20002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Ede Ifk.tim PI]thOT NO.
Building Addma: ` ° a 20002
one:
CITY OFCUPERTINO-BUILDING DIVISION
Contractor's Name. Ido.N. APPLICATION /PERMIT �]
Arch /Fsgta5C__
B=INGELECIRICALPLUMBINGMFLHAMCAL CATEGORY CO Y
T�Na .
C( �.v, , [` r� Q - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrne: 6 UT POWITISUANCE � ❑ ❑'
LICF,NSED CONTRACTORS DECLARATION
I Femby a fflrmtlatlamllceveueerpro ww.aChapter9(mamnenc APPUANCISIff4DEMTAL JOB DESC
IngwithS tun 7000)of DivWon3oftheflusieentandProfeWmsCude,and my 1 -a —
Oortse Is In full forte and effect. PANELS `J
Lkeni Cleo. LIc1 .22]x5Fi7
Date ontraor_'n'a man R'ar na nlC dl .1 � LV'L/
CI]
ARCIUTEPS DECLARATION V`O
pkp�vv{OPy7 CZnM records.C I undeUmy plan shall be used as public ds. OVER 1000 AMPS SQ.FT.FLOOR AREA 'S/SQ.FT.
Fi i tj Licensed Prvfeaelonul SIGNSELECIRICAL
<«esu OWNER-BUILDER DECLARATION' SPECIALCIRCUTT/MISE
ZF FF]/311 IM1ercby afOrmthatlam es<mpt/cootie Corur+tloh LloenseLwfw the
pO
following...(Section 70715,Buainev..d Pmrnelo.0 Code:Any city or
TEIVIR MEIFR OR POLE INST.
� muntywhkh requ4vapemat tommtrun,alter,Imptm+e,demolLeh orrtpalr
file
q' any a suaurcprbrmltahat he Isaboued!pu aottolontlasuof tm POWER DEVICES
PS S Co a signed statement that ha t r 9(c m erring t it the provisionsito! the _
FOSQu, Contnclor'a Lkemelaw(OfceaIo9(mmnrncing with Sectlonherefof Divi- VALUATION
F,ESOs .lon3dthe Bu.lnev and PrdmloreCode)orthat hebeaompttherefromaM SWatMINC POOL ELECTRIC
a Y.' the bawls for the allege<"erptim. Any violation of Section 7m15 by any
appU.t fora permitaub"theapplkanttoaddlpeunydnamomthan ` OUnXTS-SWI7CFE'FU(TURES
c, ° Iv hunamaemployeesar, W.
I,an owner of the property,or my employwith wage as their sok NEVs'RI�FN7UAL ELECT& SQ,FT. STORIES TYPECONSTRUCTION
CTION
C < c mqx atim,wllldothewmkandtheetmu mu not baeMed or offered for '
° nak Cee 7014,BueNemard Prdebv Code:The Contractors License law
5£2 docs not apply to an owrer of propertywho builds or improveathermn,and
a whodoosuchworkbhnmelfathrmgh hboweemployeeprovlde that.& OCC.GROUP RIS UNEIS
Impmvemenb arc not Intended oroffered fmaale.If,however,thebullding oc TOTAL: .
bnpwvemenl hsold wilhmoneyearofeanplabn,theowrur-bulklerwW have
t Menofprovingthet der b„udorhnprovefapurpaeo/eak.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
1,as owner of the property,am ercwNely conlmcthng with lic naed PERMIT ISSUANCE
mrca
ntcta to cermtruct the project(Sec 70K Businem and Iharesbre Cale
The Cont mors es tkt Taw don not apply to an owner d ,edrt w who ALTER-DRAIN&VENT WATEt(ESO
lou Ods r improves thermn,and who confine, for such P..vjem with a -
L_jIc7alltaam
under antSee tothe emtndors Lksrue law. BACK FLOW PRO=.DEVICE FEE SUMMARY
[_J I am exempt order Sec B 6 P C for that reawn
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT Y
yy� WORKMANCOMPENSATIONDECLARATIONIT1<"Il1RES PER TRAIT - SCHOOL T" Y_ N_
•LII htreby.Hiro that that I have.cert!ctut d cm.em to self-Insure,a a RFGI3PT a
ani0oteCompensation'Compensation Into rance or a certified copy thereof Qin-
3800,Lab CI GAS FA.SYSTEM-]RJC40UTLE15 PARK IEE Y N
Ivicya nF,Tnng-Uz.Z9. RD]TIPTY
Coorrt n WancAn Tnr.__Cit_ C'�EA'SYSrEMOVER 4(EA) BUILDING DIVISION FEES
,MXIQrtlnra copy b hereby funJnheel. GREASE/INDUSIRL WASE INTERCEPTOR PLANCHECK FEE
-St�J Conine copy h filed Mm the dry W peNon dwislm.
CERTIFICATE OF O(eTTYHON FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-gANITARY STORM EA.]OOP! Date .Recti t#
(hls.oetlon need not be Completed If the permit h fa one hundred dollars
I
(51arffyth WATER HEATER W/VENT/ELDL:M ENERGY FEE Y—
N_
rdrytnat lnthe perrnrnunadthe work mrwNththis pemdtvba.e,
1 shall not employ any perem In any manner an as to become mbjict to the WATER SYSIQA/TREATING
Workers'Canp esatbn Lat.or California. Date PAID
PP NOVPERDF14TIAL PLMB. SQFT.
n Baht
Z NOTICE co APPLICANT:to the
sRerent Come Cion p,md Exemption,ym - Date OTARtxet#
Coda, become forth tothe ply with
Compe.uaUonprmdabnofthe Labor TOTAL:
LU _N deemadoun ked. with comply with ouch pmvleloru ortw permit elull he
> dnmed revoked. BUILDING FEE
LU S CONSTRUCTION LENDING AGENCY SEISMIC FEE
1herebyall'ttluttheahamnmtmdhmkeingagencyforthepedorm
Z a neeoftheworkforwhloht 13pemJtbb (Sm3097,CIv.G) TDTAI_ ELECTRIC FEE
U O LerGeh Name PLUMBING FEE
LL F Lender'.Md. QTy. MECHANICAL PERMIT FEEMECHANICAL FEE
O W lcenlfythelhavereadtwappllotbnandrtatethatthe abovehnfon ion
Limned.IagrcetommplywMaUdtyaMd ntyo.d m�andststelaws PERMTTLSUANCE FEE$PAID:
1 mlatingtobulMing mmtmdlon,and hereby authalr iepreentativnofthia
hZ city to enter upon theabovo-mentk,rcd property for Wpeedon purpose. ALTERORADDTOMECH. Date Recti t#
— (We).gate to uve,irdem.dty an d keep harMe�the CNy of Cu ctw
agaWt habiitin,ydgmenta,cub and expecte which may in any wa).mrue AIRHANDUNGUNTf(IOIO()(X)aM) SUBTOTAL: '
age hunt aald City N cnn.egoena of the granting of thi.permit.
_� _ AIR HANDUNG UNIT(OVM IO,Il00CFUD CONSTRUCTION TAX
Vn" A0;gnatua of Applicant/ tractor Date D UST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atoreor handle hawardms BEATING UNIT(TO IW,WO BTU)
nutedalasdAruqY', e by odtheCupertinolMunicipal Code,Chapter 9.1; Date Recei t#
and the.
Ikanh.nd 5afcty Cale Sectio 75532(x)7 � HEATING UNIT(OVER IW,IXD SIU!) TOTAL:
No
Bithe appliarrca tumbuilding.p.museeguhpreentordrvicn VENTILATION FAN(SINGLE RESID) IS6UANG&DATE
which em0 haardmu m
all nu.mrunto as doe nby the Bay Area Air ts_/ �Y
Quality Management District? BOILER-COMP PHP OR 100,010U BTU)
Ye
No JUN ?. 61990
havereadthehav�oue mateHals rtqulrtnrnb underClupter6.95 or BOILER-CO..W(OVER 100,000 BTU!)
the California Hearth&Safety Code,Sectlore 255!6,75533 and 25531. I
understand that if the building don not mrmntly have.tenant,that it is my NEW RESIDENTIAL MECH. SQFI'.
rmporeihillty to notify the occupant dthe requirements which crust be met �a �{ /a 4„�.{r�
priortohwa..f.C<nOlotWe fOm.panry. MV YIFWII
G of
�GE6IYAISX C�
a auth WN gent Date aISSUED BY:
TOTAL
OFFICE COPY