21312 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ii Project ldentifkatlon PERMIT NO.
Building Address: - 21312
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r. nor.
nn 4 ,U ,] ' CITY OF CUPERTINO-BUILDING DIVISION '
Cum etor' N.mr: Lk.Na
• APPLICATION I PERMIT
L _ BUNNNGII FLTR CALPLUMBINGMECHAMGL CATEGORY COY ROL
A mhRect/Faglneer Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITI.SUANCE GAa ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am lkmeed under provisions of Cha per 9(mmmen APPEANCESRESIDENIAL JOB DFSCRFffON
ingwith Semon nvy
_ 70.0.0.y),o�fDbldo3ofthe Rd and Pmfero .e,and
I.1. foeand
PANES
Lice lawsGLle,#
Date U �
�
ARCHITECTS DECLARATION a
-1 'NIPS
aO ZpC I understand my plaro.h.Bbe used as public rcocoNa OVEiI000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
`j Licensed PMesional ,{-I1 A SIGNS ELECTRICAL .
«<G OWNER-BUILDER DECLARATION' !,
Iherebyaffirmthatlamexemptfromthe Contr.nors Lfmm Lw(¢the SPECIAL CIRCUIT/ML9C
O7 folbwing reaem.6c'ctlon 7015,Buelnew and I'nefaelmu Code:My tlty yr ? T
Z Q TEMP.METER OR POLE INST.
FE� cvuntywhlc pret.aapertnkbrorutrue Lr4thlinpL=tfe o 6prwpalr -
q 6 anyatalPed tattow lb h;t he'la BEo r Q purthe app the f¢mch permit to
O�U file a algned moment this:hr b Bmneed punwant to the provbbro of/the I'O51'FR DEVICES
003 Contactor',Ecem law(Chapter 9(mmntrntlng wkh SecUoe700P)of Divi- SWIMMING POOL ELECTRIC
o ebn3of Ne BuMev and Piofewbro Cade)orthal hetieamplttheicfmm.nd VALUATION
the basis for the alleged eaemptlm. My violation a Section 70/15 by any OUTLETSSWRCHESFUIVRFS lie
r•S$a5 vPPUant fora permitaubj la the applicant to a d 11pomlry of nH ratre t han _ -
fivehundreddollars(S500).l, I
7� n1,as owner of the property,or my employees with wage as helrmle NEW RE9DEJITAL EL[CTit SQFT. STORIES 'TYPECONSTRUCTION
0< mmpensation,wlll dathe'w¢kand theatmctunbMirdrnded ar fferecifnn /M
O sob bee 7011,Bwircss ird Pinefewloro Codi:The Coranctor. rn- ; r
r$ dare wtapply to an owrcio(property who tiullda orlmpravnt n,su OCC.GROIIP RFS.UNITS
whodoementsaor oat
orwgh hlawmemplv`yee,prot thn sudr
Inp.v mNs d t hffio dorofkndforbbet k4tC o�+vrr.th Ildingcr TOTAL:
Improvement bend wthat hed1gotbuildiltb4eheowner-bu erfsalave
t rdenof ,rofthhpro not Wild Imprweforpu oracle.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
1,a.owner of the pro (m 7D Nely mnt M liigPre Uh Ile Code:
mntractonta carotmctthe pro' (See 70W,Bwlnew and Pm( bra Code: PERMIT ISSUANCE
The Contractoe.License Taw does not apply to u owner a property who ALS-DRAM&VENT-WATER lE/0
builds or impr there, mn
and who mers f¢such pto)ees with a
ITT am
purewnt to the Cnetnnm:Lienee Law. gAp(Fww]'IeoTlrr.DEVICE
FEE SUMMARY
IJ I am eaempt under Sec B &P C for this nOUTSIDE FEES
® Owrcr Date uon DRAINS.FLOOR,ROOF,AREA GOND. SANITARY Y_ N=
.........//r WORKMAN COMPENSATIONDECLARATION ��a
I hereby affirm that I have a certlRnte of comm to uhf-Ina¢,m a FIXTIJRES PER TRAP cA100L TAX Y_ N
rtWcne of Worker'Compemtlonlrouran¢or•¢rtUkd copy Nereof see
RECEIPT 1'
3 ,labQ GAS F.A.SYSEM,11NCA OUTLETS _ PARK FFR Y_ N
Polley`rev lA.SYSTEM-0VEt l(FA) REEF?s
Co rev w Q EUILDING DIVISION FEES
�Certlfiei copy b hereby rNe city CREASE/INDUSTRL WASTE 1MEiCEPTOR PLANCHECK FEE
�CertNed copy b filed with the city Iropmbn dlvlelm.
CERTIFICATE OF EXEMPTION FROM WORKERS' CRFA. TRAP PAID
COMPENSATION I perout fu SEWER-SANITARY-STORM FA 200T Date Remi t#
(rhes lection need nR be compleLLd Uthe permit b f¢one hundred do0an
lSlm)nythrt
1¢rtifify tWATFRI-6ATERW/V /EI.ECTR ENERGYFEE Y N
to thepMorrtun¢of the w¢k(arwHch thio pemdtbb.,ra, '
I sha0 not employ any peron In any manner w asto become subject to the WATER SYSIIId/TREATING
Worker Compensation Law.of C.ldernb
CI Z Appbant NEWRESIDUMALP B. 9QF1.. Date RCoeI t#
Z O NOTICE TO APPLICANT:If,after m.ldng this Certificate of Exemption,you
alcohol become subFct to the Warken'Compemtlmr provbbro o(the Lbor
P: Ln y Caeeyw naar(orthsvhh Damply with mcF prowbro orthb pemdt.tall be
> deemed revoked. -BUILDING FEE
W O CONSTRUCTION LENDING AGENCY EISMIC E
a Ihembyafft thatthere b.corWructlon bnding agenry for the perform
7 Z an¢ofthe work(orwhkhthb permN bbeuN(Sec]097,CIv.Cd TOTAL ELECTRIC FEE d
00 Lender:Name PLUMBING FEE
LL Iender.AddresaQTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ¢
1rtlfyth.tlhavereadthbappUnibnaMs tethattheabovelnfom m
bmnect.I.greemcomplywflh aBtltyand oluotyondtrananand late lawn PERMIT ISSTIANCE FEES PAID:
} N relating to building conatmetim.rul hereby authorise repnesenatNes ofthis
F Z city to enter upon the abovementbrcd property for Uupectbn purpoen. ALTERORADDTOMECFL Date Rece1 I#
— (We)agree to save Irdcmrdfy an d keep harmless the City of Cu Peru.
.gaWt WbWtln,jadgmew,coin ndeapa hkh mayinanyway.aoue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
:gal Ciwin c.,w ;.N tld.=ft.
AIR HANDLING UNIT(OvIm l000O GEM) CONSTRUCTION TAX
c- IVigna of Appgont/Conti er nate TmiAUSr Hoof)(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
theappllardorfuturt,Wddiog.p..t.t.,r.r handle harandma HEATING IINIT(IO 100,000 BTU) Date Recei t�
material an defined by the Cupertino Municipal Code,Chapter 9.12,and the
Fleekli and Sdny Coda Ion 25532(.)1 HEATING IJNIT(OVER 100,OWTI )
Y. N
TOTAL:
ill the.None buildingocupant use equipment or eiv VENTILATION FAN(SINGLE RCSID) ISSUANCE DATE
whkh emit lunrdous.ir mnand urea as defined by the Bay Area Air
Qia WeDistort? ER-0
y Managemm tgc11 BOILDMP OM'OR 100,000 BM
P�O
LI` Y 7� id.
Fav,read the hauii[Blas materials neyulranienb under Ch:pter6.9S of BOILER-COMP(Ovalm"BTU)
the California oHealth&SafetyCade,Sectn cot bro 25505,25533 and 25531. I OCT 1990
understand that if the building doeurrently have a tenant,that It is my N'EWRESIDWnALMECH. SQT7.,
rm romllRy to naUy the occupant he requlremem.which must be met
p oL�.n¢da Ce if{ate of my.
CI_ of t�IB�nn
ner or auth¢bed agent Date TOTAL: ISSUED BY:
' I
OFFICE COPY