20629 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro I&.fifkathm p I /E. I'FJtMIT NO.
Building Addrna: /D/f 1� s, �eo (/1 JI•� Cu C/l �$a(�- 20629
( S —O 2
re . one:
^� aCITY OF CUPERTINO-BUILDINC DIVISION �iG D
c d°r•N'me: 'Lk.No. APPLICATION 1 PERMIT 6 - )- -TM Z
BUILDINGELECMCALPLIIMBINGMECHAMCAL CATEGORY CONTROL' O
Archi ed/Engineer: ./� Lk.Na
F,Ar VN i 1yk _?W BUILDING PERMIT INFO
—e�F- ----.- qm-x Q ELECTRICPERMIT FEE
Adl— yj ywzitw PFRMITISSUANCE �•pa
LICENSED CONTRACTOR'S DECLARATI N
IFereby Wlrmthal lam lbmeed under prcwWmaofChaper9(aommenc APPLIANCES-RESIDENIIAL OBD N
Ingwlth Sedbn7000)of DbrJdoo3 ofthe Bual.and Pra..imuCd.,androyA
lbemarblefullforceandeffed. PANELS
Llas rucsla _jj e.
.L{c Yt ']_ 7 /
Drte CIM IQ 2DO ANIPS
ARCHITEC'SDECLARATION 201
Z I understand my plans shall be used u public records. OV _ SQ.FT.FLOOR AREA S/SQ.FT.
OC /
t, Lbenxd Prd®lonal L 0 (1 u 7y
¢lFgu OWNER-Bl11LDER DECLARATION r r ! l
Iherebyaffirmtlatlame.emptfromthe Comm or's Lk Lwf¢the LC a.a ,l_. 0
7 9_ following re..(Section 7m IS,Bualnes and Pmf®1oro Cod,..My dty or
O/_t-� TEMP. RPOLE INSI.
K� muntywhlchPq tolap aHtomvWR,J1theaprove,dfwmchorrepalr 1 c -(-�
anynz-yatrbnrent ha he Is abensed pur than to
f¢sulumofhpethe POWER DEVICES J J ' a
O�� 6b a'gess'ehtement that he b licensed pursuant to the proWbro d the
3c, Contractor:License Law(Cpter9(commencing with Se;ten 7000)of Divi- S15rU1MING PDOL I].ECERIC
Zvi aden3 tithe Budnnaand Profs mCode)orthathebeaempthercfrom.M VALUATION
O_ the barb for the alleged eaemplbn. Any violation of Section 70115 by any 6 6 SIFT °D
<� a ppBcantforaperm bjecvtheapplkanttoadvllpen hydnut codon amJ:7'"''wITCF�SSFlXC[JRES
fir vndred ddhrs($5M. NEW RESIDENTIAL ELEC7R SQ.FT.OFEE
SIOWFS .TYPECONSIRLCTION
7�n I,a owner of the property,or my employees with wage u their wk
F mmpercilon wWdoth .e,.ndtheatru=mrcb lmerdedordfcredfar
p N p elle(Sec 7044,Buatrea and Prodmions Code:The Contractor.LI¢nse Taw
'3g dm rmt apply to an owner d property who bolds or Improves thereon,and OCC-CROUP RIS.UNITS
0. who dm»such work hmaelforthrwgh h1sownemployes,provided that such
iniprovementa arc net Intended oroffemd fm uk.If,however,thebullding or TOTAL
Improc2membsolowhhlromrarofcomplebn,t awner4b kWerwWlove
t den of proving that he,did not baud or Improve for p+rpoao of k.), Qry. PLUMBING PERMIT FLOODUINE APN
a wvnr,d the property,am eschulvely coom ding with B¢�d PERMIT ISSUANCE
contradm to mrotrod the Project(Sec 7614,Business and Profmlons Code:
The Comrador's Llaroe law doe not apply to an owner of property who ALTIIbDRAIN4 VINE-WATER EN
hull'.or Improves d
thereon,and who comrade for ouch ptojeds with a
C'MorW licensed pumrant to the Coomador:Lld,.Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
[_J I am"Crept Ural"Sec B 4 P C for thh rearm
DRAI NS FLOOR,ROOF,AREA,GOND. SAND'ARY Y— N
QIII51DE FEES
Owner Date81.4
RECEIPT
WORKMAN COMPENSATION DECLARATION Fa.NRfs PER TRAP 5p-fOOL TA% Y— N
❑I hereby affirm d msu ¢that I have•certificate neent to self-Inre, a
aml0ate d Wurken'Camperoatlmlnsunn¢era¢dills'copy th<rtof(Site RECEIPT
3800,Lb C-) / GAS FA.SYSTEM.'INCA OVD,E15 PARKFIE Y_ N
Pdky. /D6 166h GAS E.A. YSEF]dUVER4(F.1) REcarr.—
Cs nv T BUILDING DIVISION FEES
Certified copy b hereby tum a city
❑CenNed¢pybfiled with the city lropedlon division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCH�E(CK�FEE
CERTIFICATE OF FX EMPTIO.N'FROM WORKERS CRFASETRAP
COMPENSATION INSURANCE SEWERMNITARY-STORM EA 2(X)FT. Date Reuel t#
(Oita section recd n¢be completed lithe permit b forone hundred dollars
(f1001¢Im.) f wATERfWATERw/VENT/ELE`CT'R ENERGY FEE Y N (
I¢rtllythat in the perfomun¢o(thew¢kfor wtJchthbpermlthi r d,
1•hall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING �w-T�y/I S6
WorkerYCompensatlon Lawa of Cahn Date PAID it1 fV , r�
( O Z NOTICApplicant NEW RESIDENTIAL PIMB. SQI-T. Date Reeel t#
Z O NVTICETO eaubjetto the,after per of pr,lb Eaempbn,you
CC N sode,yo mme a orthwothe Worker'such probaccramthlopermite Laborbe T TOTAL: r
Cade,you runt(orthwhh comply with such pro Wbns arthfe permit shall be J Ia 1
W Q dean w revoked. SEISMIC FEE Wvllc?
CONSTRUCTION LENDING AGENCYZIherebya/firmth.t thercbamnrtrodlm krdNgagerey for the perform .TOTAL; ELECTRIC FEE
� an¢o(the workforwhkhthb permK bbsred(See 3097,Ch•.C.) t O
, 02 ]ewer.Name PLUMBING FEE
LL ~ Lew&.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
671
O W 1c rtllythat l have read thbapplbotimnaw stama
tethatthe above infortion
bmrmd.Iagrc w=ylyw aUc"ardcountyordiunm daatelawa PERMIT L'SUANCE 2x00 FEES PAID:
Nrelatingtobuldingmrotrudlm,arul herebyauthodaerepreaentatWeofthb
F. U) dty to enter upon the aboucmentbred property for Wpedbos
n purposes. ALTERORADDTOMECK Date RCCCI t#
V — (We)agree to save,bidemni/y an d keep harmlem the City d Cupertino
•phut lhbLuties,Ndgment;oosas.rd expense which may In anywayadrue AIR HANDLING UNTr(O 10,000 CFM)
age t aald City in amancl em¢of the gra ming d ova permit. SUBTOTAL:
w
AIR HANDLING IATr(OVER 10,(DOCEM) CONSTRUCTION TAX
Slgoatu,e of Appgnnt/Contrador Date DaimfSr 1I0013(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
'1 Willtheapphcam mfuturc building ocapant.torc or hawk hazard.. / HEATING UNTT(TO IMODOBTLI) Date RecCi t#
+ «ulcrialas dWrud by the Cupertlw Municipal Cade,Chapter 9.1Z andthe
He.hh and Sa(dy Code Sedlon 75971(xNI
)7 HEATING UT(OVER 1(10,1100 BTU) TOTAL.,
❑ Y. No
WW the appllcard or neWilding occupant use equlpmed¢devkea VENTILATION FAN(SWGLE RESID) ISSUANCE DATE O��
which endt Fara rdous air contaminants as defined by the Bay Area Air
hty Manageent Ow ict7 ROILER�MP OFN OR IOQO(DU
RT ^l
• Yn ❑� I No 1D
.have read mthe havnTou.matedab rcqubemenh under Chapter G95 of �'!BOILER-COMP(OVpI t00,fK10 Bill)
theerWornhatIfIf the
h&4din Cade.Sectloro755 have
a tenant,
N^y,
.p.retbuityunderattand i,otifbuied pmwtherequi mer.tenant,thatitbmy NEWRESIDINTIALMECIi SQFT. [! 91990
raponsbWty to ndBy the oavpam d the reyulrcments whkh must be net vs7 V
pdmr to leases¢ aCertiOate ofOmrpauy. / O
Ownerorawh cid agent
TOTAL a O
OFFICE COPY