20557APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Era M Identification
BoDaing aaam,.: ,,, C v 0_r (S. C
Z dip CJ �1l I S I I
PERMIT NO.
20557
netYRoat
CITY OFCUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
eonvap`'aName: Lb. No:
G�
BUILDINGELBCTMCALPLUMBINGMF NICAl,
CATFLORY
CONTROL/
Architect/Enginser. Lie. N.
QTY ELECTRIC PERMIT FEE-
BUILDING PERMIT INFO
Add.
❑ ❑ '�J� ❑
�S,I
PERh9TISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby
Sectin7MGatlamlicensed under hsBunmmaa¢sofChapter9(oammmc
lice I5I Section Dl vfsim3dtheguelreaand PmfeslonsCodeand
II¢roe b In fu 9f� and e.0
Llaemc��� ��_j�,�Lk.Y 2 .7562
APPLIANCES -RESIDENTIAL
OB DESCRIPTION
C7•p� rr/NI1
of f l �"aY I'IY V ✓V r
PANES
DER Coaraaor�anical
301-100O AMPS
ARCHITECI'S DECLARATION
I undentard my plane shall be used as publiernmda
OVERIODDAMPS
SQ.FLFLOORAREA
S/SQ.Fr.
SIGNS ELECTRICAL
Licensed Pmferobnal
5[rECIAL CEICUIT/M1SC
OWNER -BUILDER DECLARATION
I hereby affirm that I ama
exempt /rn the Contractor? LI¢rs a Law f¢ the
TQAP.METPR ORIOLE INST.
following reason. (Seaim 70315, Business and PmfesionsCode: My tltyor
county which requires a pemdt loconstruct, alter, improve, demoLLsh.or repair
anysrorn,re prem to itabwnce,sbo requlmtheappBant for ouch perosis to
Ok a signed statement that he Is B¢ns d pursuant to the provbbm of the
POWER DEVICES
SWEdA0NG 1'ODL ELECTRICC
Contratene. Lberse Lw(Chapter9(comenendng with Section 700D) of Owl-
don3 of the Budneva and I'rdesbroCde) orthat he ts exempt theref xorna
VALUATION
the bats for the alleged exemption. Any violation of Section 7MLS by any
applicant for a permit subjecta the applicant to a dvil penalty d net more than
OUTLElSSWITCFQSFlXTURES
NEWRFSTDEJTTALELECIR SQFT.
Ove hundred, asownrofthepro
I, as owner property, or
eucture n with wages act there sok
STORIES
TYPE CONSTRUCTION
compensation, will of he
work,andtheshonureh cotIMarde or offered for
sok f$es 7Dµ Boadneus
asuss alt Pm(esbns Cade: The Com s LI¢nm law
prove
to
doer rot apply torn owner dpmpertywho buildnem orimprovesthat such
who doosuch work hlmreBmthwgh hinownemplo/acts, Prwldedthatmch
OCC.GROIIP
RES IIMI'i
Lnprovemew are not Intended oroffered fmaak. If, however, the building or
renpmverrcnttssoki Mthinomyearofcamp]Mbmtheavrer-builderw U have
TOTAL
ttIcpurden of proving that he did cot build or improve for purpose ofsals.).
" L as owner of the Property, am exchulvely contracting whh licenseel
eomosomn to corutmct the project (Sm 704k gushesand PrdeselonsCode:
QTY. PLUMBING PERMIT FEE
FLOOD TONE
APN
PER^+ITFIANCE
The Contractor's Lio ruse Lw don not apply to an owner of property who
Wilds or. Improv thereon, and who contracts for such M)ects with •
cnuactm(a)lacemed pursuant to the Contractors License, Law.
Lf I am exempt under See B & P C for this reason
- -
ALTERDRAIN & VENT WATER (Thin
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTS I DE FEES
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N_
RTCEIPr1
Owner - Date
WORKMA
ANCOMPENSATIONDECLARTION
�[.,PER
911 hereby affirm that I have a certigote d consent to actor-iwre, m a
¢rtN¢teofWorken'Comperoatim lvunn¢¢a¢rtBled (Sec.
copythereof
3500, Tab
Cum a
Cam anis rill SAll Tn c� (`�
$ IR'SIr
SCHOOLTAX Y_.N_
RECfPT Y
GAS EA. SY'SrE1f-1 WCaOUILEIS
PARK FEE Y_ N_
RECEIPT' Y
GAS EA.SYSrQAOVER<(EA) �
BUILDING DIVISION FEES
CertBkd copy Is hereby fumuhe3
Cetl/led copy isflka with the city Impectbn division.
GREASE/RJDIISDtL WASTE INTFd?GQ'fOR
PLANCHECKFEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-5y1NrTARY SIDRM F.t L]L4-1'
COMPENSATION INSURANCE
Rh1e¢dbn need na be complc odIf the pemdt ts fmone hundred dollars
DatC - Recef I#
WATER HEATTRW/VENT/ELr:C7R
ENERGYFEE Y N_
(9100)yth)
arI at inther perforrtun¢ofthe wvkforwNch tMs perosistslamed,
I¢nifth
1 W R not employ any person m any manner an as to become mb)ect to the
workera'Compensatbnlawad Glimmh. Date
WATER SYSTEM/TREATING
PAID
Applicant
Nmld TO APPLICANT: H,after asking tNs CertBlp oflmofttbn, you
-
Date Recel t#
NEWRFSDENIALPLIdB. SQ17.
TOTAL:
Demmefbh totheWyd mprovbbpeolthalabor
tCampen
CWa
Cede, ym aunt fmhwhh comply with such pevvtsbns or thio perosis shell be
a
BUILDINGFEE
deemed revoked.
SEISMIC FEE
CONSTRUCTION LADING AGENCY
I hsmby.M.that there b s constructors kndingagsocy for the perform
sore of the work for which this permit Is bsud (See. 3097, Clv. C.)
TOTAL:
ELECTRIC FEE
PLUMBING FEE
Lender's Name
Ledo/s Add nns-
I ¢difythat I havereedthbappllotbnand slate that the above InfornW ion
is cormt.Iagree to comply with all city and county oedinanm and sate laws
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PFRAUISSUANCE
FEES PAI D: -
Mating to bulldlog construction, and hereby authorise representatrvn of this
dty to enter upon the above-mentioned property for usapeabn purposes.
(We) agrn to nave, IMcmrdfy an d keep baron. the City of Cupertino
against liabilities, pdgmems, costs and scpenun which may in anyway..
against Wd City Inconsequence rets grantingdthla perosis.
nature of Appfi..T/C&4na5bor `Date
ALTER OR ADD TO MEIN.
Date Recd t#
AIR HANDLING UMT(1'010,000 CFM)
SUBTOTAL:
AIR HANDLING UNTI(OVER 10,MCFh47)
CONSTRUCTION TAX
EXHAUST HOOD (WI DUCE -
CONSTRUCTION TAX PAID:
HATAR nbus MATERIALS Of SCLOSURE
HEATING UNIT 00 I W D](3 BM
Will the a ppBeantor future bu 0ding.part store or hard to hacardous
material as defined by the Cupertino Murdclpal Code, Chapter 9.1 Z and the
Date ReCCI t#
HEATING UNIT (OVER 100,000 BM
TOTAL:
Health ad Safety Cme Sectlm 7432(a)?
❑ Yes No
VENTILATION FAN MINGLE RESID)
ISSjiri181�frI�A'TE
WBl the appllndo tune Wilding oxo Fort use equipment or device
which emit hamedous air mnUmlrods as deRred by the Bay Area Air
r�/f�� V
BOILER -COMP OTD' OR 100,0(10 BM'
Quality Management District?
Yes Fj No
Ihave read the hasaidob
nmaterialsrequiremenunderChapter&95of
p
2
JUN G 199U
HOMER -COMP
VMP(OVER100,0MRM
the California Health & Safety Code, Sections 25505,25M and 75534. 1
NEW RESIDENTIAL MECH. SQ.FT
urdentand that ifthe building dm not currently have a tenant, that it It my
s
responsibility to notify the ocovparn of the requirements which most be rect
prior to issuance of a CerdfcflsoofO= racy.
K"e [ 6"2S -9�
authorized ScaSc a Dat<
/4�aa �t Is..asaaa�,�
NV of 411IR111
ISSUED BY:�G1'IW Ie
-
TOTAL:
I*19914q*61110