24348 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Address: Z
01
_7 to Irl .
�Q �rr3e. CITY OF CUPERTINO-BUILDING DIVISION 1 72'
'.Name: Lie.Nee APPLICATION / PERMIT ` 2' fp L l�
BUIIDINGELECTRICALPLUMBINGMECHAMCAL CAiFLORY CONTROL e
ArdiBcn/Englnesr Lie.No:
BUILDING PERMIT INFO
QrY ELECTRICPERMIT FEE
Address PERMTISSUANCE ❑ ❑ ❑
LICENSED CO.NMACTOR'S DECLARATION
I hereby affirm that
l am lkemadi under provldons of Cha pier 9(mmmmc APPLIANCF3RESIDEM7AL
Ing=h 70W)of Divldon3 the Budemaand Pd
refnotuCode,and PANELS JOB DENUMMON
Ikenae
UP TO 2DO
DaCoraractor
CHITEumd CURATI AMS
µqqW07 ]undennand my phmelullk used upublle recordFR.. OV1000 AMPS $Q.FC.FLOOR AREA zj
E (Oj Llmmed Prafembvl SIGNSEI )CIRICAL
<<�S OWNER-BUILDER DECLARATION 4+1'CIALCIRCUIT/MISC
F.�, liumby.fOmthatlmexempt(menthe Comrulora Llormel.awforthe
Q following rtuan.(Bectlon 70715,Basins,and Pmfmbu Cod,..Any sty or
OG coax hkh ima tommtmct,altenlm P'b TEMP.Nf=ORPOLEINSf.
K0 true Pew Prove.demoBeh,oro PTFLLED IN
ra,I any nmctvrtpfirment "masa,alao onme,E rt,ttantt the ro each perf r to
the POWER DEVICES
O S f Ui,i-
floe a signed Ice.La tout k t Iloenscd pursuant to the pmvbbv of the
Con3oftheLlcernel�w(Ckpter9(mm)ortn wRe=niptthemfh Seetion 700M ommrul
F Og do lu.f fe th,adlsaM Prtdeabr. Any virthatklaexetinnMIShy,md SWIMMING P U T 5tyy�ON
u �^ the bub for the aIle ed sae ions An ttolatbn d S ky 7(D15 H
B rrPt Y by anY OIFILETSSIVITCFffSFIXTUREScm
11h, untfor•perMtISM.lithe applkmttoa ticdl pewltydna enrothan
sFj live hundred do1Wn he pr. NEW RERDPN'DAL I=TR
W ❑I,as owner l the property,or he employees with wage u thele for
��'ournpenaTYP CONSTRUCTION
k C3c,don,7DK Butimdo the wedsandthes C de, locothdendMorofferedfor
p vie t5ee 7fIM,Buninm and]ho!®bv Cade:Tk CoraraRors LI¢me Ipw
s$ don not apply to an owner of property who builds or improves tkrton,and OCGCROUP RFS.UNITS
who doe each work hlmaelforthwgh M,own employ.,provided that.meh
ImprovemmU m nd intended oraEfferent foreale.If,however,the building or TOTAL
Improv neem bedA within oneyearofcompledon,the owner-0uilderwW have
t ram ad of proving that k not bund or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
L1,as owner of the property,am erdusWely oauucting with lloereed FLOOD 7DNE APN
oantnctueto mmimcttk pmjea(Sec.7064,Buelneuand Profesiora Code: EMIT ISSUANCE
The Contractor'.Lieenue Law doe nor apply to an owner of property who VENT-
WWW or improves thereon, and who mnucts for such p,," with ALTER-DRAIN 4 WATER MA)
cxAWet¢(.)llamacd purtuant to the Cmindds Lice.Lw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt under Sec B k P C for this rtOUTS I DF TP
anon DRAINS.FLOOR,RODE,AREA,OOND. SANTTARY Y N_.
Owner Dns REiCF 1'.
WORIQIANI have
RATION DECLARATION FDCrURF_SPERTRAP SCIB O TAX Y_ N_
I]I ra ereby affirm C 1 have a¢Nfl¢te of consent to self lnoart,u a
i t fWprken'Cunp(��rnatlon lrmuran¢gma¢dillN mpytkreo(LSec. RF('1]pT.
T38d00,ab C.)(�ZJrILY-2l%3 /,� GAS EA.SYS7EM11-1 A'CAO[J[I.EfS PARKIg RFTER'T.—
Co v `( W CAS EA.SYST OVER4(EA)
rri an nd� he �hLiml ed. a BUILDING DI VISIO.N`FEES
11,�U1(/nyBiryedoo�f.nkd�wtth the sty wpectlon division GREASE/PIDUSTRL WASTE INITIRCEPIOR PLANCHECK FEE
CERTIFICATE OF FYEhIPHON FROM WORKERS CREASE TRAP PAID
COMPENSATION cp[ ifpe4fEYlEt SANITARYSIORM FA NOFT Date Recel tM
(ITbsenbn need nukNSATI NtINSURANCE
E
AVfororc hundrtd dallae S
(SI00)arlen.) WATER HEAM W/VEJf./EECTR ENERGY FEE Y N
I¢nlly that in the pedomun¢o(the w¢kfor which W.pemdt in issued,
I.hall nor empb any P.N any manner so u to become subject to the WATER SYSTEM/TREATING
Warken'Comperuatbnlaw.of C+Womia. Date PAID
A (
PP leant
Z � NOTICE TO AI'PLICANT:IL coking king thio dlf
Celute of ElomptbNEWRESIDENTLV.PIMB. SQF7. CA
n,you Date RCtit
should become sub}N to the Workrm'Compematbn provhbon of the Labor TOTAL:
CC
N Code,you.9 forthwith mmplywlth such provbbroor this permit shall be
] deemed rt .ked. BUILDING FEE
(L C G CONSTRICTION LENDINAGUNCY SEI IC FEE
[l Ihercby.fnrm tmttkobaaomtmman Mingagencyfortkperfom. TOT ELECTRIC FEE
7 Z ance of the workfor whkh thla permit N Issued LScc.3097,CW.C.)
U O 1,rode,',Name PLUMBING FEE
LL ~ Lender.Md. QTY. MECHANICAL PERMIT FGB MECHAMCAL FEE
O W Io-rufy Natl M1aec readtlLL�app11¢tlonard nate thal tM1eabovelnformad
a bcrnm Iagrteto comply with all dtyand muntyordlnanomand nate laws FERMITISGUANCE FEE$PAID-.
r TobulWing mruwnionand herebyauthomemprraentative,rdibbZcht rupon the above-mentbrcd property fee Inspection purposes. ALTTMORADDIOMECH.a ve,Indemnity an d keep harmleae theCity ofCupedb,oDate Revel tpaga WI ,�dgmewmn,and expenue whkh yin w.yacerue AIR HANDLING UNIT(T010,OD0 CPM) SUBTOTAL:
.gl C odl79d permit.
AIR HANDIFNG UNIT(OVER IO,l1Ip CFM) CONSTRUCTIONTAX
Signature of Apptl¢nt/Contractor t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllu est or future bund Ng oeetpent war or ha M le hanrdoua HEATING UNIT CIO 100,000 BT U) -Date R
materlalaedefirHbytk Cu rtlm M. id .1 Cade,Chapter 9.17,and the
1e.hhandSdvtyc�1e M2(a)7 ITEAIING UNIT(OVER IM,"BTU) TOT _
ca Ye No
illtheapp[hn tore budding o<apant use equipment ordevioes VENTIlAT10N PAN SINGLE RESID) ISSUANCE DATE
whkh emit"rdn ..yr t.�uma ae defined by the Bay Area Nr
QF-1 YenLnageme� �1dC7� BOILER-COMP 01-17 OR 100,IXq BTU) ,
Yes r]{eo
have rtad the materials requlrtmenb under Chapter 695 of (TOILER-COMP(OVER lOD,000 BTU)
the Caluomle Hedt &Safety Coae,Sectbma505,2i533.nd2S5,16.1
undentan t t lithe building dm not currently have a tenant,that It is my NEW RESIDENTIAL h1ECIi SQFf W
report dY Ify the...pant dthe requlremenu whkh berM Aa.�
prb,to ua dlBataof Occupancy.
g� n
Owner m authorlani agent to `' ' f
TOTAL: ISSUED BY:-e`` .
"r4
OFFICE COPY