21323 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru m tdmtlfkatlon PFTLMIT NO.
01- Budding Addmv: 2,1323 IT=
pueoly
me:
�j�aG'a1/6 aNinld,lc'�-r9 as -0 CITY OF CUPERTINO-BUILDING DIVISION A
Contnder'•Name: Lie N. APPLICATION /PERMIT to^Z3—
BUILD[NGFLBCTRICALMUMBINGMF LAICAL CATEGORY CONTROL
�' Archils t/Engrnerr: Lk.N¢
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
❑LICENSED CONTRACTOR'S DECLARATION I'FRhfITISSUANCE 1:1 [;4 [1
I krebyaffkm that l am Bcmaed under prwbbrdChaplcr9(mmmmc APPLIANCFSRE.SIDEMTAL JOB DFSCM910N
Ingwlth I.ful7000)d D1Adm3otthe Bushsand liofesNor Cods and my
license,b in fu
ticermll forme and dfed. PANES
Date Cowador 1hJ tel/
ARCHITECTS DECLARATION '1 AMPS
mO OCC I understand my planse)uB kused as public recede. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.F7.
U Licensed Prdembrul SIGNS ELECTRICAL
R,Q OWNER-BUILDER DECLAMTION
Ikrebyaffirm Ul lamvrmptfmmtheCOMB eaLl¢ Uwforthe SPECIAL CBiCNT/h119C f
].p following rtasoro.L5edion 70115,Boelness and PrOrubru Code:Any city or n J
O z F.. TEMP. ORPOLE Wsr. J/
cvuntywhkhrNulrnapemdttomrmMalter,Impmve,demolbh,orrepdr -
Y5
a nyatmMmprbrtoibbvame,aLsortyulrntheappllcantforau&per tto �tygg DEVICES
C file a signed statement that he b licensed pursuant to the pmvbba d the
Contradori Lkerme Law(Cha er9(mmonnm with Section 7000)of DIA- �� � �
19o'O1 abn3ofthe Buebmeandl'mfenbm Code)orthrthelaezempttherc maned CIK)OL FLECIRIC/� VALUATION
.-t-t led bub for tie alleged ezemptimt. Any AolNbn of Seebn 703IS by a yAV
applicant fora permit abjcas the applicant to a civil perky of moretk OVDETSSWITCHESFDGrURE5
p,c Rv undreddollaos M50W.
�f �n ,as owner of the property,or my employee with wag¢ t_ To NEW l2ISmFN17Al ELECfRt SQFI'. srowFs TmE CONSLRUCI7ON
��mmrcratlan,w111dotk.,k ndtheswdurehwt Welled r for l //
p d (Sec apply Bushes all Pmfmloa who
The Comndo W e w
docs oessueot y loan owner ofpropertywho nem orlmp ded thaa,
he
who doesachwork hbaeRathwgh hbownemployegp Ided thatach. � OCG GROUP RFS,ANDS
Improvements are,amt Intended orolfered for vie.IL however,Use bW B? TOTAL
Impmvemete preAngtht he did of buil or Init,wefor rpmer e
try 1 adeno neer of
the
didnot
exelur Mpmvef¢purpmeof� QTY. PLUMBING PERMIT FEE FLOOD ZONE AFI
LJ I,oe owner of the Property,am euK Bush mt.od!I'mwith 14erM
Do,Co ae to ro Lt rue Law des not a p apply
to et owner of paler Code: PERMIT NUANCE
Tk COor Intp LI¢ e Law don not apply m an owner d Property who ALTER-DRAW&VENT-WATER(EA3 I <<
lou tr Or Imprwea tponsuint to who mmrsds f¢acL p.vkm with
cQpjlacen ,.I¢ruedrder Sec.
the Cantneor'a Liars Law. BACK FLOW PROTECT.DEVICE FOUEE TSIDE
FEES
MMARY
Ll l m exempt order Sec B 6 P C for tw rt t
Owner Dee
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N
RFCOPT
WORKMAN COMPENSATION consent
FO(]lJRES PER TRAP SCHOOL.TAX Y_ N=
❑1 hereby•((ions that I haw a¢rtl0ate d ronront to seV-mare,a a RECEIPT s .
¢0,L hof Warkm'Compeaddonlworan¢or•artifled ropy thereof lsec. GAS F.A.SYSTEtA-1 INC4 OUTLETS PARK FEE Y_ N
3804 Lb CJ
Pdey#
RECGAS EA.SYSTEM-OVER 4(EA) DING DI l
Corn ny BUILDING DIVISION FEES
I ICimmed copy Ls hembyth thehed. GREASE/WDUSfRL WASTE INTFRCF1'70R PLANCHECKFEE
CertNM copy b(fled with the city Ivpecibn dMslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMTENSATIONWSURANCE SEATIR- STORM F.I.2WFT Date Recd tN
(sin
(Thb.na) need n¢kcompldN If the
permit bfor orc hundred dodollarsth WATER IEATFRW/VENT/oEC7]1 ENERGYFEE Y—
N
Tco¢mfy Iarythat In the performance of the wait brwwhtw permitpermitbhaed,
I shall not employ any penin in any manner o as to become abed to the WATER SYSTEM/TREATING
Workery COmperation[..of CWf.U. Date PAID
O Z AppB¢nt NEW RESIDENTIAL PCMB. FT. Date Revel t#
Z NOTICE TO APMICAM:If,after raking thisCerbflnw
te of Exemption,
N shouldcome
besub)ed to the Workers'Compensation provisions of the L
[.bor TOTAL'
Coda you most forthwith comply with such provlslOa orthb permit shall be
Lu > deemed roked.
a QVILDING FEE
evC CONSTRUCTION LENDING ACMCY SEISMIC FEE
I hereby afRrmthe there b a emrdrdlon lending agency for the perform, ELECTRIC FEE
7 Z arm of the workfor wwh this permit b baued(Sec 309'/,CIv.C.) TOTAL
(,) mne PLUMBING FEE
O Lender'•Na
LL LeMe?,Add. QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
O W 1MARythe l have mad thin appllatbn a Wte that the show lnfona0m
hommet.lagree to complywlth sB dtyaM countyord Wancreand state lewa PFRh11T ISSUANCE FEES PAID-
} N ¢Rating to but Wing ronmuudlat,and hereby authorlu rtprnenulivm dthb
Z_ dte-mentbnpmpertyfalrpurposes.
ALTER ORADDTO MFt
(WORImmioaw,inddep heCittypDate Reei tp
gabuBaWtln,}dgmw, ro3aMevperwishcoyNsnyvyame
AIR HANDLING UNIT(TD 1400D CFM)
it sect Cit b SUBTOTAL:
ga anedpnen r,ker. tis twpemnk.
—10_93.90 AIR HANDLING unTr(OVER 14DDDCHM) CONSTRUCTION TAX
SignaAppllont/ ont dor Date EXHAUST HOOD(W/DLCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appl alt•future building a pant store or handle harardous HEATING UNIT CIO H0,000 BTU) Date Recti Ik
materialasdefl dbyticrd
Cupew MumdpaiCede,Chapter9.17,andthe
Heath all Safety Code SWi.2S53i(i)7 HEATING UNIT(OVER 100,OOD BTU) TOTAL:
RI Yn N No
d[the applicant ortown,building oavpam use equipment or devkua VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkh emit ha+amious air contaminate,u defined by the Bay Arta Air
Qu' aagemerrt Distriot? R.E
I Y Ye"
7 BORl�DNPPFB'ORIOO,000IiTU)lie E)
RTran No /'ti
Lave mad the Fara Oue materlabrequlrements under Chapter 6.95 of BOILER-COMP(OVER 1W,000 BTU)
the California Health A Safety Code,Sedbr 75505.rM.rd 75534. I CC� 2 3199
understand that if the building does not currently haw a tenant,that it e,my N'EWRERDFNTIALMECH SQ}T
responsibility to notify the Omlpam of the requirements which most be met ,
pr1Or to/saaau d a Cedi(latc of Ocevpancy.
Owner or athomied agent Date (}(�pit�i
TOTAL: ISSUEDBY:TTM
OFFICE COPY