19844 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldl Pmied Idmtl(leatlun PERMIT NO.
B"1dirg Add. ,% 19844
rcrs see:
CITY OF CUPERTINO-BUILDING DIVISION
ConlndoYNam: i LbN
A& APPLICATION /PERMIT
I? rr 7 BUILDINGE,ECIRICAL. LU BING-MECHANICAL CATEGORY CONTROL Y
Archued/Englver. Lie.No,
QTY ELECTRIC PERMIT - FEE BUILDING PERMIT INFO
Add. PFRh17TI$UANCE ❑ ❑ ElLICENSED CONTRACTORS DECLARATION
ON
herebnftIo.affirm tMtlamllonrdueflosi Wmuoffeed rod,an me AI'[a[lANCESRESIDFNITAL JOBD RIPIION
Ingwlth5ectbn70lp)of Dlvhlon3dmcBualrmandlarofeslovCe and
Ikenee ICI N and effect. qq�as PANES
Date Chm �Lt.eAL
Date cenmader N —UP TO 2DDAMPS
ayll.
ARCHITECTS D ZION 70- At`Q'S
q00
�uerZ Iurdentandmyptmr shaRbeumdupubhcrternda OVE2IODOAMPS .FT.nODR AREA $/SQ.FT.
U0�0 Licensed Pmfenbvl SIGNSELEC[RCAL
<< OWNER-BUILDER DECLARATION 9sECIAl CIRMT/M
Thereby affirm that amexempt from the Contractor's Llceve Law for the
7 (ollawir�g rtamn.5edlon 70t15,Bualn®ard Pmfmbv CcMydtyur
O Z e- TEMPMETER ORPOL
F� muntywhlch mrrybmapermktomrutmd,almr,impmve,demolhh,orrtryir . ,
q' anystmc mprbrtoiva ance,., omquU ffieappbantf«s chpemdb POWER DEVICES
P O The a dgeed statement that he b lnnacd purwant W the pmvhbv of the
3ANR
01 slon3otheBuslnemand PmfembrmCe)orthabehhemmothemfof Divi- SWIMMING POOL.ELE
S< thertfmm any VALUATION
the baah for the permit
exemption. My vitiation d Ee tis not
re any
<� aPPBastred delt.($50(1. the appllcanttoatlWl pevhy door rmre than OITILEIS I
,. raveb,as ower ofthepro
1 as owrcr of the NEV RFSID L .Fi. STORIES TYPE CONSIRUCTIOn'
❑, property, tesempbyemwh with as theresole
76 coIepmeatbn,willdothe workandmestvdurt brmt WLMcd or offered for
O sale(&G 7014,to anowaMf property
ropewho
TM Clmprcnle thereonlaw
S$ doe rad apply tamowrcr d pneogh who bienopildis oym,prnthereon,that ch OCC-GROUP RES UNITS
who donsuch work himself ormrwgM1 Naownemployen,pmvWed that W d
impmvemew ort rot Intended ero(fertd for Bale IL however,thebuilding or TOTAL:
Impm ce mhsddwkhlnowyearofcompletlon,tMoxnerbulWerwBl love
t rdenofprovingthehedm notbuddorlmproveforpurpweofsals.). QTY. PLUMBING MIT FEE FLOOD ZONE MN
m
L as owner of the property,am eachaamly mnwening with Hmmcd
mracton to rorolrod the pmjed(See 7DI4,Busher and Prif�bv CeS-
.. PERMIT T UANCE
The ContndoYs Licerm law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FiV
builds or improve therem, end who mmram for wch p,pm with
cWtilelorw Oceved pu mnnt to the Contractor's Llnve Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I am exempt usder Sec B k P C for this rtw
a
DRAINS FTOOR ROOF,AREA,COND. SANITARY Y— N
Owner Date RECEIIT Y
WORKMANI ha,s a COMPENSATION DECLARATION FIXTURES PER TRAP SQTOOL TAX Y— N—
❑I'erebateof affirm that I have a smtifI.me d consent to self.irwre,thereof
(Sa RECEIPT Y
ce00,L Lb C.)
lrouana ora errtitlea mpi thertd LSec GAS E.A.SYSTEM-I INC40UTLETS
I'di,Iab CJ PARK FFB Y— N_
1 dky Y RECEGAS EA.SYS147d-OVER 4 MA) DING DI Y
ny BUILDING DIVISION ISION FE F9
Certified ropyis,filed with the tltylropectbn divWm. GREASE/1NDI15ITtL WASTE INI'ErLE'TCIR PLANCHCCK FEE
CERTIFlGTEOFIXLT/I'TION FROM WORKERS GREA`¢TRAP PAID
COMPENSATION INSURANCE SEWER.SANTTARYSIORM FA ZWT Date Rcoei t#
ITd
( ssedbn need not be B be completethe permit h fororc hundred dollen
(stIo)orf certify th UWATEIIEATERw/vFNT/awns ENERGYFEE Y N—
I
thatthepeefomunnor
of the for themIssued,ed, —
I aha0 nm employ b at tob
y any.Lany manner a to becoe msub}ea1 to the WAT'PR SYSTEM/TRFATING
Ct A Banc onpsneatbn larvaa o(GWomla.Date PAID
_Z Nonce TO AIeI'LIGM:it„ kermaangtwGNfluteorExemptle ,ym, NEV�DETlALPLM3. SQ.Fr. Date Rccei [q
should become aub},”to the WorYen'Compesselon proNebru of the labor TOTAL:
~ N Code,yuu.forthwith comply wtthsuch pmvbbmit
nsorthia pershallbe
Lu 7 deemed reked.
Lu
wC CONSTRUCTION LE:DINGAGFTCY S I MIC FEE
I hertby a(Ortfor w then h a mmtrudlon bMNg agency for the perform-
� Z aner of the wort for which nth pematbhR,ea&,3097, c.> TOTAL ELECTRIC FEE
O O Lenclero Name - PLUMBING FEE
LL F I.LMCYSAadrtm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certify marl have read thio appltatbnand natemattheabove information
1 hrornM.lagrm to comply with all tlty and owntyordlnanm and slate laws I'FRMIT ISSUANCE tZ_f ; FEES PAI
} N relating to building ronMnctlon,and hertby aumodr repreaentatNm of this
I— Z dtytoe abovcrrcntbned property for lropectbn purposee. ALTFRORADDTOMECEL Date Recei t#
— )agree t .,e,IndemN n d keep harminr the City of Cupertino p
19 MI bw , me b, rad �pevnwhiehmayinaeywayamue AIR HANDLING UNIT t0,"CFM) SUBTOTAL: 11 •sl
agalvt ky f gnntingdthbpemdl.
AIR HANDLING UNIT(OVER IQODOCFNO CONSTRUCTIONTAX
Sigodwrcf AppBant/Contndor to D(HALSTHOOD(W/DU(7T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thcappIlant or forum buiding oavpart esortor handle hazard. HEATING UNIT(TO 100,000 BTT))
. O Date ReceiptR
I kalthelas decry bythe Coon 255 Murdtlpal Ce,Chapter 9.1 7,and the
T balm and arery cmL SLdion 2u3z(a)r 1-1FATTt`c uNn'(OVER IDD,000 BTU) TOTAL: ;7..�t 00
I Ym rE No
TNWthe htpndntor tun building onvpaed!by equipment ordevirn VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
wlM1theMahagement airmntamWwas defined!by the Bay Area Ab PAIS
Qu alNyy Management [:a NT BOILER-COMP OIN DR]OQIX9 BTU)
4Yn ❑❑No
luwe read the haaandoua rrwLdah rtquirtmenb ueaLrGM1apter 6.93 of BOILER-COMP(OVER 100,0000][1) MNK Y 2 1JJU
ted Glomla]ILahh&Safety Code,SMloro 755DS,25537 and 2553/. 1
uMvuaMyt.nH ebulldingdoermtmr.gni h .te hiah hm Lamy
NEW R79DINITAL MECI-L SQ.FT.
rvparo@Bky to rad Uy the ocmparn d the recrylrtments which most he met
priortolmuave of accAifiateofoccvparcy. VIj�I_CIO` of P114�
Owner or authos dag
rent Date ISSUED BY:�` _ kW17 k'V✓�•
TOTAL1 _LD
OFFICE COPY