19902 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preen Identification PERMIT NO.
B°Bding Addny: 19902
2i0o�
. a one.
/ (J CITY OF CUPERTINO,BUILDING DIVISION A�
c Na Ix.Ne APPLICATION / PERMIT y
d BUILDI NC-FLFLTRICALPLUMBING-MDCHANICAL CATEGORY CONTROL
eft/Englrcem Lie Na
QTY ELECI'RICPERMIT FEE BUILD ING PERMIT IN FO
Addres,
PFRMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am llceraed under prwWwo/Chapter9(®nmen APPLIANCFSRIESIDENTIAL BDESLRB'HON
IngwIthSeetbn7000)of Div m3ofthe Buabo dPmfes Code,and my
II=ia In ful soros deflect. PANELS
Linen Clam LfcY_u
De( Cordractor .�� �}�6-ll.
ARCHIiE ECIA ATION 201-IODO AMPS
nt0 Z I urdenotand my plan shall he,uad as public records, OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
L4cruN Prefembral SIGNS ELECTRICAL
G
6 G OWNER-BUILDER DECLARATION L Iherebya(Brm that!aro exempt from the CorunctorsLbeveLaw for the SPECIAL CfRC1RT/MISC
�p f ntyngte requ&ctape7 town mOt ,mpm , Co h, tl ar
6Li—� Y ty 7FAiP.METQt OR POLE INSF.
F muntywhlCh megnwapemdt to[Ovinct,alter,Mprove,drrrolbh,orrtpair
anystructurepol toltab au ,ab mqu4e eappeontfwsuchpemdtto POWER DEVICES
!'S O Ole a algned datrmert that he b Raved Pennant to the prmv doro of the
PQj uu..rI� ContraetOri Liceve Law(Chapter 9(wromenWgwith Sectbn700MofDiv.
k,�ol ebn3 of the Busing and Profembra Code)ortbat he is eampt therefromand SWIMMINGIIDOLELECTfuc VALUATION
a Sn.••,-ill the bub for the ahaged e.emptbn. Any vldatbn d Seebn 70115 by any �:[J
o� appeeent for a permit subjects the appheant to a eivll penalty of not more than OUIS,ETSSWITCHFSFDn IJRES /� <,jA
t � �fundredddan M. NEW RsmFNnA.r Ec RsQF STORIES TYPE ONST CU On'
7�n I,a.owner of the Property,or my employees with wage,as their sole
pe ion,will do the work,and the structure Is rot intended or offered for
p alesnot apply t-an
aandf Property
ropeCode The or imp or.Llnvelaw
don not apply loan owner dpmpemtywho does.6 woric horeself or through s owo,d.orim,provithrron,and OCC.GROUP REST Trs
cied that such
Improver mare notIhffioM arofced(orale.them ver,irksbuildingve TOTAy
improvemrnt hwld whhln orcyearofcompletbn,thewvner-bul6ierwW have
tkajZurdenof,movingthat he did sutwlldorimnprowforpurpo,eofsale.). Cry. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am eachoively contracting wBh lloeumd
ntneetoa to core
fired the project 7Dlly Business and Praf®bv Code.
PERMIT L%UANCE
a
The Contradori Lieeroe Law does nor apply to an owner d property who ��DRAIN&VEM-WATER(FA)
Wild. or imp.thermn, and who enortl
aa fee such pepjects wuh a
.MlIacter(O Bansed p.swot to the Contactor.Llh v.Law. gAp(pl,pw PROTF�t'.DEVICE FEE SUMMARY
LJ 1 am eump under Set B L P C for this Pawn
OUTSIDE
DRAINS FLOOR, SANITARY Y_ N_
S Owner Dale R RODE.AREA,GOND. RECEIPT 0
WORKMAN COMP aN5AT10N DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_
❑1 hereby affirm thatCor I have•.roost,d convent to ON thereof
ora RECm'I Y
3MLcretuloateCof.�Workeri C«npevatlanlivurannaa/anrtlffed copy thereuf0ec. GA FA,�.�-1�+0��TS PARK FEE Y N
owl 1'_lfL�e lf/`�Y77 —C_ RKEBTI'
Comm�nx�j�Q� ���� GAS EA.SYSTEM] DVERA(EA)
I ICen ifled dtpy Is hereby( mishhed. BUILDING DIVISION FEES
pwcJ rlNed ropy b filed with the City ivpenbn divhlob. GREASE/INDUSTRL WASTE INnRCEPTOR PLANCHECK FEE
CERTIRCATE OF FXIMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.I.IDOTT. Date RCCCI pN
(ITISx im,need not be completed Bthe
per h fororc hundred dollen
(51 W)or les,.! WATTR kffATER W/VQJT/ELECTR ENERGYFEE Y N
I mnify that b the perforrvnm of the work for which W.pemdt b homed,
I.hall not employ any penon in any evnner an n to become subject to the WAITR SYSTF]vl/IRFATin'G
O AWOrkaWutbWmn
CompennlAw.ofGia.Date PAID
PP
Z 0 N TICETOAPPLICANI':If,after making thisCettilleateofEumpbn, NEWRF9DENTIALPIA7B. 9�ST. Date Remi to
shculd beenm e.obFCt to the Workers'Cornprmotlon provision of the LaWr TOTAL:
~ N_ Cade.You moot/nthwlth mnply with suN prod.bv orthb pemJt.hall he �,
Q ] deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CLO Thereby filrok"fo hat lherebamvttut soed(See ,Ciforth,perform- TOTAL. ELECTRIC FEE
� Z lana of the work(orwhlch thh permftbbsred f5ec.3p9a,Civ.C.)
U O Lender—Name PLUMBING FEE
LL I— Lendee.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iadl/ythelhavenadthbappllatbn.Ms tethaltheabave in(orrmvtlm
ll hromxt.Iagreeto comply whhaBtltyard muntyordlnanmmd lat<law. PFRMITISSUANCE FEES PAID.
>. relatingtobuildingmvmarb
trecti ,."herebyauth
N reptesentative of tbb
F my to enter upon the above-menllavd property,for WperUn perrpo.ea ALTER OR ADDED MECH.
U)
(We)agree to save,irdemharmless But an d keep harmlethe Cly d Cu ni.. Date RCcel tq
V agar ilabWtln'l cis rn am vpew whiehmaybanyway.ocew AIR HANDLING UNIT(IO 10,000 CFM) SUBTOTAL:
d City In the gnntln dthls pemdl. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
O
gvture of Applira ontr.nar le miAUSF HOOD(W/DLrT) CONSTRUCTION TAX PAID:
H RDOUS MATERIALS UISCLOSUR
WBlthcappevntaht -Wildingoavp.ntm.o .,latdbha.dma HEATINGUNTT(fO100,ODOBIU) Date Reccl IN
mmaterlalns defined by he Cope A o"dFal Code,Chaper9.l,,and the
dean ye, sarery cme u,5epyoel( SoJ2p)i F7F.Inhe UNIT(OVER 1pp,00O eTu) TOTAL: Q
I�Ilitho appBnnt« tort buildingm pant use equipment or devim VENTILATION FAN(SINGLE RESID) ,15�5lU3ANCE DATE
whkhav
h emit rdm.air roodaminant.u deBrrd by the Bay Area Mr P
Qu Wy Management DM rlct, BOILER-NMP OFR'OR 1W,IXO BTU)
Y.
H}�/ MAN 2 6
4haveread calth>dfet mode,h equtremenbunder nd 2533 , I of BO CR.NMP(OVER100,000 BM 1990
the Celiforntaat Ifth kSafety Code,not rr .dyrei h ve 33 a tenant,
nan,that it
urdcnlaMOat nth,Wilding ooruoa of the
ntlyhiveateichLthat it mot NEW RESIDENTIAL MECH. SQFT.
mapovibility sato of a Ce
oaopf dthe rayuiremrcnb which mmusl be not
prior to issuance da Ce d pa Wv7 Ta3� t
3 l Qo
nermauthortuda t c ISSUEDBY:12� Oils.-I V(/��C
TOTAL:
OFFICE COPY