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21766 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project IdentlfkaBon a.�_r-/_ _� fRJRa _'►"� PF�ihflT h'O. \ BuOding Addw: � al—`/-+R`�](� 1�.K7V U�� 21766 1 C 1-115- 72 �2z2 SIR 2 r. CITY OF CUPERTINO-BUILDING DIVISION cunt" 'sNatne �I ek.Nv. APPLICATION / PERMIT Y"C BUILDINGRWELDC PLUMBINGMDCHANKCM, CATEGORY CONTROL Y Arth m/Engineers Lk.Na Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO Aaarac PERMIT ISSUANCE Is ❑ ,❑ ❑ LICENSED CON uR erSDECLARATION withS alflnn3)ofamM 30fe eB provhndPmfhapter9( c APPLIANCESRF9DF.MTAL PBD RIPDON IngwlthSMbn force of Dldsbn3 ofineBuW�sand PmleWwuCod d 11¢Ne b In full forte and effect. PANELS 1 Lianx Cllas LILY �2 Q G' rE soRow— ate Contractor Y.,JJ�� v�0` v ARCHITECT E RATj 201,10DOAMPS mzC IundentaMnyplavalu0beueedaspubllcre®des OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.Ff. 00 `j Licensed Prdmbvl SIGNSEL2C7RICAL �.. OWNER-BUILDER DECLARATION SPECIALCIRCUITIM13C p I hereby affirm that l am exempt from the C.m,M:tor'n Lice.Law for the p fcWwing reason.(Scdsan 901 S,Business.mi ProfmloN Code:My city or O] e TEMP.MET79t OR POLE INST. F� mystm lchrequHeaapemmt alco mmqu dtheaprove,derml&orrtpto flky any atnnureptementahar he,is licepursuant t the forauch,of to POWER DEVICES K Co a Ngnrd statement the he h licensedl)( pursuant it the pmvhbN of the CnmradLhe Licenselaw(Clmp 9(mnvnndng ek Seaton900))d ard! SWIMMING POOL ELECTRIC +m0� sbn3olthe Rusbmand Prdmbn. Ary orthdhof ScoU tthnrefu by and VALUATION �n the hash for the dleged exempteap Any vlalatd n of Scab"n" by any OSA applcandred Pela.($5 jedn theapplkanttos ddl penalty dna mon thin 0[IfLETSo'TVI'ICEQSFlXNRES r� (Wc Hunan,ddlan he pr. F1 1,an owner of the Property,or my employees with wages astheir sok NEW RISDENTULEI.Ff7R SQFI'. STORIES TYPECONSIRIXTION compeNatlon,wllldothe wmk,and thewuaun b wt IMeMed or o(fenM far do,,ts not O xk(Sec 7011,to an owner w and Pmlmbv Cade:The CoMnctves IJreve law property 1$$$ who..Achy rkhw lfdth=gh s hemplyuilils or l ,p Wt that=chen,,and OCC.GROIIP RES.UNRS 0.0. whouvemorh wm nm Intendedawgh hl so sak.IC never,thebulhat gor Improvemenb an nm Intended orolferN faille.IL However,the WlWinga TOTAL: 1 ' Improv menu inewi g th t o did nes build r Impro a for purpose u poserwW love try9,j Lr owner of the pMatdmwarlortmprwelarwgwith licensed QTY. PLUMBING PERMIT FLE Ltr L or owner of the Propoty,( 70K Buss mntn i n owXn s,Code, FT'ODD ZINE AI'N mntndastomvtNnse Law doe outapplyt stn nand PmfmbN Godo: PERMIT ISSUANCE The a or Imprl Ulnae law dart out apply to an owner p property who ALTER-DRAIN&VENT-WATER(FA) Wilda or Improves thereon,and who madnda for such p.ojeav w0) a qL3jador(emeeptunder Sec. the Cm�tndaiLf¢nz law. BALK FLOW PROTECT DEVICE FEE SUMMARY LJ f am e.emp[order Sec B k P C for this reason e Owner Dace DRAINS FLOOR,ROOF,AREA,OOND. SANITARY Y— N_ WORK MAN COMPENSATION DECLARATION RECEIPT Y ❑I herby affirm that 1 love certificate d o not to ydneae, FDCNRFS PER TRAP SCHOOL TAC N certificate ofWorm'CompeNauo Ivunnamaatrtifed copy thrreof(See. RECR'I Y ]800,Lab CJ GAS F.A.SYSTEM-1 INCL OIIlI.E15 PARK PEE 'Y_ N— Policy 1 RECEIPT Y GAS EA.SYSTEM-OVER l(EA) BUILDING DIVISION FEES Com + �IOed copy is hereby turNdnd. GREASE/INDUSrRI,WA57E wrERC=R PLANCHECK FEE ❑CenBied ropy h filed with the city Inspection dlWYmn. CERTIFICATE OF IXEMPTION FROM WORKERS GREASE TRAP PAID ' COMPENSATION INSURANCE SEWER SANITARY STORM EA 700FT Date RC i t# (Thor lesson neM not be complded tithe pemat h fmorc hundred dollen LYI IIB mI®J WATER HEATER W/VENT/ELILTR ENERGY FEE Y N Ianetify mployat In an person manynce of the work sores to ich pemdthhothe I What not empty any penin f any Hunner at as to become erb)ea to the WATER SYSTEM/TREATING wmken•compen.amnlaw,are.uranh. Date - PAID O = Applicant NEW RL4DFN71ALP MB. �FT, Date Rroei tb Z NOTICE TO APPLICANT:If,after making this Cenlflnte of Exemption,you N should become subject to the Worl,en'Compevatlon pmvlsbv ofthe Lbor TOTAL Q j Code,you mrrtforthwith comply with such prmbdoN or this permit shall he deemed revoked. U •E CLC CONSTRUCTION LENDING AGENCY SEISMICFTE I Hcrebyaffirmthat there Is.construction knding.ge for ttspeform ELECTRIC FEE = arta of the work for which this permit is homed Sec 3099,Civ.C.) TOTAL, t U O Lander'.Name PLUMBING FEE LL H Lndcr'.Aadrm QTY. MECHANICAL PERMIT . FEE, MECHANICALFEE W O Iai" nt l have read thhBca apptbnarci Yatethatthe above lnfomudan 0. feco, .lagreetocomplyw audtyaMa ntyordiNnmandetatelaws PERMIT ISSUANCE FEES PAID: >. N relating to building construction,and hereby authodam representathres of this F Z city to enter upon the above-mentlored property for hopedbn purpmm. MTFRORADDTOMECFl Date ReCel t# _ (We)agree to alae,IMemNfy.n d keep harmless the City of Cu peniro agaWt liabilities,y dgmentn,coda and expenses which may In any way accrue AIR HANDLING UNIT CTO 10,ODO CFM) SUBTOTAL: against Bald City In consequence,of the granting d W permit.s pedt. . AIR i-FANDurrc UNIT rovEn lo,DaocE,n CONSTRUCTION TAX Signature of Applicant/Contrattor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX-PAID: HAZARDOUS MATERIALS DISCLOSURE Will the a pplica rd arfuture W ldbg occupant Mom or hand le haaandoua HEATING UNIT CFO 100,070 RM Date Recel tic material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the liealt h and Ssfety Cad a Section 755370)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑yes No Will the appilodm m Wilding oaapant use a ipmen mdnvim VENTIATION FAN(SINGLE REED) - ISSUANCE DATE wnich eMt hazvaous atr con?Mvme 1a definN by lM Ray Area Alr Quality Management IXarfct7 BORER-NMP QI-I'DRlfl(I,0(q B71p 40 Yve n ❑his loread the na Nwu materials cpdmme.tsunder Chapm,6.95 of BOILER-NMProvp210],000BTU) ��� ���� the California Health&Safety Code,SeabN 25505,25S33 and 755M.1 understand that if the building dm not currently h.vea tenant that it h my NEW RESIDENTIAL MECIi SQ.FT .poNlbil,y to notify the omupart of the nequlremenn which corn Ix met prim to Issuance da Certificate ofOavpavy. Ownerm authorlscd agent Date ISSUEDBY:�V-U�PTI ••+�� `"'eaV TOTAL: OFFICE COPY