20052 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY /
11.1tcling Pro cct 1 "read. I'FJUAT NO.
Bwd2waarcee�O Q D �7 AJl S G 20052
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r. ams: one: A
CITY OF CUPERTINO-BUILDING DIVISION / o
• crchLL mw m.N.mo: Lk.No. APPLICATION / PERMIT
BUTRICALML
fLDING-ELECSINGMECHANICAL CATEGORY CO. OL 0
ANa
7_. Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adel— O D S 1 PERMITISSUANCIR El FJ ❑
LICENSED CO.NTRACTOR•S DECLARATION We
Thereby
DnealMmed p im ChapIt-er9( APPUAN
CESRFSIDENML
ingwhion0 )ofDiAo3dha6uMmandPmfensCc, ndry - 1��IJ D�^
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licenseb in farm and effec. PANELS
LicemCIs . rah LICI Tm�� Comnr Kaan MArTaniCal PLIJ �
(J3
ARCHrrECTS DECLARATION 201-1000 AMPS lkn
X 1 understand my pars shall be used as public record.. OVER 1000 AMPS SQ.Fr.F R AREA $/SQ.FT.
zCOC
U Lioersed Pmfexbnal SIGNSELECTRICAL -
R6N OWNER-BUILDER DECLARATION SPECIALCIRCNT/MLSC
7 t.., IherebyaffimmthatI am exempt fromthe Contractors License Law for the
pp (u tYngreason.(S ap7 ttoB dant Props . Code:hocitym
TEMP.METER OR POLE INST.
Ky countywhkh mryireapermlt tomnshua,alter,9npmve,denuLLsh,orrtpalr
any structure prim to Its beuance,also requires the applicant for such permit to POWER DEVICES
ov2 file a Jgmed natement that he Is lloerued pursuant to the proWbns of the
Contractor'sLicense Law(CWpter9(commemcing with Section 700D)of Divi- SWW[MING POOL ELECTRIC
111--- Jon3ofthe Bu•Inenand Ped®brs Code)orthn he Is emmpt thee,fromard VALUATION
the Weis for the alleged exemption. Any violation of Section 70315 by an
applicant fora permit subpst theapplianttoa civil pensltydna morethan O[IfLE1S5W1rC1�T.Fl%TURI5
Cu n�,�hunaredddan(S5W).
N L as owner of the property,or ray employee with wages as their Mile NEW RESIDFN]IAL ELFTTR SQF7' STOW ES TYPE CONSTRUCTION
compemsetion, work.and NevUuclum brat Intended or offered for
C p
sale(Erc-7014,Business and Prdubne Code:The Comnaare Wane Law
r don Mit apply to 0 owner of property who builds or Improve th,.,and OCC.GROIIP RFS.UMTS
who doessuchworkhma tforthough Msown employees,provided that such
Improvements are Mit intended oroffered lorsale.If,however,the building or TOTAL: r
Improvement bmld wllhln orieymrofcmnpinbri,thewvner-buBdmwlO have
try�p.,rds owner
of the PreeWrmlb exdorimy contracting
wedwe.): QTY. -PLUMBING PERMIT FEE '
LJ L as oo con tr the property,(S a 0K Buly ms and r with IbevM, ETl]DD HD'JE APIJ
The Co
contractions,to constructtheLaw
oet not apply
&umm andP property
Cade: PERMIT ISSUANCE
The Contractor'• et, tLicense Law doe who
apply lo m e such
d property who ALTER-DRAIN k VENT WATER(EA) HCl
9104a or improve thereon, and who coadra. for L ptojem svLLh a FEE SUMMARY
cgp(pclor(eexemptrdpuer Sec. theCmtnctar.Llns P Law. BAIX FLOW PROIECT.DEVICE
LJ 1 am exempt order Sec B k P C for tats reamn
OLITSID
DRAINFLOROOFEA,.ARCOND. SANITARY Y— N—
® Owner Date DRAINS- OR RECEIPT X
WORKMAN COMPENSATION DECLARATION
®1 hereby affirm that I have a cert slate of consent to self-own,m a FDnURES PER TRAP SCHOOL TAX Y N
anlflWeofWorkers Compero minsuranmasmnYle copythereof(Sec. RECEIPT
2180(),LabQ GAS EA.SYSTEM.]WG/OUTLETS PARK FEE Y— N—
Poky! 061 n ret]p7']a RECEIPT X
Co ausau 1ris��'.n_ CAS,EA.NEEM-O�*�`) 9UILDWGDMSION FF.F.S
�Certified copy b herefiled tumle city CREASE/WWSIRL WASTE INTERCEPTOR PLANCHECKFEE
CeniBed copy b(iled'wlththe ci'Y Inspection division. -
CERTIFICATE OF O-k]MPTION FROM WORKERS' GIEk•¢TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT. DBIe RCmI t#
(rhlseectlonneednabrcomple Ifthepermit afmonhundreddollars
fslm)orleae.) ENERGY FEE Y N—
IcertBythat toOrperf..csofthe work fmwhI6 this pemW a levied, WATER HFATER W/VENC/ELECTR —
I.113 notemploy any person in any manner o u to become subject to the
wnrFx sYsrFM/TREAnnc
Workcry Compenutbn lawaolCaWoma..Date
PAID -
O Z Applicant NEW RESIDFNTLkL PWB. SQF. Date Recei tic
Z Q NOTICE TO APPLICANT:1/,a9m tRlote molding this Cerof Exemption,you
should bemme.ubject to the WorLen'Compensation provisions of the Labor TOTAL:
BUILDING FEE
N Cade,you rtunfmlhwlth mnply with wch proWlov orthb pemm.WIIW
deemed revoked.
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffirm that then b a construction lending agency for the perfortry ELECTRIC FEE
7 Z
an oftheworkforwhkhthbpemmbbwed6ee3W7,CH.C.I TOTZ
U 0 I<nder.Name ST� PLUMBING FEE
LL F I.endrr's Addre.. QTY. MECHANICAL PERMITFEE MECHANICAL FEE
OW IcerU(ythatl Wvereacithbappllatbnand sbtethatthe above lnfamsum
4 bcorroct.Iagree to comply with all city and county ordinances and elate I. PERMIT ISSUANCE FEES PAID..
} Hating to building constroctlom,and hereby autbeelre representatives of this
N
[— Z city to enter upon the abovcmentlorcd Property for Inspection purpova. ALTMORADDTOMEGH. Dais Recei LM
(We)agree to.ave,Indemnify an d keep harMu the City of CupertUio
V aga WtWbilltice,)adgrrena,mn.ard expeneewhkh mayor anywayaermre AUR HANDLING UNIT(r010,W0 CFM) SUBTOTAL:
ag.Lut.ald City In mnwque. he g.ming of tMs permit
i� / ,�aj�_(� AIR HANDLING UNIT(OVER 1D,0)OCFM) CONSI•RUCTIONTAX
'SI Wmof AppOam o dr Date EXHAUSTHOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZAR Ug MATERIALS DISCLOSURE
Will the appilam orfuture buildingoaupant atom or hamik haurdous HEATING UNIT(710 100,000 Bll) Date Recel tit
materlal as defined by the Cupem W Municipal Cade,Chapter 9.I;and the
I❑alt Yend SafctyCadLen.-�S�.ecion 25532(A)I HEATING U1,1117(OVER 1(X,000 BTU) TOTAL: OL V
Will the epplics m or(utun building ocovpart use equipment or devices VENTILATION FAN(SINGLE RESID) lj% DATE
which emit W urdoru W contaminants as defined by the gay Area Air r/U '
Quailty Management District? 00IfF.R-COMP CID'OR 100,0(0 RIl)
I haveYe No
ss req a JUN-- 6 1990
yes read the han�w.materials inments under Chapter 495 of BOILCR{O.MP(OVQR l00,IXA BLV)
the California 1k.1th dL Maty Code,Sections 25505,25533 and 25534.1
understand that lithe building don not currently have a tenant,that It a Miry NEWRESIDENTIALMECH.- SQFr.
repansibdlty to notify the acovpam of the requirement.which must be fret _ Gusty ofcno
prior to^bsvanceda Certificate of
� pan W/�YW�l.1F��/E'�
�r�"��, - '�
Owm ncraulhorlrcd agent�' Date
TOTAL ISSUED
OFFICE COPY