19686 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buidln PI]LwTND.
Building Addren:
g' eaTavo 19686
rceeA/ �OW/l.� m CITY OF CUPERTINO-BUILDING DIVISION
CWNyrc:a/C_)Co/r �✓145U�/gp Lk.N¢ APPLICATION / PERMIT 3 -2-0 - 90
BIII1DDJGELECTRICALP1,UN1BINGMECHANTCAL CAT RY CONTROL e
Amhded/Fsgineer. Lb No:
QrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I MhSedion700D) fDi,Bcm.Murderpetuando(CxionsCde,and me AIaI'LIANCESRFSmENTIAl JOB VESCRB'RON
Ingwith Sedbn700BjolDMelon3dthe Budnrnand Pmlesalona Cade,and
Ll Class 'tdL�fi2 SSn4 PANELS .
Dat runtraa /VS �jG//rn��'� /2
ARCHDECIPSDECLARAID N -1 AMPS
µµqq++a0 OC I imdeommd my pIuu sh 1J be u n public remrda OVER 1000 AMPS SQ.Fr.FLOOR $/SQ.Fr.
k U Lkem Pmfembrol SIGNSELPLTRICAL
<5 OWNER-BUILDER DECLARATION SI'ECIALCIRCUIT/ML9C
71.., ; I hereby affirm that am exempt from the Contrd,Wes Lteenae Law for the
following reawn.(ScNm 7m1S,BuaNm and Pmfeebv Cade:Any dty m
6 TEMP.METER OR IaJl,E INST.
F muntywhkh requ4vapemdebmnMrud,alter,bnprove,demoLLeh,ornpatr
Jr,�< anyarudumprbrbhefewamealsomqubetheappna tfmwchpemdtto POWER DEVICES
file a ggned statement that he la]lamed pursuant to the pmWlora of the
Comwith Sedom'
30;} abn 3ofthe Buanmand PrdedWra Code)orthath Is exempt therefromMM. SIVIVLwNC POOL ELECTRIC VALUAT]IX•j ,O
P •77 the baala for the alleged jee Cheap My violation of ra tbn nat m by any /y
�5 the baanfora pertNtabjednVftr.pAnyvioa ion fSectld ndmorttlun OLITILETS-SWIT }�MTURES o`-I
$ i1 lWe hundnod
rorof hepr. NEW RESIDENTIAL ELEM SQ.FT. SIDERS CONSfRUCMNT
7� uowrer tithe Property,or m7 employee whh wage ulhelr wb
conpewHon,will do thewarpf lheatnnde: lurotbdeMNor offendfor
Osale(Sec. pply to an mend Prdeaebra Code:The mImp on'.Mame law
$$ does neesucytoan ownerdthmugh property who 1sawneldeoym,prvnthereoM and OCC.GROUP RFS UNITS
whoovernrflamnhwork hlrr�Bmthrwgh hlaow le.Ithee,provdedthatetch
improvemM arcrotintendedorof(eredforrale,t(however,tMeru ingve TOTAL.
Improvement bold wlthinorcyeardanmpldbM1 theawner-0ullderwnl love
t rlenofpmvingthathedd wtbulldorlmpm furpurpoeeofule.L QTY. PLUMBING PERMIT FEE
L n owner of the property,am exchuthely comn1ing with homsed —FLOOD TONE AI'N
mntraetonto mralrud the projeet(See 7044,Buslnm and Prv(embru Code: PERMIT ISSUANCE
The Cordnaoro Lure.Law doe not apply to an owner d property who ALTER-DRAIN 6 VENT-WATER(EA)
Wilds or Improve thereon,and who wrmam for d
wch p(ojes with a
cgRt(ador(s)Bcenaed pursuant to the Comradoi'a Llmrse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B k P C for this xenon
DRAINS FLOG SANITARY Y— N
• Owner Date R ROOF,AREA,COED.
WORKMAN COMPENSATION DECLARATION R�FIIT Y❑1 hereby of loo that I have a rerlj"te d eros.]to sell-Lwre,m FTXTlJRFS.a PER'IRAP SCHOOL T53F Y_ N—
RECElPPT Y
.diflote of Workers'Comporsueon Insurance m a,x,o copy me,6ec. GAS F.A. YSI77d-I A'C.40IJII.EfS PARK IEE Y N
38(0,Iib C��Q� -
ra Za C✓l7�G RM]EIPT
Com v� UW /nn GAS F.C.SYSTEM-0VPR4(EA) BUILDING DIVISION FE FS
�Cemfied ropy Le hextwthMshM. GREASE/WDUSIRL WASTE INTFRCIT"IOR PLANCHECK FEE
❑[edited ropy b Hied with the city Inpedlon dfWam.
CERTIRCATEOFIXtT1PEIONFROMWORKERS' GREASE TRAP
CI'NseMbn need CSATIONINSURANCE PAID
out becomplded Bthe permiBVfoorchundml dollen MFA NXaT
Date Ri tp
Rlao)mfehI WATER HEATER w/VENT/EII'CTR ENERGYFEE Y N
Imnot that In the ped.to anof y
wart for which HJsdsubjpemnit idto the —
I mlu not employ any peeem�N any manner at u to bemme wbjed to the WATER SYSIFM/IRFATING
Wmlicn Campenutbn laws of UllfarNa.Date PAID
z Z NOTICEt NEW RESIDENTIAL PLMB. SQFI'. Date Rcad tit
Z NOTICE eeme suLICANt:a ghee mating UW Ctiorn p ,lx rax oftt the
o
aholdo mm<wrth to the Workeri Cock pm lonprovl.bra ofthe Labbe TOTAL:
tr N ddeedmy eked. tlh mmpty withwch proVlebra or this permit shallbe
dp corlsrRucrloN LEnvwc AcwCy SEISMIC FEE
I hereby affirm that them b a mrdrudion lending agery for the perfomt
Z arae of the work for which thb permit is bac.3097
ted C3e ,Civ.C.) TOTAL: ELECTRIC FEE
() O Lender'.Name PLUMBING FEE
LL ~ Lender'.Adde,e QTY. MECHANICAL PERMIT TEEMECHANICAL FEE
O W I mdtfytiut l have mad this appliatbnard nate thatthe above infommdon
I
Iageeetom PlywhhaBdtyaMmuntyordtnenaaand Katelaws PFI114717 ISSUANCE FEES PAID
} S m(aungtobWdingmratmdton,ant herebyaudnorE,e repre.entatFroofthla
F U) dty to enter upon the abovrmentlorcd property for impedbn purposn ALTERORADDTOMECH.
— (We)agree to save,IMm
eNfy an d keep harmlea the City o(Cupertlm Date Recci tit
agarat Wbilities,jidgnrms,mats a nd expenses which may in any way acrue AIR HANDLING UNIT(TO 10,(*0 CFM) SUBTOTAL:
age Ln 1d City to mnsequen he rain g Chir perm B.
C ,.1/a. /J AIRHANIwNCUNTT(OVERlo,aaOCFM) CONSTRUCTION TAX
Sig 7�¢f Hupp anvCKon-rn e Dae DcHAusr HOOD(W/DL)CT) CONSTRUCTION TAX PAID:
HA7A ROO MATERIALSDISCLOSURE
WWtheappncammfutu bulldingomnpantstomorhaM4haaardous HEATING UNITDO 100,000 BTU) Date Rccel IN
material ae deRred by the Cupertino MuNdpal Code,Chapter 9.12,end the
Hr.hh ant Seldy Cadee.Se�75532(x)7 HEATING UNTr(OVER 100,000 BTTI TOTAL:
W ll e /Tito
Illmt aprxrdrt a tumbu0ding o defInxuby the Ba Area AI vim VENTILATION FAN(SINGLE RESID) .ISSUA ATE
which em.rusemoue Wrist? mWnteu de0rcd by the Bay Arca Ale k {
�i YMamgement DL+irid7_ BOII.ERNMPOM'OR100,000 B11A / . ..'I
4 Ye. -Til• ✓ Ty3U
hnverHealth
requ under of BOILER-CONP(OVFR 1fD,000 BTU)
the California Health ASafety cid Sedbu255QS,ve a tenant,that
1
uMrntandthat If notify
Wilding doe ndmrmnByme.t.tenant Chet It mot NEW RESIDENTIAL MECH. SQ.R. C+ea pf r(/nP..{{
re,panuronuy,to of.Cent
omv ntdthe mrylrementswhich m,a be mel Imp
p fasuarecdaCertl f pa 3 �.
ermaut and edagen Rate
TOTAL RUED BY. V-a�*•I V�yri-^�l
OFFICE COPY