19972APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY _
BOW. Pouted Identification
Budding Add res:I
PFA.wr No.
-) a�Sco sro o� uwtts
19.972
G me
Fp(Zu:K �uP
CITY OF CUPERTINO-BUILDING DIVISION.
APPLICATION if PERMIT
BM- TNG ELBCIRICAL-MU\iBINGMECHANICAL
A
—� E'�
Cunt dor'aName: n 'm � Lk. No:
L� �` `'V`�
CATEGORY
CO L Y '
Archked/Englrcer. - Ile No:
2' G
QTY ELECTRICPERMFF FEE
BUILDING PERMIT INFO
c �
Add— LTJ. To S F
PERbeTISSUANCE
El ❑
_
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that t am licensed u Mer provblou of Cha peer 9(connunc
Ingwith Section 7=)olDNm3dthe BuMim dPmfsal Code,and
APPLIANCESRESIDENTIAL
JOB Dpi RIPTION
bee. b in full f....d dfed.
PANELS
LI¢nec Ch. LIeI
Dale Cowador
ARCHITECT'S DECLARTION
TA
[ uedeewM my phu shad be used as public eemNe.
P TO 200 ANTSI
c
k.�X
1-1 (X70 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
SIGNS F"^TRIC::
Licensed Profeasbml
OWNER -BUILDER DECLARATION
dorm thatln 70313, thaenntnda/s Lkel My fort he
following
fodowingreaseequimn. (Section toBusinessandr,op , emlCode h,ydtyor
muntywhkh requlm a pemW tomulruct,.ken improve, demaibh, orrepir
E D IN
9'BCIAL CIRCUIT/MIST
MAL
TEMP. OR POLE RJST.
COMPU��
anystruehre prbrto Its lewarue,abo ecqulmn the appeant forsuch permk to
file a signed statement that he b econsed pursuant to the provbiom of the
Cantrada/s Lkenx Law (Chapter9(mounencing with Sealers 7000) of Divi-
elon3ofthe BuslnemandPa.i.mCode)orthnhebaaemptthemfmmard
POWER DEVICES
14 / 4 I•
SWE.fMING POOL ELECTRIC DA
AL/U� N
the bub (or the dlegM eaempHon. y vlolstbn of Section Ml1 by
M any
appeaet for a pemdt mbjeas the applksni to a dAl pen.Ry d nil more W n
livrwndred dollars (f W.
I, u owner of the property, or try employeeswith wages as their sola
� SSWITC1 ESrFDT RES
1 r '�� g r co
NEW RESIDQJ]IAI, ELECIA SQyL
STORIES
TYPE CONSTRUCTION
campenmtlon,wdldothework, andthestrocture bnotleterded orofleredfor
®le (Sec 7044, Business and Peofessbv Code: The Contacior. License taw
`v ��.
doe not apply to anowrcr d property who builds or leop.therm,and
whodoessuch.ktdm Umthtough Msownemployempro Wedthatmch
OCC GROIIIa
RES UNITS
Improvenrware rot intandedaroffered forsae. It hmveven,thebuildingce
improvementbsdd wkhlnorcyearofeompletb,theowner-bulWerwW have
- - TOTAL
�7
I�r
rde.of proving that he did not build or improve for purpose of sale.).
X..
L.0 awner of the property, am erchulvely mntraaing with rimmed
aasbmuwdthe project (See 7044, Buaines cent Prolesebe Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD TONE
APN
,
The Commetori License Law doe out apply to an owner of property who
or Improve therm., and who coereas for sueh p(ojots with
c9ldIaitmW emnad pursuant to the Contador'. License Law.
U m
I am exempt under Sec B ! P C for this renin
ALTER -DRAIN 4 VENT- WATER MA)
FEE SUMMARY
BACK FLOW PROTECT DEVICE
DRAINS HOOK ROOF, AREA, GOND.
SANITARY Y_ N_
T #
�
Owner I weRECEI
WORgHAN COMPENSATIO ON
❑1 hereby affirm the I u e • certl b! cement to self-Wasre, a a
eirteirste ofWorkeriw
Cnpermation lnsuanea as certlfled ropy thereof(Sec.
350, Tab C.)
FIXTURES PER.R2AP
5C7 pOLTAX Y N
RECEIPT #
GAS EA. SYSTEM -1 ING40[JILEB
PARK FEE Y N
Policy#
RECIPTs
GAS EA. SYSIT fOVER4(EA)
Csoy
BUILDING DIVISION FEES
Certified mpy h hereby furnished
gcertNed copy b filed Mth the city lmpeeHo.division.
GREASE/INDUSfRL WASTE INTERCEPTOR
PLANCI-IECK FEE
GREASE TRAP
_CERTIFI(ZATE OF E)i0VPTK3N FROM WORKERS
COMPENSATION iNSU bfE
H Meseabn need nil he complded ti the pemet b fororc hundred dallam
PAID
Date React tk
SEWER SANITARY -STORM EA 7o0ET
61I0)wlm3
I unity .ot malehat the pedoemab, e of any he week an as to h W s peeredt b bored,
1 sfud not employ.ny person th any mannerat u to become �jed to the
WaekeeApplleer Cmripeuatbn tow. o/Callfomla. Date
WATER DATER W/VENT/M DCTR
ENERGY FEE Y N
PAID
WATER SYSfEMIDiFATIM1G
NOTICE TOLyons
NOTICETOre,sub APPLICANT: If, aftereraWo thissatlmprovisions Eu of the
Comprovisinorhisofthe Labhe
Code, becomst fort witet the W,ly with
Code, you rewq fathwkh comply with such provisions or this pmdt shall he
dmmM revoked.
Dale Remi to
NEW RESIDENTIAL PLMB. SQFI'.
TOTAL:
DUILDING
SEISMIC FEE
*CONSTRUCTION LENDING AGENCY
Ihre
eby.ldrm thattherebame Cimleedingagercybrtheperfore,
ance of the work for which this permtt is Issued (Sec. 3097, Civ. C)
TOTAL
ELECTRIC FEE.
Iemer'. Name
Leeeer'eMdeesa
I nerHfyth.t I have red thio applla(bn cent etaMthat theabove In(amatlm
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:. ,
bore Y.lagrt toewnplywXhaddtya"m ntyor iWnavandsatelaws
PERMITISSUANCE
relating ro building mrvt act" n, and hereby authortao representative of thio
City to enter upon the abo onentbned property for inspection purposes.
(We) agne to save, bidemd/y and keep haemlesethe Cky of Cupertino
I ALTERORADDTOMECH.
Date Rester" Iii
-
SUBTOTAL
agaWtllabWtks, jrdgmew,cmnaM <xprten whkh nvy Wanyway acauc
against psai�d� City It, mnsequ e. of the grant"' °fthbperAmB.
6'(�QV Z 4
(Chun
AIR HANDLING UNIT CTO 10,000 CFM)'
AIRHANDLiNGUNTT roVER 1,WOCFhI)
CONSTRUCTION TAX
�-
fA
Slgmare o(Appdont/lbnteeasw mte
WiAUSTHOOD(W/DLY'D
CONSTRUCTION TAX PAID:
HAZARDOUSMATER ALSDISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Wel the applicant orfuture budding cecupnt store or handle harardous
naterlal as defined by the Cupertino Munidpal Cade, Chapter 9.17, and the
Health and SafetyCode Seerb' 25537(x)7
❑ Yen (L) No
Dale Recei Ib
HEATING UNIT (OVER 10,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
x .
!
Will the applkam or future building oaupnt use equiperatm or devices
whkh endt her edaus ab contaMvnts sue defined by the Bay Area Air
Qctility Management Duitridi
Ye :°
have read the hares matertebmrylremenbunder Chapter 6.95 of
BOILER -COMP OHPOR Il0,00D BTU)
BOILER-CONP(OVER 100,000 BTU)
1
the C.utedt at tithe
Cods SCabm755a5,ve 33 a tenant,
building oft
uMostai[hy
Hthethe
a+ V
NEW RESIDENTIAL METH. $QFT.
to ocepam
respoeulbeky to .day the oavpnt d the tequlrtercnts which recast he nrl
he mquiyhavea hich trust he trait
'
prior to Lvuance daertWa
Ch,dOrepaocy.
CITY of Can
j erFinr>l Wvs"•r)
Owner or authorised agent Date
TOTAL:
ISSUED BY:
OFFICE COPY