23190 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru en Identification T PERMITNO.
Building Addnv: 23190
"1^alnO
ante: ane: p
rs Y CITY OF CUPERTINO-BUILDING DIVISION
can .Natne: Llo. o: APPLICATION I PERMIT O
�� BUfUNNGELECIRICALPUI.NBINGMECHAMGL CATEGORY CONTROLI
Architect/Englncer. Lb.No.
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION
thereby
Section
provisho's
CedreaC(mrtndrrT APPLIANCES-RESIDENTIAL
itts us
700D)force of Division the Buelnmard Pro/nNoruCode,and 10 DFSC ON
1 lams b In full form+nd eic.# PANELS
Lfrtnac Chm Lk.I
Date Cud ad r ['y—mow
ARCHITECPS DECLARATION X)1"1000 — • 1�' eJ
M IurdentaM my plam+lullbe used As public records. OVER1000AMPS SQ.FT.FLOOR R AREA _ $/SQ.FT.
xCj Licensed Prde samad SIGNSELECTRICAL I- N 1
OWNER-BUILDER DECLARATION g,[pAL CIXCUI.I./A715r _r�J�n�n IherebyafRrmth+t Iam exempt from t the Contractor'.Licilaw for the
ER
Dl..,O �
F following meson.Section 70115,Bwlnm std Pt.fmbru Code:My city or d
F4�� countywhRhtequbnapemdt[omrelnun,ilter,Impmve,dennLLvF,or repair TF7..IP.ME[TR ORPOLE INST.
�Z JrQf
anymmMmprbrtoibba,once,.bomrybe cappBcentfwwapemdtto POWER DEVICES
i fik.elgned statement than he b Bomaed pumrant m the ptovbbm of the
CLLGCnta
octor'+License Law(CNm
pter9(mmencing with Section 70M of Dm. SWIMMING POOL E=RIC0 elon3oftheButlnens And PmfmbmCode)orNatheit,exempttherefromand VALUATION
y-' the Nal.for the alleged eumptLm. Any doladon of Section 7MIS by Any
�j pP ppilant for a permA.ubjects theapplkaet to a civil penalty ofnct more than OITILETSSWrfCFIESFLYfURFS
c, Ove ndrM ddbn(SSOU).
NEW RESIDENTIAL Fr RCTR
76 +ownerof t heproperty,or my empbyenwflh wage as thelr.ok SQ�' STORIES TYfaE CONSTRLCTgN
aatlon,wlll do the w«k+not the.tnctvrt is not Intendedor offend for
O (Sec 70K Ba.inessa M Profmbm Code:The CoMnctoJ,Do.Law
�jsTd don not a pph to an owner of property who Wild.or Improv.t I.,and nmES.UNII5
OCCGROI/P R
whodo .uch work himself orthugh hbownemploym,provided that inch
improver arcnot Intended.,off.mdforuk.ILhowevu,thebuildingor TOTAL:
improvement b sold wdhln orcynrofcomplelbn,the nvnerbullder wBl love
tlturdenofpmvingthanhedId rwtboAdorlmprovef«purpoaeofuk.). QTY. PLUMBING PERMIT FEE
U I, ncr of the property,am vely contrana
contracting with becaA FLOOD ZONE APN
AA wv
contranm to mrutrun the project(Sec 7014,Bulnm and Prdmbtu Codr. PERMIT LSUANCE
The Contnctot.Liana Law dm not apply to an owner of property who pLiFR-DRAIN k VFM-WATER(FA)
Wilds or Improves thereon, and who contract. for v ch ptn*U whh a
OG¢+dor(a)Bceturd punu+nt to the Cmtnnda Lkeroe Law. BACK FLOWI'ROI'ECf.DEVICE FEE SUMMARY
UI am exempt under Sec 0 k P C for thio mm�
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N_
Owner Date R
E=
WORKMAN COMPLNSATION DECLARATION pIXIVRES PER TRM Sa100L TAX Y_ N_
❑I hereby affirm that I have a«ni0ate of cnn.em to adf-trwrc,ora
antfiate of Wtn,a Compeo.atloo Ivunnce or.angled c pytheleof(Sec. RECEBT
3Af
(100,IAb C.) GAS EA.SYSTEM-111 C40UTLETS �� PARK FFP Y N_
M{ry I GAS FA.SYSTEM-0VFR d(EA) RECELrf a
Ca nay BUILDIEG DIVISION FEES
CertiOed copy b hereby th the cid.
CartWed mpybfiled with IN city Inspection division. CREASE/MDUSTRL WASTEIMFRCF]TOR PLANCHECK FEE
CERTIFICATYOP UEMPfION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SFWERSANITARYSTORI.t EA.700FT Date, Rcoef t#
(Das eed na Ncomplsted Bthe pemdt bfa one hundred dollen
($100)«I..)3 ENERGYFEE Y N
Icertllythat lathe pcAomunmof Ne work forwNch title permit bbued, WATER HEATER W/VFM/ET,EC"IR
I shell not employ any paean In any manner An As to become object to the
WATER SYSTEM/TREATING
Waken'Compenutbn l.ays of GlBomla. Date PAID
Z Q NOpIICE TO APPLICANT.II,after making thio Certifiate of Exemption,you NEWRmDENTIALPI.MB. SQFT. Date Repel t#
F N ahold Nmme+ubkn to the Workets'Compematbn provbbns of the Labor TOTAL:
Code,you const forthwith comply with avch provbbm or thio pemdt shall be
> deemed revoked. BUILDING FEE
dCONSTRI ION LENDING AGFNCY SEISMIC FEE
Z Ihercby.Hirmtlut thnrt b.mmlroNon ktding agency for the perform- i0 �� ELECTRIC FEE
once of lho workfor which ddA8 mdt b lAnued(Sec.3097,CW.C.)
02 Lender's Name PLUMBING FEE
LLI- Iender.Aderm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Ian"at Ihave read thbappliadonand tlale than the above In trnatlan
O W bconec.Iagreetoc plywkh&UdtyaMd ntyatd mm.ndztel+ws FRMR ISSUANCE ` FEE$PAID
F_ N relating to Wilding mrutnctlon,aM Nrtby authorb rtprcxntativn ofthb
F = city to enter upon tlr abovctnenlbned property for inspection purposea. ALTERORADDTOMECFL Date, Recei t#
(We)agree to nave,I demtdfy an d keep hamod the City of Cupenlro
U ago Wt NbWtin,ludgmen4 mtsatd upen.n which maybanywayamue AIRFIANDONGUNTT(TO10,000 CFM)
agawtaala rybmn.eque The ntbg dtw treyglSals^� SUBTOTAL:
AIR IiANIwNC IINrr(0VFR 14o00CEM) CONSTRUCTION TAX
.fA Brant tactor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDOU$MATERIALS DISCLOSURE
Will the appllant«future building oavW
pant store or handle hazardous FIEATNGUMT(TO100,0DOBTDate Recel t#
material a.deflud by the Cuperdsx,Municipal Cade,Chapter 9.1;and the
Iiea1tharNSafcty Code+-S,enbn 75537(a)I FIEATING UNIT(OVER 10B000 BTW TOTAL: r
I�1 Yn _Q
u
Wlhe appliantorTuture building occupant use equipment ce devices VENTILATION FAN(SINGLE RFSLD) ISSUANCE DATE
hicb eMt hazatdwa air mntamW ata n defined by the Bay Area Air
%u Iity Managcmcrd Drtct7 BOILER-NMP OIIPOR 100,000 BTW
l p
Yn No M
/I ❑btetead the hazaN w.
materials requimmennunderCNpter&95 of BOILER-NMP(OVER 100,000 BM
'tie Cahfomb Health&Safety Cod',Soabru25505,75533 and 75534. I JAN 15 1992
undentard Uutlfthe WBdingd.e.twtcvrtently have alcrunLthat It b my NEW RESIDENTIAL MEOi. SQFT
raporumBBtr
y to notify the pard of the nquiremem,which truss be met
prior to bsuance of a Cemfl.w of Oavparq.
CITY Lir GUrchl Ivo
Owner or authorized agent Date ISSUED BY:
TOA -
OFFICE COPY �`