22175 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Protest ldentif"'TenPERMIT NO.
Banding Address:74,-Pix r—ciiler\ 1(f`eoi L n 22175
Hers a e: e AFPLI�MJN SUBMITTAL DATE
1+7-Z?-73 CITY OF CUPERTINO-BUILDINGDIVISION
o. o/a _cone: 2. .No: 8 APPLICATION /PERMIT
BIIILDINGdECTiUCALI'LUMBINGMFLHANICAI, CATFLORY CONTROL Y
Archbeet/Engineer: Llc N.
G QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addroc'3'r5 GS . SaGa 1� PERh9TISSUANCE
LICENSEDCONTRACTOR'SDECURATION cri 0
I hereby afftrm that I am Leensed under prwbimuof C1hapter9(carrimenc, APPLIANCFSRESIDENp1AL - ]p8 __ N
lice.
In fon7000)anddfmn3oftheBudnessandPmfeadrruCade,and V�Qw3s�
Liense bless force andeffed. - PANELS .J
Date In
LILY '
Dna GOrdlidarUP TO 2DOAMPS
����- ...
ARCHITECTS DECUBATION AMPS
I understand my phro ehuB be used as public reeceds. OVER IOW AMPS SQ.F7.FLOOR AREA S/9�.FT.
E o[j Lle,nxd Prof.[..] SIGNSELFLTRICAL LED IN
OWNERex exempt
DECLARATION SPEC1ALCIRCU1T/MISC p T E R
3 mvingrafRn.(Se .7031mptfmmtbe Comractnrbslams MydtybeC ON
'09_q =AtYngrc req(Sedlon7 toBuWassand ProfessionsCode:Mytltyor U
O GI-.qqqqq iF7NP.ME'I FR ORIOLE INST. ♦ s0®��
�`5�y7 countywhlrh nequlnesapemdtto mnatrud,alter,Mprove,dennWh,or repair tlf�+V/
Q any etmdurceatemoimbat heels aboredi pulbeat to the
such pemdte POWER DEVICES TE
6 0 5
file• rrel sire.La that het ,9 from pmeuant to the provblons f the �G
3u, Co.3.ft/e LkemelAw oefesser9(mmmentlng wilhels Sectbn70Cmo(Dlvl- VALUATION
aton3afthe Baalnessand ProfessionsCaddorthat hebeeempt thenefromand c'�MINGIWLI7.ECfRIC
�^ the basin for the alleged exemption. My violation ofSection 7015 by any ' F'�w_'
0{�j• appBantforapem •u
iRbke theapplbanttoaddlpemhyofnm=m Hun OU7LEISSWI7CHFS�FMURFS Ol .� w
�c five hundred dollars(S5M.
�n
F1 1,as owner a the property,or my employes with wages es their sole NEW RFMIALELFLTR SQFT. STORIES TYPECONSTRUCTION
mmperoanon,willdothe work and the atme an ro
tat imuded or offered for
sale(Sec 7014,Buelrcu and Pnofonbns Code:The Comndol.U.Taw
�,IS@ dm not aPP)y to an owner of property who build•or Improves thereon,and OCC.GROIIP RES UNITS
6 whodomsuch workbimaeBarthmugh hi•ownemployeee,provided that such
Impmvem,i s arc rotintendedorofferecifor Bale.If,however,thebuildingor TOTAL:
Impmvernembsoldwhhl.oneyesrofcompk tomtheownerbuIlderwllilove
t rdenofpnodngthatlsedd notbuildorlmprovefapurposeofsale.). QTY. PLUMBING PERMIT FEE
I,a•owner,of the property,am exehaively antraeting with I4msedFLOOD ZONE APN
antradas to mM
rruet the pmjed(Src 70K Busines and Professions Code: PERMTTISSUANCE-
The Contractor's Lkxs Law don not apply to an owner of property who
Wilds or Improv 6.1 and who centrads for such ptojem with a ALTER-DRAIN&VENT-WATER MA)
ogIlVac'te(e)lkenaed punauant to the Contrado/s Lune,Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec B Jr ve
P C for this man �F FEES
,• Owner Date DRAINS FLOOD RCDP,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATIONRECOPY Y
❑1 here —by iffbm that I have a artinale of eauent to self-Troon,or a FDCFURES PER TRAP SCfTOOL TAK Y - N
artlfiate o(Worken'Compensatlm Insurantta•rertnfed appy thereof pec. RECEIPT
3800,I&b CS F.A. INK
_4�t qq GA .SYSTEM-1 4 OUTLETS PARK FEE Y_ N_
pwuI Y /I 2� � /V_ REC=If
CAS EA.SYSTEM-OVER 4(FA)ny CBUILDING DIVISION FEPS
( IC/rtl(led copy b hereby
Lr1OY_r b` furnished.
rtNed ropy b feed with the city IvpeGlon division. GREASE/INOUSTRL WASTE INUERCEPTOR PLANCHECK FEE
CERTIFICATE OF IXEM MON FROM WOR KERS' CREASE TRAP PAID
-
(This
SEWER-SANITARYSIORM EA mtarl' Date Recti t#
(1'Na aedbn need not be<ompldM tithe permitb(sone hundred dollue
(510).rles.) WATER S�AIFR W/VENT/ELECTR ENERGY FEE Y N
larti(ydutlothe per(omana olthe wvkforwNch thio pemdttabvted,
I shag not employ any person W any manner so as to become arbje t to the WATER SYSTEM/IRFA,IIIx
Waken Canpenmb.Laws of Olifomia.Date PAID
O = NOTICEApplicanTO
NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICETo se subCt to the
orftenakingthls Conn provisiof ons
of the
atho
should bemnne mbFct to the Workers'Compen.aHon pmvbbro of the Labor TOTAL:
LU N Crannedr eked. hwhh amply with such provbbro orthb pemJt shallbe
LU ] deemed revoked. BUILDING
colvsrgurnDN rucitLENDING
en AGENCY _ SEISMICFEE 1
a 'e of he
y oZHutthercbammmctlond(Sex,ding ,CIvorthe pedornF ELECTRIC FEE
� LendertNwork forwhich thio pern4tbbanN(See 30T7,CIv.CJ TOTAL
(.) 2 Iendni Name PLUMBING FEE
LL Lrnder.Add,ese QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
]anify thatI have read this appila
O W tion and slate that the shove information - -
4 fs cornad.I agree to comply with all city and county ord trances and state laws PFRMTPISSUANCE FEES PAID:
} Mating to building ravtnndion,and hereby authoilloe representatives of this
F U) city to enter upon the above-mentioned property(o inspection purposes. ALTERORADDTOMECH. Date Recei t#
(We)agree to•ase,Indemnify..d keep har W.the Clty of Cupedlro
U agabmnabWtles,lad mew,man and caperaes whichmayinanyway... AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agairo idC ems of thegrant Ing of this permit. AIR HANDLING UNIT(OVER t0,000CF\) CONSTRUCTION TAX
A 5-,7-91
Slgmtuneof Appnant/Contracts Date E(HALIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllam orfutum bonding omrpam.t...r handle havNw• HEATING UNIT(TO 10,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recef t#
Health xM Safety Code Sectim 75537 W7 HEATING UNIT(OVER 100,000 PATqAL:
rl
Y. r]No _
Ill theappliam orfumm building ocapant use equiprrcm or dew es VENTILATION FAN(SINGLE RE O) ISSUANCE DATE
whkh enut hamrdoua air mntaminams as deBrcd by the Bay Area Air MAY d �/ 1 1
S Qaality Management DletddLE
7 BOILER-NMP DIV OR 100,"BTU) S
Yes ❑No
have read the ha pens m
material,nequimenb u nder Cha per 6M of BOILER FR-COMP(OVI O,"BTU)
the GUbmb Health&Safety Code,Section 25505,25S33 and 75531. 1
undmiand that if the building dm not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT
naponsibnby,to notify the wmpard d the requheenents which at be met -
prior to bsuane of a Certifiate of Oavpancy.
Owner or authadred agent pate ISSUED BY:
TOTAL
OFFICE COPY