19960APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro M Idemifkatlan _
Building Add.:
PERMITNO.
1 I"a9J� n
a35oo G !k -!9b DR , c» i [ S L { I It Z Lk 3 PE 5
try 1V'1
1990
O
nerd N.: Phone.
A
U U
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
6'"�-8 "'8
ContnRor. Name: Lk. No:
L'
BUILDINGELECIRICALPLIIMBINGMECHAMCAL
CATEGORY
CONTROL
AnchRect/Fatginar. Lb. No.
1 C — 6
QTY ELECTRIC PERMIT FEE
_ BUILDING PERMIT INFO
(`•
Add—I S •F
PFRMITISSUANCR
Dl ❑ ❑ El
-j�l
CONTRACTORS DECLARATION
I hereby affirm that lam Bcmaed under prwWons of Chapter 9(conumere
Ingwhh5eWon9000)of DlNdmt3ofthe Budraaa.nd Prole doroCode, and my
APPLIANCESRESIDF14T7AL
JOB DESCRB'I'gN
Ilaroe b in f." rota and effect.
PANELS
Llaroc Clam Lk.a
Date GOII[ratlef
�x
201.1000ANIPS
ARCHITECTS DECLARATION
I udebaod my pbro e4aB be u i u public omnia
1 ate'
OVER 1000 AASYS
SQ. FT. FLOOR AREA -
5/SQ. F7.
SIGNSELRCTRICAL
Llceru d Prdeabnal
D IN
OWNEReBUILDER DECLARATION
I hereby af0rmt)ut I am eaempl from Rho Contntlor'. Lkeue Law fa the
f ntynhlchre.6etlion70I15, gudnesand Profeabro Code:Any tltyor
cwnty which requbn.pematmcorotrutl, dter,lmpma, dennWM1,or repair
SPEWALCBRCUIT/MISC
T E t3
TIMP. MEITY OR POLE♦NST.
anymrocturt prbrto ib bwarce,aLw rcqulrealhe appllrant(w wch pemat to
0k a dgnd statement thrt k b Barod punwant b the prowioro of it.
Contntlor'. Lkevel�w(Chapter9 (wewencing whh Sectbn 7000)of DIW-,
^ POWER DEVICES DATE
SWIMMING POOL ELECTRIC
.2;1 AV
ATTON
the basis for the alleged e.emptbn. Any vidmbn of Seetlon 7m1S by any
applicant for a permit subjects the appleam to a civil penalty of nee mart than
LY1C"'
OLIn ETSSWTTCHFSFP"TURFS3p,0
NEW RESIDENTIAL, EH.TR —SQ -Fr.
five hundred adlars(S5DUL
OI, as owmr of the pmperty, w my employm w h wage u thek wk
`70J
STORIES I
TYPE CONSTRUCTION
campcwtim,wlll do the sunk,. and the mm=m is not Wended or offered for
ale(Sec 70K Bu.k ami Pmfndoro Code: The Contractor. License Law
don notapply loan owner of property who bu Bdsor lmprovn the., and
whodonwchwmk him elf athrough Msownemployees, provided thetnmh
OCC.GROUP
Q6.()NT15
improverrcnb are rot Intended neutered fauk. If, however, thebuRding or
ImprovementbwldwB or yurofcompielb theownerbullderw Ml
TOTAL
l lrdenofprovingthat he did wt buds orlmprove far purpae otu�.).
La. owner of the property, am ewlusively contracting with 1lmmd
t d. to comarud the project (Sec. 70K Bu.lnea sod Prdevbro Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE Y
FLOOD ZDNE
APN .
The Contractor'. Lkeaae Lw don not apply to u owner of property who
build. or Impove
rthereon, and who contracts fee such p(ojems with a
.galpoaw haemes pursuant to the Contradeas Licnnse Lw.
f am evempt uMer Bee B (r PC to thl raison
ALTER -DRAIN & VFM-WATER (EA)
FEE SUMMARY
BAac FLOW PROTECT. DEVICEIJ
DRAINS FLOOR, ROOF, AREA, GOND.
SANITARY Y N
RECEIPT♦
Owner I D e
WORKMANCOMPENSATIO. RATION
❑1 hereby affirm Uut I have . certlfleaant to self -boort, or a
artdla4e of Workm'ComperoaBan lrmu wacertBkdcopyummaf(5ee.
3800, Lab C.)
FDCIlJRES PER TRAP
5Q-Rp[•.TA% Y_ N_
RECEE]PTI
GAS F.A. SYSTEM -I INC4 OUTLETS
PARK FFR Y _ N _
I
FTN
GAS P.S. SYSTEM( -OVER 4 (EA)
Colley
Co ray
DING DI
BUILDING DIVISION FEES
certified copy b hereby with the d.
certified copy b face wltn the city wpcatbn alvwan.
�
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E)(EMPTION FROM WORKERS'
PAID
SEWER-SANTI'ARYSORM Ei 3IA;TDate
COMPENSATIONINSURANCE
(This. flhm need not be completed ti the permit b fee one hundred dollar.
Recd [N
WATER HEATER W/VENT/ELECTR-
ENERGY FEE Y N —
PAID
(yt 00)wfy that
Innote ploy an pees rnnnof tmumnerhe week wastofor ohthb pemltbkud,
Weri not employ any peas In uy rr nia. w L to become o,bjec to the
'ComperoaOnn lawsofGWorNa. Date
WATER SYSTEM/TREATING,
Appli
NOTICE
NOTICE em APPLICANT. If, mldng per Certdlate is Exemption, you
Code,y n= forth totheMbar
Code, you num forthwith amply with such provbbro orthb pemdt.hall be
ca Workers' Cath pre umsoron lb permit
deemed revoked.
Date Recei til
NEW RESIDENTIAL PI.MB. SQ.FT.
TOTAL:
BUILDING
$ ISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a mnmmction lending agency for the perform-
anre of the work far which this permit b bwd (Sec. 3091, CW.C.)
TorAL
ELECTRIC FEE
PLUMBING FEE
;.ender. Name
;ender. Addmse
I nrtlfythat I have read thbappdotbn and etatethatthe above Inforounten
boormd.lagralDcomply wgh aBcltyeod cvuntyortllnano.hand mmelawe
QTY. MECHANICAL PERMIT FEE •
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relatingtobut Wingcoretructlon,and herebyauthorizerepmsenuut dthk
sty to enter upon the abavcmentbred property, far bapectbnpurp ,
(We) agree to ave, hdeeudfy an d kap harndea the City of Cu,,mW,
ALTERORADDTOMECH.
Date Recelptq
SUBTOTAL:
agaWtllabWtln,ydgmew, mmsaM eaperou whkh eery banywayamue
agaiw mid City In conmquerce of the granting dlhk permit
�i moi/
Jam( "r^
AIRFUNDIINGU[TT(I010,000CFM)
I`m
AIR HANDLING U(OVER 1Q"CFSO
CONSTRUCTION TAX
Sigaatumof Appllant/^--•--' Date
D(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATERIAL DISCLOSURE
HEATINGUNIT(TO 10,070 BTU) I
WBl the appBaM«Future bu0dbg aceupant Blore or lundk haaeadoua
material u defined by the Cupediw MuMdpal Cade, Chapter 9.17, end the
I
Date RL`cCl 141
HEATING UNIT (OVER 100,ODD BTU
TOTAL:
I leakh and Safety Cade Semon 25533(1)7
❑ Yn No
VFZM LATION FAN (SINGLE RFSID)
ISSUANCE DATE
d:T
`�®,
WWthe app0ant orfuture building occupant use equipment or tf v
which emit h rdoo. air mntandrunb ae de0 nd by the Bay Arta Air
a Ity Management Dot rkt7
BOR.PR-COMP OHI' OR I00,DM BTU
Y. ❑❑ 110
BOILER-COMP(OVER 100,000 BTU).
havereadthehavrdoua rtaterlab equlrtmenb under CFapter 6.95 o!
the California I lahh Sc Safety Code, Section 75505,75533 and 25534.7
undenbnithat lithe buddbgdon not currently have a tenant that it o my
-E
.fit "'•'r "r'J
I„ •`
NEW RESIDENTIAL MECK SQFT
rnporoibll Ry to miry the.pam d the rry4. r m m. whkh mom be met
prbr to kwarc da CertlOate ofOavpanry.
'
Cir,• ofII--rllnayrti�no�
ISSUEDBY:30a
Ownerw autharlTid agent Date
TOTAL
OFFICE COPY