22375 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm et Identification PFRMLTNO.
Banding Adak: r — 22375
c� l S+o450 V/1►fsL 3I, air I pe��
ra .n,e en( APPIMA
CITY OF CUPERTINO-BUILDING DIVISION
Cmtnctesa Namr. Lk.Nm APPLICATION /PERMIT
A mhtea/� BUILDINGELQ:fAICALML BINGMOCHAMCAL C.9TWORY CONTROL#
girecr: i.ic No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PExwTlssuANCE ❑ ❑ 1 ❑
LICENSED CONTRACTORS DECLARATION rs�no
I krtlryaffbnn flat lam Bcrnsed underprovLtlmaol Cha)ter9(oornvr,en API'LIANCISRFF—RDENI7AL )OB DESCN
ingwlth Sedbn70D0)of Dlvimm3dthe Butlrieseandl}o/mdouCade,and my / Q• �-'Ie v�/�
liL.me b In fun, p,d effsot PANELS L V
Date •b Comnamr UP TO 2DQ AM
AMT'S �lurn
ARCHITECTS DECLARATION
q�q�uu o4 Iurdem nd'nyptamsl Rbeumdupubhcreuds OVER 1000 AMPS !!!SQ.FT.FLOOR AREA $/SQ.FT.
Fi �j Licensed Pmfeabrad SIGNS ELFLTRICAL '.�tp/�IQ�S
<<�< OWNERNes BUILDER DECLARATION SPEC1ALCIRCLIIT/MI'S ,P L�.
IherebyafOrmthat lam nempt(romthe Conlnaoh Lf¢melaw for the
o Oppp
following reason.(Sem70315,l3winand Pmkmlom Code,Any city or erml
F$ county which requires a perMt to mroeua,alter,Improve,denroRsh,or repair TFS P.METER ORPOLE WSI.
anymroaumpatrnneibhe heh,Licensed
restheat W the /¢suchpof to TONER DEVICES �/ /( �
file•tlgned yatement that k h Ilmined pursuant m the prvvltlnro of the •r oO
O<O sContra(theButlemwel ndP(roaspt bmCod )ortnanekbemnbtthemfroma"
SWIM NGPOOLELECTRIC
VALUATION
Thelot.6for1hrallegedixemption. MnyvivofSoction7QI15any
applicant faraperMt wbjsde the Applicant toodlvil penalty of nor more
than OUTLETSSWITCFIESFLYTUIRFS
cave hundred dollen he property,
ro
FIT,.,owner doth mwp"ndrmy employees wg eMa r ffebmle NEW RESIDENTW,ELECTR
TYPECONSTRUCTION
0 zQ car (Sec 70 ,wWdotkworkand Jom Coduebcotblended arofferedfor
F Cl solo bee 70 y Bueiruae ed f pr pe ny Code:Ther i,.p oh Name Law
S doesocapplytork ownerapropertywhowendsloimpmvmted that and RESUNITS
who domwchworkM lforthrcstglh Ithees,providedflatsuch
lmprovemeNa are rot intended oro(femd!«solo.Il however,lhebuilding« OTAL:
improvement bsold wthinoneyearedcompletbr,,the ownerbullderwW have
tl�urden of proving the he did not build or lmpmve for purpose of We.). QTY, PLUMBING PERMIT APN '
"1,as owner of the Property,am essluaWely cont,wkh I o,eo
contractto mrotrod the Project 70K Bueine�and Prdeabm Code: PERMIT ISSUANCE
The Commaale License Lw don rat apply to an owner of property who ALTER DRAIN A VENTWATER(EA)
bu Rds or Improves thertor,and who mntracit for ouch a
InnJe ,with
o➢pacter(a)"eee a pursuantto the Cmtradoh Ll¢roe Law. BACK FLAW PROTECT.DEVICE - FEE SUMMARY
LJ I am-e-pt uMer St, B k P C for this mown - -
DRAINSFLOORROOF,ARPw,COND. SANITARY Y_ N_
Owner Dale RECEIPT a
E- J WORKMAN COMPENSATION DECLARATION FD(TU<ES,PER TRAPSCITOOL TAX Y_ N_
IpLbereby affirm the I have•¢miRamm m rsd
te of coestuum,(or a S
38M,L eofWorker'Comperoatimlwnn¢ova¢rtBled copythtmof$ec. RECEIPT N
3800,Tab CJ //�f CAS EA.SYSTFAf.1 WGIOUTLEIS PARK F� Y N
Policy 0L`_ 2—6 7
69 7 REGRET 0
GAS EA.SYSTEM-OVER 4(EA)
' SCer LCaa r� BUILDING DIVISION FE FS
eAllied pyb ertbyth shed. GREASE/INIWSIRL WASTE INTERCEPTOR PLANCHECK FEE
Allied copy b flied with the city IropecUon dlWelm.
CERTIDCATEOFFXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION N .N
SURACE SEWER.gANITARYSTORN EA NOF[. Date Re i tit
OTla aectbnneed cad k c«npleed Btk pemdt b f«am hundred dollars
(5100)or dtfy J WATER HEATER W/VENT/ELDCLR ENERGY FEE Y N
Trent slut intht person in aoftkwnet(or to btoe etsubj dined,
1 noun not employ,any Uwm f any meaner at u to become subject to the WATER SYSTTM/TREATING PAID
Wostkca Compenvunn lawn of CaW«nis. Date
nt
Z Q NOiICETO APPLICANT:If,after nakingthls CenRi¢tea/Exemption,you NEWRE9DFNfIALPLMB. SQFT. DatC RLaeI tit
should beconne subject to the Worker''Comperuatbn provbbro of the Labor TOTAL: r
N Code,you=it fort hwth comply with such provisions or this permit shallbe
lL > deemed revoked ITT ITT nTM(-P1717
S ISMIC FEE
CONSTRUCTION LENDING AGENCY
CL O CONSTRUCTIONeofthhereby aid rmthettkrtisam is sastlend,309 my for the perform ELECTRIC FEE a
� = an¢of the work for which permRbbened lsK 3(197,CIv.G TOTAL Y�V
U O Lender'.Name PLUMBING FEE
LL F Landers Addoete QTY. MECHANICAL PERMIT FEE MECHAMCAL FEE I
O W I¢rtify the l have readthbappBationard Katethat theabovtblomwlm
b restorer.I agree to comply with ail city and county ord]nwm and state laws PERMITLSSUANCE FEES PAI D:
} N relating to building comtmel and hereby authorize representatives of this - 1 Q • I ly/ r
F Z city to enter upon the aboserentbn i Property for Wpeebn pu'poen. ALTERbRADDTOMECH. ate ReCC1 tic
— (We)agree to oK,ind emNfy an d keep harnde�the City of Cu pertiw
egaeut MbWtlte,jadg is,mete sndexpeneawhkhiruyinanywayacvue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against CI In thegramingdthiepemlt.
���,1,-�n 7/x/91 AHeIUNDUNc1NITrovER](,000cEM) CONSTRUCTION TAX
Sigiu molAppH /C Fact«M �e.17— EXIAAUSTHOOD(W/DUCT) CONSTRUCTION TAX PA In:
K RDOUSATERIALSDISCLO REQ
Will the applicant or futum building ocovpant mom or handle havndom HFATINC UNIT CTO IM,ODO BTU) Date RCCCI tM
rm[edal a delmd by the Cupemiro Mu Ndpal Code,Chapter 9AZ and the
1 leach and sfery Cade Sexxlm 25532p)7 Eff aTiNG UNIT(OVER IM000 BTU) TOTAL:
F�
Y. No
I e"hennit ez prard tvrcbullding ascupant use the Ba¢nt«dtWm VENTILATION FAN 3WGI.E RESID) ISSUANCE DATE
which emitnaerninn air oontamWrdta deOrcd by the Bay Area Nr
iia Wy hlanagemeru DlytEicrt BORFR-0DMI'OIiP OR)OO,UO eTIn .
4 Ym f��`No
Mveread thetzar out rCodelois mqulrementaundeand2553 .1 of BOILER-COMP(OVER l00,000BN)
the GBlomb Ileakh A Safety Cada Sections 75505,15531 and 75530.I _
understand that if the building dm not currently have a tenant,that It bay NEW RESIDENTIAL MECH. . SQFT
rapomibRRy to rally the o paM of the requimerents which must ne met
pdorto«uanma mi to pancy.
C
th gm t '
TOTAL ISSUE
OFFICE COPY