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21983 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PELwTNO. Building Address: 21983 I - CITYOFCUPERTINO-BUILDING DIVISION e ^� c tra or'sNa rN�o: APPLICATION /PERMIT �'t-• BUILDIN aDCE TIUCALPLUMBINGMF NKAL GTFSgAY CONIROLe A Nea/Fn(dPryr. IY.Na 2 Cry ELECTRICPERMIT FEE BUILDING PERMITINFO PLUMB MJ�H Add. PFRMITISSUANCE ❑ ❑ -Y [:1LKENSED CO.NTRACTOR'S DECLARATION c- Iherebyaffl tm wtlam Ucm undrrpr Wmuof Chapter9(mmrmlc APPLIANCESRESDENFIAL JOB DESCRIPTION ingveth Section 7000)of DivWnn3dthe Bualness Profnnau Code,and lice.6In fun forte d effect. LS 1 PANE Llmnw Cha Llc. L, Dna Contractor '� UP TO 2DOANIPS �l r� ARCHITECTS DEC RATIONn-10W AMPS �Z Iundereard my phvalui be,used u publics coda OVERIODDAMPS SQ.FT.FLOOR AREA $/SQ.Ff. Lkxnsed Prof.ional SIGNS ELECTRICAL �6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/ML9C 7Fp, 7y Ihereby.fflrm that l en exempt from the Contradori Llmnre law for the 6Zt- following.. action 7031S,70315,Buslnand Profmbv Code:Mgyp,METER OR POLE INST. muntywhfchrequlmapem tomrutmct,altu,lmprwe,derrnlbhormpalr 'y any MUM prtenwAtehe he Is.hnaoduoraueat to tho fneuchpmNtto POWER DEVICES w Bk.ilgned u.tement that on b Bmrued pursuant to the provisions d the wwrl� Contractor',Lkeae Lav,(Chapter 9(mmmnetrRwith Section 70D0)ofDivi. 3C1J sbn].feM Buslneuand Pmfea,brmCode)orthn hehese S'WafMING POOL ELECTRIC VALUATION mptthcmfmmard a Sit_ the b..6(or the ilkged exmp�. My dolatlon of Section 70315 by any .ppnontlora permit wbje btheappBcanttoa tlWl pevltydnot morctlun �"��F�SFl%Il1AF5 0� $� Ov h. dreddo]Iea%500). NEW RESIDENTIAL ELFGfR �'�n n I,u owner of the property,or mY employee with wage,u their sok SQ'7' STORIES TYPE CONSCRUCTION mmpewit wllldo the work and the stuctum b wt Wended or offend for O ask(Sec 7044,Bunnea and Professions Code:The Contractors License Law dm mtipply to an owner dpmperty who buiwor lmproveathereon,and OCC.GROUP RES LIMB C whodmm&work Md a Uorthrwghhi. w emplaym,prwlded thatsuch improvcmew are not Intended or.flercd forsee.If,however,thebullding or TOTAL Imbpnoven,m sold within one yea rof completbq the uwner,bulderwW have t"rden of proving the he did net bond or improve for purpose of tok.). QTY. PLUMBING PERMIT FEE U 4 u owner of the Prop ,am erchod ely mmtraMctiog with flat FT.ODD 20NE APN erty, contract.to mat uct the pmjed(See 7014,Bush.and Prdealons Code: PERMIT ISSUANCE OD The Contractor's License Law does not apply W an owner of property who ALTER-DRAIN d:VENT-WATER(EA) builds or Improve thereon, and won mnrad, for uch ptujees with. ry��dm(n)IloenaM purmant to the contradors License Law, BACK PIDWPROTECf.DEVICE FEE SUMMARY L , am..,t under Sac w B k P C for this reanQ1JTqjDE FEES Owner pee DRAIN&FT.00R ROOF,AREA,COND. SANITARY Y N_ WORK MAN COMPENSATION DECLARATION RECEI'T FIXIURE4 PER.TRAP SCHOOL TAX Y_ N_ 1 la he of orfUm that L have a mducarr of cwuent to,eu-Irwm,(s. ie rtBl eof ken'Cmnpevatly lwrancenamrtlfkd mpythereof(5ec. RIX:F]PI'Y 380(1,L. C.) �O1. r GAS FA.sYS14]d-I INC4oVf1El5 PARKFEE PolREC=Y— kY 1 CJ- GAS F.A.SYSrEMNOVFR A(FA) - � y '�d�LL_ Q/I'1 BUILDING DIVISION FEES � ` °rtbnedcSpy led with the citM.y GREASE/wpUSIRL WASTE INTERCEPTOR PLANCHECK FEE c.erlNed espy b Tiled with the dty IvpeNon division. CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID COMPENSATIONINSURANCTi SEWFR-SAMTARYSIORM FA x03'1. Date Recei [M m (1'hls.edion need na bemplded B the permit b fororc hundred doRara Rt)o)nlcaJ WATE I mrtlfy that In the perforvunm of the work forwhlch tw peoNt b bued, R HEATER wrvENT/EtLCrR 5,O ENERGY FEE Y N — I Muel not employ any person In any manner so u to becou�subject to the WATER SYS1E7.1/TREATING Waken Compca.tbn Iaws.f Callfomh.Due PAID O Z Applicant TO FNEW RESIDENTIAL PLMB. SQFF. Date Revel tk ZO NOTICErrn Psu ICI tothe after ms'Comene,jon Awk EvempteLalu shmld ionone aubjeet to the Workers'Compermnbn provisions oHhe Labor TOTAL ~ 03 Cade,You nud fnthwhh aanply with mch pmWsba orthb permit Dull be LU > deemed revoked. WILDING FEE W CONsrgurnoN LFNvwc AGENCY ISMIC d IhercbysfOrtn thatthercba mratructlon Imcling agency for the perform 7 FE Z ance of the work!or which this,=h bued(Sec.3097,Civ.Q TOTAL: .j0 ELECTRIC FEE aaa O O Ierderi N. PLUMBING FEE LL ~ tender.Addreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W I mnlfy that l have madthbappllatlona ci state that theabwe b(orrrnlon b correct.Iagmee to comply with.11 city.nd muntyordbnanoea.nd state U. PERMIT ISSUANCE FEES PAID: a relating to bullding mvtaction,and hercby.uthorlx reprc.ent.Rves ofthis F Z city to enter upon the above-menticned property for inspection purposes. ALTER OR ADDTO MECH. Date RCCCI [k V — (We)agree to acre,bdemnify an d keep harMa ethe City d Cupertlw igawt liabilities,Ndgmerds,mn.ard epean whkh mayln anyway... ARt HANDLING UNIT(TO t0,000CFM) SUBTOTAL: agent said Cky in conseq.e.of the granting d thio permit. AIR iiANDLING UNIT rovER tD,tD)cF+I) CONSTRUCTION TAX SIUe,mof Apphant/Cmlractor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Win theapplkant n/uvrcbudding occupant store on hardk ha ecdous HEATING UNTT(TO 100,000 BTU) Date R)c)i IM material a,;defined by the Cupertino Municipal Code,Chapter 9.17,and the H,eth and Seelyc on 2553](.)1 HEATING UNTT(OVER 100,00)BTU) TOTAL: ❑ Ye . Wintheapphaint'm buildingoccopantuseequlpr ntndevices VENTILATION FAN(SINGLE RESID) 19'aRt1�`��'�'th &DATE which emit luardous.ir mntaMnant,as defined by the Bay Ana Alr Q�La myMaaU.nt 1 BOTLFR-COMP CTRsOR100,000BTU) YYes N. OCT 3 1991 , read Neh ous matcrfab rcqulmmente under Chapter 6.95 of BOILER-COMP(OVER I W,1100 BTU) it.CalBornh Heahh k Safety Cade,Sedlov 75506,15533 and 75534. T urdmtand that lithe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFI' ((�a�� aass{� re,povbBLLy,to notltyt nccupard d the requirements which moat be curet SEly of Lt�NIInl�\ pr4once a 1-ote olOauparcy. Ow at .rix age t Da TOTAL ED ISSUBY: `+`�"' • 'e OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PELwTNO. Building Address: 21983 I - CITYOFCUPERTINO-BUILDING DIVISION e ^� c tra or'sNa rN�o: APPLICATION /PERMIT �'t-• BUILDIN aDCE TIUCALPLUMBINGMF NKAL GTFSgAY CONIROLe A Nea/Fn(dPryr. IY.Na 2 Cry ELECTRICPERMIT FEE BUILDING PERMITINFO PLUMB MJ�H Add. PFRMITISSUANCE ❑ ❑ -Y [:1LKENSED CO.NTRACTOR'S DECLARATION c- Iherebyaffl tm wtlam Ucm undrrpr Wmuof Chapter9(mmrmlc APPLIANCESRESDENFIAL JOB DESCRIPTION ingveth Section 7000)of DivWnn3dthe Bualness Profnnau Code,and lice.6In fun forte d effect. LS 1 PANE Llmnw Cha Llc. L, Dna Contractor '� UP TO 2DOANIPS �l r� ARCHITECTS DEC RATIONn-10W AMPS �Z Iundereard my phvalui be,used u publics coda OVERIODDAMPS SQ.FT.FLOOR AREA $/SQ.Ff. Lkxnsed Prof.ional SIGNS ELECTRICAL �6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/ML9C 7Fp, 7y Ihereby.fflrm that l en exempt from the Contradori Llmnre law for the 6Zt- following.. action 7031S,70315,Buslnand Profmbv Code:Mgyp,METER OR POLE INST. muntywhfchrequlmapem tomrutmct,altu,lmprwe,derrnlbhormpalr 'y any MUM prtenwAtehe he Is.hnaoduoraueat to tho fneuchpmNtto POWER DEVICES w Bk.ilgned u.tement that on b Bmrued pursuant to the provisions d the wwrl� Contractor',Lkeae Lav,(Chapter 9(mmmnetrRwith Section 70D0)ofDivi. 3C1J sbn].feM Buslneuand Pmfea,brmCode)orthn hehese S'WafMING POOL ELECTRIC VALUATION mptthcmfmmard a Sit_ the b..6(or the ilkged exmp�. My dolatlon of Section 70315 by any .ppnontlora permit wbje btheappBcanttoa tlWl pevltydnot morctlun �"��F�SFl%Il1AF5 0� $� Ov h. dreddo]Iea%500). NEW RESIDENTIAL ELFGfR �'�n n I,u owner of the property,or mY employee with wage,u their sok SQ'7' STORIES TYPE CONSCRUCTION mmpewit wllldo the work and the stuctum b wt Wended or offend for O ask(Sec 7044,Bunnea and Professions Code:The Contractors License Law dm mtipply to an owner dpmperty who buiwor lmproveathereon,and OCC.GROUP RES LIMB C whodmm&work Md a Uorthrwghhi. w emplaym,prwlded thatsuch improvcmew are not Intended or.flercd forsee.If,however,thebullding or TOTAL Imbpnoven,m sold within one yea rof completbq the uwner,bulderwW have t"rden of proving the he did net bond or improve for purpose of tok.). QTY. PLUMBING PERMIT FEE U 4 u owner of the Prop ,am erchod ely mmtraMctiog with flat FT.ODD 20NE APN erty, contract.to mat uct the pmjed(See 7014,Bush.and Prdealons Code: PERMIT ISSUANCE OD The Contractor's License Law does not apply W an owner of property who ALTER-DRAIN d:VENT-WATER(EA) builds or Improve thereon, and won mnrad, for uch ptujees with. ry��dm(n)IloenaM purmant to the contradors License Law, BACK PIDWPROTECf.DEVICE FEE SUMMARY L , am..,t under Sac w B k P C for this reanQ1JTqjDE FEES Owner pee DRAIN&FT.00R ROOF,AREA,COND. SANITARY Y N_ WORK MAN COMPENSATION DECLARATION RECEI'T FIXIURE4 PER.TRAP SCHOOL TAX Y_ N_ 1 la he of orfUm that L have a mducarr of cwuent to,eu-Irwm,(s. ie rtBl eof ken'Cmnpevatly lwrancenamrtlfkd mpythereof(5ec. RIX:F]PI'Y 380(1,L. C.) �O1. r GAS FA.sYS14]d-I INC4oVf1El5 PARKFEE PolREC=Y— kY 1 CJ- GAS F.A.SYSrEMNOVFR A(FA) - � y '�d�LL_ Q/I'1 BUILDING DIVISION FEES � ` °rtbnedcSpy led with the citM.y GREASE/wpUSIRL WASTE INTERCEPTOR PLANCHECK FEE c.erlNed espy b Tiled with the dty IvpeNon division. CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID COMPENSATIONINSURANCTi SEWFR-SAMTARYSIORM FA x03'1. Date Recei [M m (1'hls.edion need na bemplded B the permit b fororc hundred doRara Rt)o)nlcaJ WATE I mrtlfy that In the perforvunm of the work forwhlch tw peoNt b bued, R HEATER wrvENT/EtLCrR 5,O ENERGY FEE Y N — I Muel not employ any person In any manner so u to becou�subject to the WATER SYS1E7.1/TREATING Waken Compca.tbn Iaws.f Callfomh.Due PAID O Z Applicant TO FNEW RESIDENTIAL PLMB. SQFF. Date Revel tk ZO NOTICErrn Psu ICI tothe after ms'Comene,jon Awk EvempteLalu shmld ionone aubjeet to the Workers'Compermnbn provisions oHhe Labor TOTAL ~ 03 Cade,You nud fnthwhh aanply with mch pmWsba orthb permit Dull be LU > deemed revoked. WILDING FEE W CONsrgurnoN LFNvwc AGENCY ISMIC d IhercbysfOrtn thatthercba mratructlon Imcling agency for the perform 7 FE Z ance of the work!or which this,=h bued(Sec.3097,Civ.Q TOTAL: .j0 ELECTRIC FEE aaa O O Ierderi N. PLUMBING FEE LL ~ tender.Addreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W I mnlfy that l have madthbappllatlona ci state that theabwe b(orrrnlon b correct.Iagmee to comply with.11 city.nd muntyordbnanoea.nd state U. PERMIT ISSUANCE FEES PAID: a relating to bullding mvtaction,and hercby.uthorlx reprc.ent.Rves ofthis F Z city to enter upon the above-menticned property for inspection purposes. ALTER OR ADDTO MECH. Date RCCCI [k V — (We)agree to acre,bdemnify an d keep harMa ethe City d Cupertlw igawt liabilities,Ndgmerds,mn.ard epean whkh mayln anyway... ARt HANDLING UNIT(TO t0,000CFM) SUBTOTAL: agent said Cky in conseq.e.of the granting d thio permit. AIR iiANDLING UNIT rovER tD,tD)cF+I) CONSTRUCTION TAX SIUe,mof Apphant/Cmlractor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Win theapplkant n/uvrcbudding occupant store on hardk ha ecdous HEATING UNTT(TO 100,000 BTU) Date R)c)i IM material a,;defined by the Cupertino Municipal Code,Chapter 9.17,and the H,eth and Seelyc on 2553](.)1 HEATING UNTT(OVER 100,00)BTU) TOTAL: ❑ Ye . Wintheapphaint'm buildingoccopantuseequlpr ntndevices VENTILATION FAN(SINGLE RESID) 19'aRt1�`��'�'th &DATE which emit luardous.ir mntaMnant,as defined by the Bay Ana Alr Q�La myMaaU.nt 1 BOTLFR-COMP CTRsOR100,000BTU) YYes N. OCT 3 1991 , read Neh ous matcrfab rcqulmmente under Chapter 6.95 of BOILER-COMP(OVER I W,1100 BTU) it.CalBornh Heahh k Safety Cade,Sedlov 75506,15533 and 75534. T urdmtand that lithe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFI' ((�a�� aass{� re,povbBLLy,to notltyt nccupard d the requirements which moat be curet SEly of Lt�NIInl�\ pr4once a 1-ote olOauparcy. Ow at .rix age t Da TOTAL ED ISSUBY: `+`�"' • 'e OFFICE COPY