21990 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identukation PURM[T NO.
B Add.
"20 „ E s�P�e. 21990
;b757 N 4 aK CITY OFCUPERTINO-BUILDING DIVISION _ � _c�
GA
a APPLICATION I PERMIT L
r �k9BUILD)NG-FT,ECIRICAL-PLUMBINGMES LAICAL CATEGORY CONTROL Y/
Amhltea/En arcs. Llc No: O
TY ELECTRICPERMTT FEE BUILDING PERMIT INFO
Add.
PFRh9TISSl/ANCE
LICENSED that Ia CONTRACTOR'S under SDECI.ARA IONhaps _
)herby allure,that of C]uptm9(mmndm AP19.IANCFSRFS'mENITAL JOB DFS N
iim ISealon70(10)ofD effoet o!thee BuslmsandPMesalonsCod4 and
Ibetue b in Tui f and ic,# PANELS /� // s,�
[)45,-1 — '—cont �o p�aY` [An
Dale TTS—�� Contratlor �//�
ARCHITECT'S DECLARATION I-1000
wrsZ I understand my piamahail be used u public records OVER 1000 SQ.IT/.FLODR $/SQ.FT.
od LI¢nseci Pmfm inial SIGNS FI,ECTR��ILCp�A�LLr�r� 6 2 Teff , 17��♦4 Z'
«<�S OWNER-BUILDER DECLARATION 5I'FLULCIRCuaAi'C
I. 4 I herebyaffirmttWlame.emptftmnthe Contras./s LI¢t Uwferthe ( Y
P. lolbwing reason.healon 7015,BwlnemaM Prot®btu Cadr.Any dry or ��
O/1=. TEMP.METER OR POLE INST.FEQ munrywhk rryulrmaper mmr tmM lter,Impmve,demo h,ormpalr
anygmu mpflertolbl arc,alsorequimtheappU=tfersu&pe to POWER DEVICES
1 file a signed cc
statement that he la Bnnead puont to the provisions of the
33 Coet.d.r'a Ucetuc L v,(Chapter 9(m.curg with Seebn 700D)of Dent- SWIMMING POOL IlECTRIC
sbn3ofNe Businessand ProfubrmCode)orNat Feb therdromand VALUATION
the bash for the alleged e.ereptbn. Any vldaHon of Section 7MIS by any
�>� opphuntforape tsub)e theapplkanttoadvllperultydnannretlun CSJOUTLETSSWITCI-IES.FWTURES ' PIZ
five hundred dollar x500). Q
❑I,as owtter d the pmperty,or my empbym with wage u the wk NEW R®FMIAL EI'ECTR SQ.FI' S1UR16 TYPE CONSTRUCTION
14❑� mmpetuation,will do the worknd atheatmaum It not NterdMoroffend for
sale(Sec 70K Bu.iwa and Pmfembm Code:The C.M.d.e.Uceme Taw
I r>� domndapplytoanowrerdpropertywb Wlidsorimprvvnthen andOCC.GROUP
W who doessuchworkhimselforthrangh hisownemployers,provided that such RIS.UNITS
Improvements are not intended oroffered ferule.If,however,the building m TOT
Mpmvement bold whhln.neyearofmmpktbn,thenvner-W IlderwW have
tlE, ,,mien of proving that he,del notbulld or improve for purpoae of sale.). QTy. PLUMBING PERMIT FEE FLODD ZONE APN
LI I,as mwner of the property,am ns luslvely eontrwting with Ibemed
comrad¢s to mmtruet the project PERMIT'ISSUANCE .r�s
P doesne7 apply
ytslnmsane aproprt Code: �lJav
The Coornaor's Lkeve Lw don fid aPPre ct an owner d property who ALTER-DRAIN A VENT-WATER TA)
builds or Imprwn tbmeon, and who mmnas for such w. with a
cQ161actor(s) rmpaM pursuant tothe Contnaor'sll¢�ueCfo BACK FLAW PROTECT.DEVICE FEESUMMARY
�I Ll I am e.empl order gee. B k P C for this rcmn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N
Owner Data BBC=0
WORT Mu COMPENSATION DECLARATION FSS-PER TRAP e-� �s SCHOOL TAX Y_ N—
�- 91 hereby afflrm that I have•¢rtiB¢te d mnrnt m arI-Iruure,ora I 4 W
rtl0cete of Worken'Comperwtlon Nunn¢er a certlfkd ropy therm!(Sec. .r� RF!'Q[T j7-
38a)
38a)UbCJ GAS FA.SYSTEM-1 INCA OUTLETS 2AW PARK FEE Y— N—
FblkyY �i C3 GAS EA.SYSTEM-OVER/(EA) DING DIVT Y
Cg-,
on^ ' /y1 A ern BUILDING DIVISION FEES
[]cewled copy b hledwth de,cid. GREASE/INDUSIRL WASTE INTERCEPTOR PL.ANCIIECK FEE �g6o
CertNed ropy b/Tied with the dry Irmpedbn dW Wm.
CERTIFICATE OF EXESIMON FROM WORKERS GRELSETRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARYSTORM EA.20[FT Date Recei tit
(Ehtsertlbn need fiat be completed U the pemdt b for one hundred dolue
OlW)or less.) WATER I1EATEt w/VENT/H-ECT'R ENERGY FEE Y N
1¢rtifylhat In the performan¢ofthework brwhlcb theta pemW bbved, — — Sd •J
1 shat not employ any penton In any manner an as to become subject to the WATER SYSTEM/TREATING
werkerr Compensation L.w..f California. Dare PAID _, l tf 3(
z Z Applicant you NEWRES[DEMIALPLNB. SQFT. ate Recel tit
Z O WTICETOAPPI]CAM:ll,aBermaWompemationng thus predons oftlon,the
ehmlab®maeubjM to the watkeA compematbn pnovbbn of the labor TOTAL: - 6D
CC N_ Code,You moat lerthwdh comply MtF mch provbbv orthb pemdt shall be
W ] deemed revoked. _ L t
W a CONSTRUCTION LENDING AGENCY SEISM) FEE t D
Il Iberrhy.fift thattherehamrmrtuctlonkndbgagercy for the pedomm
Z arm of me work!..which thbprrmR b beset srr.3097,Civ.C.) TOTAL. ELECTRIC FEE t
U O Iendera Nam PLUMBING FEE '
LL H Lendee.Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certify that l have read this appBrattonand slumthattbe above Information
CW FEES PAID.
bmrrsa.lagnetoaoneplywithaldtyand countyond4unmandstatelaw. PERMTT15riUANCE
>- N rebting to building mmtrudlon,and herebyauNoe
rlrerepnentathvaofthb
F = Cty,to enter upon the above-mentbrcd pnoperyfor Wpectbn purposrs. ALTERORADDTOMECH. v�
V — (We)agree to leve,indemnify an d keep harmlm the CV of Cupertino Date Recei tit
aga WtllnbWtln,PdgmeNa,cvstsard r.prnsnwhieh may in anyw.y..e AIR HANDLING UNIT CN 10,000 CFM) SUBTOTAL:
aga t Id City in mneeque of the granting of this Permit..
AIRHANDUNC UN1T(OVER lo,oOocE>n CONSTRUCTION TAX
Slgrutureof Appllant/C�ontracttorw_ Date IXHAI)ST fI00D(W/DUCD A CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
WOltheappllorrt NWrtWildingoccupant A..orha khat cats HEATING UNIT(TO IM.000 BTU) Date Recei tN
material as de0nd by the Cupertino Munidpal Cade,Chapter 9.17,and the
I IMtheM Safety Codt,�pctlon 25532(.)7 HEATING UNIT(OVER 1W,”BTT)) TOTAL: t
yea, R9
Illtheapplbrd brfuturebulldingoavpantuseequlpment ordevkn VENIILATIONFAN(SINGLERESLD) ISSUANCE DATE
which emit havrdoua aI contaminants as defined by the Bay Area Ale
Quality Management Dist 7 BOILER-COMPOEI'OR100,00OBTT)) `
❑ Yee fumyM
�- Ihave read the h uus matelots requlnmenb under Chapter 6.9;of BOILERCOMP(OVEt 100,OW gill) `L�
the Calfnmb Flealrh&Safety Cade,StttIma 25505,25,533 and 755.74. I
understand that if the bulldirgdoes not currently have a tenant,that it is my NEW RESIDFNi1ALMECH. SQ-FT.
"Potability to notify the noeopaet of the requmments which must be rent
I
rior to bsu ce da Certlfi of Ooeupancy.
authy -3-9/
er fit) &
Owner authorl:ed agent Date
TOTAL: ISSUED BY'
l
OFFICE COPY