20056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build]. Pro en Identification
PERhBT NO.
Building Address 0
20056
anon. one: APPLEcATT
CITY OF CUPERTINO-BUILDING DIVISION ^,�^
Cp�y/�aA°�°�NQ•n���Q� (/yj N 'APPLICATION I PERMIT e
n& rev "o Na DIRUILNGELECIRLGMTR
ICAPLUMBINMLCHACAL CATEGORY C
AONOL,1
rchReR/Fsgl L1e
ST
Z G — C 6 Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: \�� � PFRMBTISSUANCE ❑ ❑ ❑ ,.
LICENSED CONTRACTOR'S DECLARATION I hereby,lfirm that l am llcerued under provWOss of Chapter 9(owmmnc APPLlANCESRESIDENITAL J B RIPIION
ingwkhSIn full(p00m0y)of drff m3ofthe BualnevndProleWonrCndgrid I —t � ^ Vpl�
Lioer.sIn(ull(..GOdL1.1 PANELS 1....1•..`. I--J 1�
Date / Contractor
ARCHITECTS DECLARATION 371-1000
ceOZ$� Iunderstand my p]arashal]be used as public remrda OVFRIWOAMPS .SQ.FT.FLOOR AREA S/SQ.FT.
Ij LI needProfubn,l SIGNSBLECTRICAL E D I N '
res<LLbbuull OWNER-BUILDER DECLARATION SPSCALCIRCIIIT/MLSC
EFfd Iherebya(Or (Senthat l.meaemptli.a Comf.WLlcer�e-l yd the �-
>fl tollI hetereason.(Semon70315,Buslne,nd Profmloru Code:My tltyhe
6 G t— TEMP.METEI20R POLE INST.
Fv�a nlmtywnmpere totU mRromiorequi lttheaprove.demowh,or to
YO file.ImRurt statements that
he is ahersed pursuant
to the ,mIsdo of the POWER DEVICES
yCµ� Ok.stgned statement thst h b BaruM pumant o the pmvbbro of the
%!µ Contnaor,Lke.Law(Cbapbr 9(commenting with Section 9000)of Did- SW34NUNG POOL ELECTRIC
IW, Oaf rin3 ofthe Bualnneand PrdeelunsCode)mth9 he b exempt therHromard VALU�,TION
Q a•�] the Nssb(or the.Ikged eaenryHm. Any do]tlbn of S ios 90315 by any
fv� ,ppBant Tor,permit wbj<ethe applicant toff dvllpn,Bydnct more ttun OUTLET'SW1TCtESFD(TURFS
p. Rv ordred dollars%W. NEW RESIDFN77AL EI.ECTR
I,,s owner of the property,or tory employees with wages u their sok SQ'Fr' STORIES =CONSTRUCTION
5 O daus ale(Sotapply to an owner
w and pnopeom Code:The C impro rs Lemon,aLaw
d
whodoosuch torn imserdprough who Wllds or mploymprwnthemRu& OCCGROUP RFS.UNITS
0.0. whodoeseuvasamowork hlmsendesicwghhlamvnemplgeea,provided ebulldtwcA
Improvememo nminte ort yr ofcomp[eW It h er-bathe Wildlnga - TOTAL
Improvenem bsoldwhhln oroyearof<omplelogtk mvnerbullderwW wvz
tt,p+rdenofpmArSthan hedfd rotbund orimprwefoeptipose.f.k.). QTY, PLUMBING PERMIT FEE
U L as owner of the property,am emIusively contracting with licensed FILX3D ZDNE APN
contractors to mmbud the proyd(See 70K Basion and Pin f ebro Cods, PERMIT ISSUANCE
The Contactors Limm a Taw does not apply to w owner d property who ALTER-DRAPI k VFM-WATER(EN
Wilds own
r Imprthereon, and who contracts for weh p\ojem with
-pips,tor(a)Ikxbed punufint to the COntrad&.Llarue Law. . BAIX FLOW PROTECT.DEVICEFEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR RODF,AREA,COND. SANITARY - Y_ N_
WORKIMAN
RICEIPT r
COMPENSATION DECLARATION
J]�Q/hereby afMn that I have,certlRate Of consent to self-Awa,ora FTXNIff_S PER 7RM 5l7100L TAX Y_ N_
'Fertifrais of Wortrn'CanpenWon Iwr•nce or•artifled copy thereof i5s, RECEIPT
3800,Lab GAS E.A.SYSTEM-1 INCA OUTLETS PARK FTE Y_ N
PdkyY I�O '8 GAS FA.SYSTGI-0VERA(FA) AF�EIPTa
Co y N4cJK BUILDING DIVISION FEES
�CertiRod copy cloy roissid' /r GREASE/IKDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertifled mpy b filed with the city,inspection didstm.
CERTIFICATE OF EXFROM WORKERS GRFA'SETRAP PAID
COMPENSATIONINSURANCE SEIVERSANITARYSIORM EA.20()PT Date. Recei t#
TTMa season need ria tr completed B thehepen
mdc b(ororc hundmn
l dollars
(fl 00)m1yth WATER HEATER W/VENT/F�.IR ENERGYFEE Y N
I¢rtlfythatln anyphe (ormunaof tit nerfonw thbp bje Weed, —
1 shag oat employ any nems f any manner at u to become eub}ecd to the WATER SYSTEM/TREATING
Workcrs'COmp<nsatbn Laws of California. Das, r - PAID
O Z NOTICEAppitca
NEW RESIDENTIAL PLMB. SQ.FT. Date Retpi t#
Z O NOTICE TORP ublectM:R,after nuWng thio Certilfoted ExempteLaIx, TOTAL:
Code, become areato the Workers'Compev,tbnprovbbruo(the Lobar
Q >
Codeyou, suet forthwith comply with wcF provlelom orthb pemdt shall be
`> dewed revoked..
BUILDING FEE
a F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I bemby rffirm that thereb•mmtmnion kMNg agency for the perforrry
7 Z arta ofthe workfor which this permit b bmred(So,3097,Civ.C.) TOTAL ELECTRIC FEE
Q O Lender's Name PLUMBING FEE
LLr ]emer,Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W rt
I mRythat l havereedthb•pp0otionand statethattheahmeeinfomutlm
Iaoure .I.gres to comply with.]] fty.rd muntyonAnancnand statelaws PERMIT ISSUANCE 0 FFESPAla
�. a relaling to Wlldingm Rion,.ed hereby authorlu representatives of this
F N ehytoenterupont mentis rte for in
purposes. ALTFRORADDIOMECH.
Z ( lel:rest WemN d ph, the Cj.'a Cupertlro Date Reccipt#
V ,galmn Babl ,p mems, oars apensn muyln rnywry,mue AIR HANDLING UNIT(IO 10,000 aM) SUBTOTAL
againt By gn this ps.R.
�3 ATRHANDLIN'GUNTr(OVER1Q000CFM) CONSTRUCTION TAX
gru of AppBant ontr.ctor Date EXHAUST HOOD(W/DUCn CONSTRUCTIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or lutea hu Ed trig eau N st store or ba ni le hazardous IIEAlINGUNTTf10100,000BTU) Date Recti I#
materlalasdeRr i bythe CupeNoo Mumcipal Cods,Chaper9.1Z and the
Health,rd Safety Cade I 25532(x)7 HEATINGUNTP(OVFR100,000BTU) TOTAL:
MYee o
Will ths.ppian tun Wading« pant use equipm,rd or tl voea VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkh enot hazardousak IamWnteas defined by the Bay Arta Air by;t r7
Quality Managemem Eptr ct? BORER-NMP PHPOR 100,DM BTlp Ajfu#
4Yes, '`NT��}I�yy,
haveread the h mate abttq recon underCaper695of BOILERNMP(OVER IW,000BTU) JUL 1990
theUWornla Health Safety CMe,Smdb 2S505,SS33and2-;5U.i
understardtloitiftw9ildIngd rm.tlyh a aterartthatitbmy NEWRINDFNTIALMECEL SQFT.
no'
porow hyto RY oocc� t erequir corn which Ad in be riot
PrbrnO Ins d rill t4 of cm P.-Y. '� C�iV ('-e' rrlRnrtinn
0. wnhortred agent Date TOTAL: sx 1$UED BY: �_/
fit/
OFFICE COPY