢nne hanared.arses.
Rt O) Ify.)
lWATERHFATTEW;VEvr/ELE= ENERCYFEE Y ,N
¢rtlfythut tath<perfamun¢of lhew¢klorwMch Wepemdebhared, —
1.hau n¢employ any pennon In any manner m a to become sub)tt[to the WATER$1,SI-EM/TREATING
OAe<keWCornpen.nlnepawanfaluomla.Date PAID
Z NOUCETO APPLICANT:B,after making thio Certlfiute o(Exemptbn,you NEW RESIDENTIAL PIMB. 901.7, Date Rcoei tll
should become sub}at to the WorkeriCompereallon pmvWom of the Labor TOTAL:
~ N Code,you mina forthwith comply with such provbbro or this permit shill be 1
> deemed revoked.
W —p CONSTRICTION LENDING AGENCY SEIWIC FEE
NG FEE
CL lhembyafftrm thatthereleamrotruNonleMingagenry for the per(ortry TOTAL ELECTRIC FEE
7 Z ono of the work for which thio pend[blecoed 5,3pg7,CIv,C) _
U O lender.Name PLUMBING FEE
LLF Lender.Addrea QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W 1¢rtitythatI haw nual thisappliodnd n
o .ratethn the above lnfomutlm
Is cornet.I agree to comply with all tltyand county ordinances and state law. PERMIT ISSUANCE FEES PAID:
} N Natingto WlldingmnmWw,aMhtmbyautho mpr nUth ofthls
F Z city to enter upon the above-mentbnrd property fee bupecdon purpose. ALTERORADDMMECH. Date Revel tic
V — (We)agree to ave,Indemnify an d keep herrolem the City of Cu rano P
a galetllabWtln,Ndgme ., sardexpenaswhkhmyinanyw�aac a ATR HANDLING UNIT CTO 10,000 CFM)
.gaunt City In ecreequence of the granting d this SUBTOTAL:
/460 AIR HANDLING LMT(OVER 10,000 CFM) CONSTRUCTIONTAX
M/ to F USTHOOD(W/DUCD - CONSTRUCnON TAX PAID:
HAZAR DUDS MATERIALS DISCLOSURE
Will the a pp"M or lona¢baud Ing occupant Blom or handle:havrdous HEATING UNIT(TO 100,000 BTU) Date RCCCI til
materlal as defined by the Cupertlw Municipal Code,Chapter 9.1 2,and the
f leach and Safety Code Section 15532(.)7 HEATING UNIT(OVER I00,M BTU) TOT
E Ye �]No _
Hi the.ppu .mtutu¢building occupant urs equipment or devices VENTILATION FAN(SINGLE RFSM) ISSUAIJCE+DATE�
whkh emet hanrdous ab oantamlaMs a.deRnud by the Bay Arca Air n /
lily Marugement Dutrictt 130rUT COMP PHP OR 100,000 RTU)
(� a Y. n No AUG
.e
-1 )averead Healthvr�frtyCerlabtioo,2menn5511an2553urderChapter 695uf BORER-NMP(OVER 100,0008TTn A{/ 1 1992
the aufomla Health A Safety Code,Sections 25585,currently have
a tenant,and 25531.1
uMerstaMthat ifthenotif Wudingdoe of the mnurvmoea ,hihthat It not NEW RESIDENTIAL MEC}L SQF7 CITY Q.
rnpoto tan.
y to.f.Cthe oavpaM of the requhements which men be not f
prkx to leuan¢daarti(late o(Omnpanry. .- UUrtfYfery�,I
Owner or autho agent Date ISSUEDBY:
TOTAL:
OFFICE COPY