22801 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruildl Prn'M Identification PIXWT NO.
B°I`b des, �ro 22801
CITY OF CUPERTINO-BUILDING DIVISION
Con Ror'aNanr: WLac N. APPLICATION / PERMIT
BUILDINGELECTRICAL ML INGMCCHANICAL CATEGORY CONTROL Y / ) ey?
wp/ IS M�H
TITL_
(D O I
�/ BUILDING PERMIT INFO
mY . Q ELECTRICPERMIT FEE AddnPERMITISSUANCE �;OO
LICENSEDCONTRACTOR5DE RATION
IFertby affbmthatlamllcrnsed uederprovidoruof Chapter APPLIANCES-RE4DEMTAL
LIonfngceweiNStton70 )of Ddn3ofthe B .. dProdn ,
B O
limvelalnful NdeffM. PANELS 00
xCLk. 5-9 N
A
VVCortracto
ARCHITECTS DE ARA Npp - rnC, -1 AMPS
uedenbed my p used r public remdP OVER 1000 SQ.FT.FLOORFA $/SQ.FT.
lx �j Lfa min SIGN ETEC 7 OWNER-BITILDER DECLARATION �l
Iherebyaffirm that l am exempt from the Contractori Luceree law foe the SPECIAL T
15 EE-- follwngma+on.6ecim7m15,BunnesaaMPm(embrb Cade,Mydtyor MEW OR
IFS muntywMch requlrtroa pemdtmmn,requiresthlmpewe.demoWh,orretto
�e anyR aignertpdmmdtIft hathe a ala nquhestheat t-the (nauNpeaNte POWER DEVICES
C c.�
file a dgned abbment that he t Bcenud pursuant to the pmvbbv of the
ow ContnRor't Lkereelaw(Clupter9(mrmrcncing with SeGbn7000)of pd- SlVA1MING POOL ELECTRIC '
�O� don 3 of the Buminen and Po(emlonu Codel or that he b exempt therefrom and VALUATION t7v
�'•..tt the bub(or the alleged exemplbn. Any violatbn of senbn 7m1S b/any v (I
appllantfor a pemdt m
subjects thea pphcmt to a civil penalty of not oat t han OV[LEISSlVI7CFIESFU(TT1R6
five hundred dol Ws($W.
❑I,as owner of the property,or my employees with wage an thein sole NEW RESIDENTIAL ELECTR SQFI. SIORIES TYPE CVN,i UCfgN
mmpen,atlon,whldolhe work andthe swRure b wt Weeded or offto d for
5 O aIle 6m.7044,Busiruve and Prcif.t.ru Code:The Contractors Uceree Law
�s$ don not apply to an owner of property who builds or Improves thereon,and RF9,UNn5
(TCC.CROIIP
who doesauchwerkMm,eB mthrough hbownemployeeti,provided thmuch
ImprovementsarerotIntended e2rofco (hale.IChowever, Elder ldb8oe TOTAL:
enprovemerrc bald within oneyearofavnplelloM the owner-bullderwlll have
ben of proving that he did rot bund or improve for purpose of male.). QTY. PLUMBING PERMIT FEE
lLj L u owner of the property,am e,eclu.hely contracting with licensed FLOOD ZONE APN
mntraRorttommtruct the project(S 70Klitainemand Pro(embvCode: � PERMITLSSIIANCE ,Ob
The CardnQOr.Lire—law does not apply to an mvner of property who
builALTER-DRAIN A VFM-WATER(FA)
ds or Improves thereon, and who mMntda roe inch pinject,with a V
cgRlpcta(a)BcxroMµuauant to the CantraCea Llmrue Law. BAIX FLOW PR01}ZT.DEVICE FEESUMMARY
LI I am exempt under Sec B 6 P C for thin renin
Owner - Date DRAINS FLOOR RODE,AREA,GOND. SANITARY Y— N_
WORKMAN COMPENSATION DECLARATION R10E117 0
❑I he affirm thH I have a mrtlliob err conrnt to uB-loomer. FIXTURES PER TRAP p p SCI1001.TA)( Y— N
certlOcate of Workerv'C.pematlon Irwrranm ora cenRled copy thncvr(S, R�'I
3300,1abC.) CAS FA.SYSTEM-1 INCA OUTLETS 3. C* PARK FEE Y— N—
voiky Co Y GAS EA.SYSTEM-0VFR 4(EA)
ftECF4'I'Y
Y BUILDING DIVISION FEES
Cerro d copy b hercty th t l ed. CREASE/PIDUSM WASTE INTERCEPTOR PLANCHECK FEED
Cenirled mpy b filed with the cityIrepectbn dlddon.
CERTIFICATE OF IXlf,IMON FROM WORKERS GREASE TRAP PAID —,2-7 6 2V
nmM co plT ff INSURANCE
eSEMTEt,SANIfARYSIOR.M EA POPE Date Rcecf t#
(LNse., need oat be mmplebd Bthe permR bfworc hundred dollen
(f10�mlrs'I WATER HEATER W/VENT/ELECTt 3 ENERGYFEE Y N
1m tfythat In the pet..ion of thevrork for which this peendt is bored, OD q7d�
I shall not empby any Person b any�manner so u to to the WATER SYSTEM/TREATING G L
wmken'c or�jT/% to /M _ PAID _ � �
O = W rkont /T/
Z O NOTICETOAPIr1.ICANT:1f,after making thin Cerdffcate of ExemppIinn,you NEW RESIDENTIAL PLMB. 9QPT. Date Re f t#
PN ahmld become subject wthe Wahen'Compewtbn provisions he labor W TOTAL'
Code,you moat forthwith comply with such provblore arthle permN shall be] deened invoked. G
W O CONMUCTION LENDING AGENCY $ SMIC
CL Ihereby.mrm tlutt embamretmoibwmgagemyfortheperrorm- Tm,�: p ELECTRIC FEE ,7
FEE
� Z anceof the worker which thin peredtb .a,el(See 3 ,Cie.Q •]�, O
U O IeMd.Name PLUMBING FEE 2, aO
LL. Il- [erder.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imnitythatihave read lhbappllotbnaM tatethat theabwelnformatlm
a lecorna.IagreetocomplywdhBcityandmuntyonlbanmaandpablaws ' PERMTTISSUANCE
} N city to gtobupong coaly rcm,aedhertbyrty feelnrtpmsenbuvnofNb
Z city toenbree to ave,inve.mftly an d property inspection of Cu ens. ALTER ORADD70 MFCI-I. Date Recel t#
V — (We)agree ts,save,IMemnify an d keep eai which
the city of Cupenlno
*Willthepli
enb,mdsand experen which nuyln any wayamue AIR HANDLING UNIT(TO 10,070 SUBTOTAL:
.equanee o(the gra ntingo(thlapennh.
AIRHANDUNG UNIT(OVER 10, CEM) CONSTRUCTION TAX
Sig /Contonor Date E%IiAUSf HOOD(w/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
(utuce WOding arvpant store or haedle havardoua ' HEATING UNIT(TO 1WODO BM a
mDate Recel t#
alerbl a,defire,d by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Seaton 25537(a)I HEATING UNIT(OVER IWODD BM TOTAL:
❑ Yes [�j No
WIIIthe.pptant orfutumbuildingaavpantumaequipmont ordcvim, VEMILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdout air on,taMrunb as defied by the Bay Area Air
{
41ynagentent Dirt rkl7 BOVFR-NB'MP OTOR 100,OW BMP A I D Yn F[l Na
have read thenuaout nubnab ingYberrenb under Chapter 6.95 or BOILER-COMP(OVER100,000 BM
ted Cahrarnia Health A Safety Code,Benton,25.505,7SU3 and 7553!. I DEC -9 1991
urdersbed n b that lithe building donot currently have a tenant,that It my NEW RESIDENTIAL NISCH. SQXT
/ mpore@Blty to notify the occupant of the requirements which nest be met
prbr to lmuance Of a Certificate of Occepamy. CITY �7ry,UrtNIINU
Ownerorauthorbedagent Dab ISSUEDBY:� 6 � •
TOTAL: _OD' -
OFFICE COPY