22150 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuIIEIn Project bix.lU.d. - PEMT NO,
Building Address:
7S-o9 ZUM45- DQ GOP +TWO q so l� 22150
rcrs Name one:
r B P-I Al I LCH II-IS�j ;53 —jgqy CITY OF CUPERTIN46UILDING DIVISION
Contr,tlda Name: LIc.N¢ APPLICATION / PERMIT
G SOM OIC. S S BLnMNGI].ELTRI PLLTMMNG-MECHANICAL CATEGORY CONTROL
ArehBeC/Engineer. IIc Ne,
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add—P.O. BOX 36286 s4,dol6 9 IS
PERMIT155IlANCE ❑ ❑ ❑
LICENSEDCONT uMer5DECLARATION Ihenebyafflmsthatfam llcemed eB prwW dPm Ch,ptcr9(mmmrn APIrLIANCESRFSIDENI'fAl pB D�TCRB'IION
ingMther.hinfull form)and eff n3dtheBuNressand Pm(eulomfade,and my
Lkm Cla full form and e.0 PANELS
Data Class LICE AM ! R p O
Date 'Gaf4raQOr lJ/
ARCHITECPS DECLARATION
000 IundenstaM oryplansaluilbeuadnpublicrecorda. OVER lO30 AMPS SQ.FT.FLOOR PhFA $/ .FT.
Lfmecd nProlesbmELECTRICALl SIGNS ELECTRICAL
OWNRR-e UILDER DECLARATION SPF,CIAL CIRCUIT/MLSC
Z Ip.., 7, Ihercby affirm lhd]amev<mptfromthe Core raCor'e Lienx Lw(a the
0'L F. following reason.(SeClon 7015,Businem aM Pro(esebm Codr.Mytlty or TEMP.MEIFRORPOLE INST.
FO„q emntywhkhrequs apertomrwructAter,Imprwe,demollah,ormpair
SW5 anyzmc mprlmtalu Wuame,alwrequimtheappnontforwrhpe to POWER DEVICES
(Ile a signed statement tateent that he 19 llmun
nsed puant to the provisions of Ne
a, ContraCot's License Law(Clupler9(mrmrcncing with Sai1nn 7000)of Diel- SWBsfMINC POOL ELECTRIC VALUATION,
30e� slon3ofthellusinessand P mWmCode)orthathebere thmfmmasd
Q Q? the basis for the alleged exemption. Any ddatSectionn of Sen 7015 (]
by any oLrnzrs 5W110Eff&F-D(TURES D O
O� appllon[fora permit wbjeabtheappBcanttoa dull pemltydnd moretFun
4v hu ndnmddaI[.mi$OOs. NEW RESIDENTIAL ETSTR SQFr STORIES TYPECON5MUCTION
pea H rcr ldote ro ice ndr egm byees wkhwagn ueher dfo
mmpewtlon,BondothwaitandtheYrude: hrctormam'Intended ordfertd(or
� p dale not.pp4,to an owner l'ndmbns who bull"
CordraCols Game Lw
$ don oessucyto,nowrcr ofpropertyis o nempicyres rrvvidedtes at and OCCGROUP RIS()NITS
w%^ wprovrosrobaam khlmsededlf orough hisowne.If,ho ea,erwNMtlutwch
Improvemew am not Intendedo rofredtarsale.ILhowever,thebuildingve TOTAL
knprovemnt bsom wXhlnorcyuro/completbss,theavner-bullderwlll have
tliltiurden of pmvleg Na he dm not build or Improve for purpose ofmk.). QTY, PLUMBING PERMIT FEE
LI 1,as avner of the property,,m exclusively comruting with llrensed FLOOD ZONE APN
contraton to cormtruot the projed(Sm 9014,Bualneat and professions Cody. PERMIT ISSUANCE -
The Commadoes Limine Lw dm no apply to,n owns of Property who ALTER-DRAW 6 VENT SSV
bullets or Improve thereon,and who contracts for.6 piujee.with, FEE SUMMARY
+der(s)Beamed pumo,nt cap tha Contratlorl Llorme Lw. BACK FLOW PROTECT'.DEVICE
LJ I am exempt under Sm IT 4 P C for this reasonOUTSIDE RES
Avner Date DRAINS FLOOR,ROOF.A1tFA,COND. SANITARY Y_ N_
WORKACOMPENSATION DECLARATION RF�F21'I4
MN
- QI hereby afMn that 1 have a certificate of worn,to aeB-Imurt,or FTK7l1RES PER TRAP EZ 400L TAX Y N
aatlBue of Worken'CampanutlmImuran¢as oertl(led copy thereof(Sec. RECE Pr 4
3SW,LbQ GAS-EA.SYSI7Af-1 INCA OUTLETS PARK FEE Y_ N_
Policy 0 RECEIPT
y GAS PA.SYSTEM-OVER 4(EA) BUILDING DIVISION","
LLicertiflect copy is,hereby f Crushed.
F-ICcrtl(lei copy Is Bled with the city impennon division. CRPASE/12=5171,WASTE INTERCEPTOR PLANCHECIC FEE
CERTIFICATE OF IXEMITION FROM WORKERS' GR1ASETRV' PAID
COM PENSATION INSURANCE gElyp,pg,YNp(ARY STORM FA 27ff[ Date Rcml tic
(I'hlasecibn need era be emopleted B the pemdt is fororc hundred dollar
(fI OO)Of1ea') WATER HEATERw/VENT/EI.ErDe ENERGYFEE Y N
I artdythat m the perrartsuna orThe wait for wMrn wa permB is wiled.
I siuil net employ any person To any manner w as to become subjeC to the WATERSYSIE.'./TREATING
Wcrkers'Campenutbn Lwsa(CeltfomY. Date PAID
AFF Bent
Z 0 NOTICE TO APPLICANT:If,after making iMs CeCBlnte of Examptbn,you NEW R131DPNTIAL PLMB. SQ,pp, Date Recei t#
F0 should become subject to the Worker'Compensathm provisions of the labor TOTAL:
Cade,you nwet forthwith comply with such proviabm or this permit shall be BUILDING FEE
.p0
W > deemed n voked.
CL c CONSTRUCEIONLENDINGAGENCY SEISMIC FEE .J
I hereby alarm that there la a mmtmnion kndiog agemy our ,the perform ELECTRIC FEE
7 Z ante or the workfor which this permit is issucd(See.3097,Civ.C) TOTAL:
U O Lendarl Name PLUMBING FEE
LL r Lendrracddrea, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LU IadL"AlhavereadthbappBe naMYa thea theaboveln(ormatimn
bcomv.lsgrmto comply wlthaR city and county ordleancre and state]am PERMIT ISSUANCE FEES PAIL .
} miatingtob iMd gmmtmdim,aMkmbyauthari mpresenUtivnofthla
F coy toentu upon the above-mentbmd property for lmpsdbn purposes ALTFRORADDTOMECH.
ITT Dale Recei tic
(N'r)agree to uve,i drmNfy an d krrs
keep 6adethe city of Cupertino SUBTOTAL:
V against Wbllltwmenm
,y dg ,¢ sandevpemnwhkhnuymn ywayam a NRHANIXIMR
ING (IO10,000CFM)
aga.-"id Ch
mnaryuoue:(the grvntingdwapertnit p AIR HANDING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
s/�0/-r I CONSTRUCTION TAX PAID:
Sigmtur App ent� ,lsntU DaT EYFiAl15T FI00D(W/DLCI)
I FIntor If rob MATERIALSDISC105URR
Will the apines!b the ure rtRohI.r1ding copant YorcorluM handle, aedthe IihAnNG UNIT 10,0000TU) Date Recei t#
Health las defSafety Code
MuNtlpal Coda Chapter 9.17,and the
l-kaltnes srery emo sralan 7sv7(.)r HEATING ul.Tr(ovER lm000 BTU) TOTAL:
Yn ` No
Wthe applforda Cure building a¢vpant useequipmentBnrcntar davim VENTILATION FAN tSWCLE RE57D) ISSUANCE DATE
which eMtluementaakrict? meas deRned bytM Bay Arca Air
QaalLLy Mavgemerrt IXstrkl7 gpB co-COMP DEIPDR 100,000 BTI]) PAID
4 Yea, FIN.
No nv
have read the hao ave matedab requlremenro under Chapter 6.95 of BOILER-COMP(OVIY 100,000 BT11) �nl 7 O �QQ�
the G Nfornle HeaNh k S frty Code,Sea ism 75545,75533 and 75534. 1 A b 47g
u rdmta rd that If the ho Tiding don rot mrmotly have a tenant,that it is my NEW REST DENTIAL MECH. SQ.FT
responsibility to not Ey the ocapant of the nequirerrems whkb most be met
prior to bsuanee d a Certificate of Oaopaocy. Of Q40URD
Owner or authorrei agent ]Ale TOTAL ISSUED BY: - ls IA� y`✓ I Iv
�f-
OFFICE COPY i—