19798 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm;ce Wemlfleatan PERMIT NO.
ulldirg Addrts: 19798
one APPLILA I liJfe hUBMI I I A
L. t To wla Z4 p — y- CITY OF CUPERTINO-BUILDING DIVISION p_Q1
. Cmtractor'sNana: ILk.Na APPLICATION / PERMIT
BURDINC-FLECTtICALPLUMBINGMFL}NMCAL CATI)ARY CONTROL#
Archdect/Fsgirar:r. Uce No,
d'— Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
FLU LC
Add— o -L I� 'rw PFRMUTISUANCE 1717 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam lkerueel under p.Wmteof Chapter9APPLIANCES-RESIDENITAL JOBRIPIION
ingwthSmbn7000)of Divldm3ofthe BudnesandPmfesdov c,and
license Is In hill farce and effect. PANELS
Chas Lk.N
Doe
Dale Gic.N r `•R nab ,`
ARCHITECT'S DECLARATION 1-1000 ANTS
Z I urderaand my plan.Fall be uad an pubk rexxda. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
yy UPrdest.�
L Licensed bvl SIGNS msCrRrrar
H
�6 OWNER-BUILDER DECLARATION SPECIALCIRCIIIT/MLSC
t. Z I hereby affirm that l am exempt from the Contractor's License Law for the
7 Q following reason.LSMIon 70715,Bushes and Profeabv Code:Any city or
r5 L i- TEMP.METQt OR 1'OIE A'ST.
I5� muntywhltlirequ4vapemdtmmvwct,alter,4m
tenpve,dennlbh,or repair -
Y anyamctum prlorto lb Lvrave,abo requbesthe applicant far mrh pemdt to
C ilk a slgned statement the la is nn licensed puuant to the provisions of the 1'JWF-R DEVICES �I
DwG Contractors Lkenoelaw(Chapler9(commendngwkh Setlbnmag)of DIW- I
C don 3 of the Business and PrdeabroCode)or that he b exempt therefrom and S'N7M4`4NG POOL FG.E � !✓� VALUATION
y.' the basis for the alleged exemption. Any violation of Section 7m1S by any. ^ t'
applicant fors perMteubjectstheapplkant too evil penalty d not marc than OUTLETS PUCITIRES i. 1\ II _ --\, I S o a oV
� �— (Iyhyndrcd ddWs(f50Pj. NEWA®ENTIAp tr lR g]FI'. n 1 SIOR16 TYPE CONSfkUCIION
ee
as owner of the property,or my employwith wages as tMir sole --
�7a compensation,will do the work and the.tvCcoed
u m is t mordor offered for
❑ sale(Sec 7W4,Business and Pofes em Code:The Cordraao,3 U¢roe Law
(/j5$ dm rent apply to an owner of pmpertywha buldsor impnnen therrerc and �� V
C who doeasuchwork M1imxBmthrough hlserwoemployees,prwded itOCC GROUT' ALS UNITS
utsurA - as
ImprovemuNsarenatbtendedorofferedforaek.If,however,the bulldln8 or T T'IfC
Improvement baldg than did
drant Wild
or bnpamn frpurpser f s lute
t nofpm of the tope ty,otbu0d arimpm.Tracingwith licensed!
QTy, ' UMBING PERMIT FEE FLOODZDNE APN
L as o con of the property,am es0K Busy contracting with licensed
TheconCo ore to mmtnn the pmdoe(Sec 7 apply t eines and ed pro ons Code: +d-y
Ila s or i oro License Lw don rein apply to an owner ot property who ALTER-DRAIN 4 VENT-WATER CFA)
Wilds or Impewes thereon, and who tradram f¢each p4ojecv with
ry➢t(�hh��.Ier�aff=ihat
am
dner art Sex,tothe CmntnctalsLf¢nx BACK PLOW PROTECT.DEVICE FEE SUMMARY
pEvv%
1_I pt order Sec B(r P C for this reason
IXtAINS FLOORAREA,COND. SANTFARY Y_ N
QvnDae ROOF, RECFR'T#
OAN COMP SAT RAT# FIXNIffS I'ER 7RAP SCITOOL TAX Y N
I hive a m to of crosent to veil-iwrc,or a R[�EU'I,#
3800,Lab CJWorken'CompeuaMm rourmcecea¢rtlfkd ropythertof LSec. GAS FA.SYS1EM-1 WC4 OUTLETS PARK FEE Y N
Policy Y Rl]CET T#
Corn any GAS EA.S1SfTM-OVFR4(EA) BUILDING DIVISION FEES
f 1Cedl/led copy b filed wihereby th
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
L�Ji Certifiedcopy b Ukdwith is city Inspection division.
CERTIFICATE OF EXLTIPFION FROM WORKERS' rWATER
TRAP PAID
COMPENSATIONheparRANCE SEWER-SANITARY-STORM EA.NIRR' Date Recti ttl
TI'hla.ectbn need not M cornplaed If the pemdt b f¢ov hundrN dollen
M WJ 4f 1C1e') ENERGY FEE Y N
Icertifythat In the perform,nm ofthe week forwhich this penmen b Issued, HEATER W/VENT/ELECT _
I shall neat employ any person N any manner n as to became subject to the YS IN/TREATINGWorkers Compensation Lawn of California. Dae PAIDO Z Applicant gppT DAL PLMB. SQJ7 Date Recel tit
Z O NOTICE TO APPLICANT:If,after making this Cartfflcate of Exam1ple ,you
Fy
should becoe meubjen to the Worken''ComWevat ion provisbru or the Labor TOTAL
_ Cade,you trust fort hwLLA mrnply with e,ch provisions or this Permit shall be
cc > deemed revoked.W m
F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL lhereby•f8mnthat them ba mvtnnlon krdingsgerry for the perform
7 Z once afthc workforwhkhthb permitb L.mred�309'7,CIv.CJ TOTAL' ELECTRIC FEE
U O Terser'.Name PLUMBING FEE
LL Leader.Addrve QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O IU 1¢rtlfy(hxlhave rtad this appBcatbnard staetM1a thcabweln(onvtion
bmnen.lagree to complywuh ail cltyaM county ordWnmand wte laws PERMIT ISSUANCE FEES PAID.
} 0. relating to building mvtnGtan,arol hertby..thoroe representatives of this
[_
z Z city to enter upon the abo crentbnab
i property for upectbn purposesALTERORADDTOMECH.
Me)agree to save,indemnify an d keep harmles the City of Cupertino Date Recei tit
V ago Wt lbbbtan,}Idgnenb,oras and expenses which may In anyway., AIR HANDLING UNIT TIO l0,0D0 CFM) SUBTOTAL:aga Eat said City b cora siaenoe of the grading of of this permit.
AIR HANDUNG UNTT(OVER I0,000CF CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the.ppBrau or future building.,nt store or handle havmious HEMTINGUMTODIM,00011M
rmDate RCCCI tic
terfal as deflvd by the Cupertino,Municipal Code,Chapter 9.1 Z and the
I eath an,!Safety Cade Section 25532(a)? BEATING UNIT(OVER 100,00)BTU) TOTAL:
rl u
Y. No
ill the appBM¢ tore building onvpant um equipment,or devices VENTILATION FAN CSINCLF RESID) #SSU A4ll�p'�'TE
which emit harandous air mntambards as defined by the Bay Area Air
Quality lelavgemend District? BODLFR-COMP OFIP OR IK()(D BTU) n y (�
1 s'c read then vdaNOmat a requirements underehapter G95 of BOIIFR-NMP(OVER 10),0DO BTU) FES Aa 8 1{177J
the Coliform.Health 6 Safety Code,Sections 25505,25D3 and 75534. I
urdmteal that if the building darn not currently have a tenant,that it is my NEW RESIDENTIAL MELT L SQ.FI'.
respovbBity to notify the canniN td the require—'s which at be met Ia. (1(I^ �
prior to issuance d a Certificate ofoccapamcy, al , —
Avner co.whorieed agent Date ISSUED BY: `as/� V'-CwVY
TOTAL
OFFICE COPY