19954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Fluildirat Project Idents tient f� �}R,ypi NO.
Beildl Pao G1' `r`l {=- R-. .
u�, r a 3 19954
If
rot Rena: GTZCLFHg�.1'C St
G Vµ [{.. VP CITY OF CUPERTINO-BUILDING DIVISION
Centrader.Name: Lk.No APPLICATION / PERMIT
Architect/Englvrn 3UILDINGFLEC7RICMLPLUMBINGM NICM, CATEGORY CONTROL
MOW/, C7►-1
GH +_ — BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address& H61F, PERMITI.SUANCE 1:1 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
lM1 rebyaH thatiam11ceveduMerpr WonsofChapter9(mmmen APPLIANCES-RESIDENTIAL J N
Ingwlth5ectbn70p0)or Div .3ofthe Bua..dPvfe .Co ,and my
Iknnx b In full form and effeei. PANFTS - c
Clam
Date I ISI �L F--xt
Date Cord
actor UP TO 2DUANIPS
ARCHITECTS DECLARATION 201-1"
ntOZ IuMemua nTplamshaBbeiuedupubllcmmrda OVFAI"AMPS SQ.FT.FLOOR AREA VSQ.F7.
Fi o�j Licensed Professional SIGNSFT TRICAL
<� OWNER-B UILDER DECLARATION SPECIALCIRCUIT/MIS '
Ihe.b afflrmthetlamea fmmthe Covtradorb Lionel fathe
'I:O G following eason.(5nedon 70315 Business and Profesbw Code:My city or
OF G t. TF]dP.METER OR MICE INST.
� muntywhkh enquired.pemdr tomMruct,ilter,lmpmve,dermWh,or rtpilr
6 anyatmmmprbrtoltabeuancgaborequlreatheapphl t(ar apemdtto POWER DEVICES t
r.U file a signed statement that be Is Ibense t pursuant to the provblov of the
Contractors Llcerue Law(Chapter 9(mmmendng with Section 7000)of Divi.
stS-µrptqvgNG I'(IDL F],EC7R3C VALUATION
O on3 ofthe Business and Profeeebm Code)orthat be la exempt therefromavd
fi,haat for the alleged exemption. Any violation of Section 70315 by any S1Y1.(CItfSFlJCIVRES ''') )•-y7 appBantforaptemdtaabie theapplkantt.ad"lpenahydndmonthan
0 hundred dollam(S-W. NEW RESIDENTIAL ELECTR SQ.ET. STOWE9
TYPE CONSIRIICIION'
�j.. I,as owner of the property,m es my employwith wages u their sok
F,7 mmpevatloe,will do the work and the stvctm,b not Intended or offend for
C� p suit Sec 7DK Bosbes and professions Code:The Contractors Wove Law
don not apply to see owner of property who builds or improve thereon,and l7CC.GROl1P RIS UNITS
CC who dm such work himselforthrough his own employees,provided that mrch
ImPoreemenb are not intended or offered for aak.ILwr
haver,the build Ing or TOTAL:
Impmmment baoW wdhNoneyearofcempldbRthewvner-bullderwlB hart -, 2�
t rden orpvdng thatkdu riot Wfld orlmprowe Por purpou Maak.). QTY. PLUMBING PERMIT FEE
�1,u owner of the property,am exchulvely,contracting withlicensedFTaOD ZDNE '1PF7
ortrEtoa to covtvdee the pm),d(S70K Businessand Profesbv Cade: PQtM171S6[IANCE
11s Cont.==.Lk a om Law dm not apply to an owner of property who ALTERDRAIN&VENT-WATER CEM,bulbs or Improve thenmnda
en,and who ntfor such pm tojewith a
ryllt(�da(a)bmnxd pursuant to the Contradora Llonu Lw. FEE SUMMARY
IJ I,m sump under Sec B&P C for this mason M
L r% I hi OUTSIDE FEES
p SANITARY Y_ N
Avner
• WORKMANCOMPENSATIO )e ON SIiODL TAX 9111111, RECEIPT
Of hereb affi m th M I ha e•¢rtifla of consent to sell-Inum,or a R L II'I I
mrtifiateof orkeriConpevatlm lvuvna ora mrtifkd copy thereat See GAS FA.SYSIEd-I iNc.4 OWM ARK FEE- Y N
3BOQ UbC.)
Pdky I W I f RECEE71'N
Comm any • G'��' BUILDING DIVISION FEES
I ICenNed copy b heat with
GREASE/1NDU5TRL WASTE INTERCEPTOR PLANCHECK FEE
LYJ,Ced Ned copy b herewith fis city inspection divWm.
CERTIHCATE OF EY10i,IPEION FROM WORKERS GREc-SETRAP PAID
COMPENSATION INSURANCE SEWEILSANITARYSIOR.M E 20FT Date Rtmii tH
(Ior1 bnrent not be<omplded If the permit bfroom hundred dollen
a100)nly that
IWATER HEATER W/VENT/D.ECTR ENERGYFEE Y N
certify that babe performance of the which Wapermhle blued,
1 ilaR not employ any prrvm in any manner n as to beeome sub)ed to the WAITR SYSIFA{/TREATING
Worked Compenutbn l.waof California. Date PAID
0 Z Applicant NEW RF9DE]VIiAl I'LMB. SQFT. Date RCceI t#
Z NUTICETOAPPLICANT:If,after making this CertlflateofExcmp�in you
shmldbe subjecttothe Worked'Compen.atlonprovbbvofthe Labor TOTAL:
CC N Cade,ywn fa hw hmmplywuhuchprovbbvorthbpemJtshillb.e
LU j deemed revoked. G
FFE
C CONSTRUCTION LENDING AGENCY KISMIC FEE
d Iherebyafflrm that then b a mvtructlen lending agenry,for the perform
ELECTRIC FEE
e
7 Z rue the of whkh this permit (Sec.3091,CW.CJ TOTAL,
00 tender..N.meN.me PLUMBING FEE
U. F Lender.Addnss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imreifltun l have dad this application and state that the above Information
b oernd.l agree to comply wrh all ety and county crdhanees and state law. PERMIT ISSUANCE FEES PAID:
Nrelating to Wilding mvtvctlon,snd hereby Ruthotc e representativa this
I— U) dty to enter upon the n,hove-men0oned property for Wpedion purpose. ALTER OR ADD TO MECH.
(INO agree to save,Indemnify an d keep harmless the City of Cupertino Date Rttci tH
V against liabilities,judgments,costs and expenses wh may In anywayacmae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaivtsaid Chyinconsequenma thegranting hbpemdt.
P:Mt)M &O �� AIR HANDLING atm(OVER lo,Daa cFM) CONSTRUCTION TAX
SI gwtvum of Appllant/Om[raetar Fill !Date D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant,or Wrote Wilding occupant snort or handle havrdous HEATPvGUMT(TO100,000B'DT) Date RCCCI t#
matcMl as ddircd by the Cuperti.Murddpal Code,Chaptrr 9.12,and the
Heahh ant SafetyCoke+Sooiw 2SS32(a)1 HEATING UNIT(OVER 1011,000 BTU) TOTAL:
n Yn No
Bl the appllanta vre buOdNg occupant use cqulpmentordevkes VENTILATION FAN SINGLE REM) ISSUANCE6A3'E
which cmlt lavrdm s W contaminants,as defined by the Bay Area Air
Q�jality Management Dbtrictl BOMERCOMP OHP OR 100,OM BTU) .
Yn No -i.
have read the havr�aus matedala requlremenb under Clupter6.95 of BORER-COMP(OVER 100,0003170) rpt t.
the California Health k Safety Code,Setlov 25505,25533 and 25534.1
understood that if the building does not currently have R tenant that It is my NEW RESIDFNIIAL MECH. SQ.FT. )2
reapovibility,to notify the occupant of the requirements whleh most be met / City of rimertino
print to tsuano of a Certificate ofOmop ocy.
Own,orauthortred agent Date
TOTAL: ISSUED BY:VIiF YIW IlL1INw`^l
OFFICE COPY