19888 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification I'kRh11T NO.
Build initt, FOR46c- Mvpl 19888
re
n�
ncare: Cp Za5 . CITYOFCUPERTINO-BUILDING DIVISION
Contrsmor.N.are: — Lie.No: APPLICATION / PERMIT 3 —( 6 —?0
BLURINGdECnUCA4PLIIMBINGMECFIAMCAL CATEGORY C
ArdiNea/EnBlnav �/ Lk..NL
�'�9 RQTY ELECTRIC PERMIT FE BUILDING PERMIT INFO
PERMITISSUANCE ❑ ❑ ❑
RAT O
I herebyafllren thatlam llcrneeduMeprwWonsafChapter9(mmmec APPIlANCFSFffSIDEMTAL JOB DESCRETION
ingwlth Seabn 7000)of DW1,dno3 ofthe Businenand PmfeWtu Code,and my
Lieenss in fam lClasa lfort wd ,,# PANELS 1'r�\�l�e/' 11/CA�.ar a
Daft Clan Lk.Y •G�n�a� `a'✓r��(/��j
DaftComnmor —UP TO 2DOAMPS
ARCHITECT'S DECLARATION 201-I000AMPS-
�2. I rd faro• I e d bit rrmrds OVFRI000AMPS SQ.FT.FLOOR AREA $/9Q.FT.
e
Ween Profembro � SIGNS FJJL'IRICAL
�<
OWNER-BUILDER.rILDER DECLARATION SPECIALCRCUIT
F, owing afBrLast.(Sntia70315, drums a Comfessiolkeue Law fee the
'r 416 following reason.(Sects pe7 t,Business and Professions a Code An tl or
10/ Y tY TFMP.MET�20 LE IN ,
Cy .uyty khra toiapemJct aLioruct,alttheaphvntfmolL&per oro '
�S any atm¢ure pater ent that
kesuant t the frcwlons of It a POWER DEVICES
� Bk a signed statement thrt k b B�.ed pursuant m the proNnbro of the
O�pf^ ContMor'a Lkenx Law(Chapter 9(mmmendng with SeNon 700))of Divi- NG� L CM
don3ofthe Buslneuand Paa(e»broCade)orthat hebeae therefwmard VALUATION
the huts for the alleged earmptlon. Any violation of SMb 7mis by any SWI
*too coo
�^ applicant fora pnmdtsubjectstheappllcanttoatlWl pevH 121.etko
R4 ave hundred dollars(S.M. N R61D SQJ+F. SIOWFS TYPE CONSTRUCfK)N
�n ❑I,uowncroftkpmperty,ormyemployee hwage utkk wk
t c mpensatlon,wul do the werk.and the structure Is not, eMed or offered for 1 nqy
5 � axle 6r'c-7D34,Bwbessarta Pmfeaabro Codr.Tk Comnmers Llaroe Lw { V N p
�$ don not apply to u owner of property who builds or improve thereon,and OCC.GRnOUP RFS UNITS
whodmwchworkhlmeeStthrurghhlaowne.If,h u,Prwbe build Bch 6� v
impmvemrm is so not intended
omyearofoom for orale.theownvegthe bulldin w iQfAL:
or
knpmvemem pm gtwithlt hedid rofcernparim rowforpurpderw111have
p trytynraen weer of the Pro ert ,ai rs,Baertmy cosmut[ng with lJor se QrY. LUM INC PERMIT FEE
(, LJ I,os owner tr the Property,( 7DK Buai mnVacting with is Codd E FLOOD ZONE APN
TheconCo ova to mrolru¢the project(Sec 7 apply t an owner
Pf prop rt Code:
The s or impmeror'D Esther saw doe not apply ct an owner of property who ALTER-DRAIN&VENT-WATER MA)
Wilds or Impme thawR and who mmnN for wch p(ojeas with
oq➢t(�ctt(.)Ilmnsed pursuant to the Contraaora Lken.e Law. FEE SUMMARY
LJ 1 am exempt uMer Sec B&P C !or tn6 reason BACK FLOW PROTECT.DLYICE
DRAINS FLOOR,ROOF,AREA,ODND. SANITARY Y N_
Owner Date /
WORKMAN COMPENSATION DECLARATION FA"Il1RES PER L7tA1' SCJ{ODE TAX Y��N, 'J
QI hereby,slfirm that I hart a trtillrote of consent to self-Usure,a a RECEEIPI,s
tnlfiateof Wor Comperort I mutaramAifkdmpythn flee, GAS EA.SYSEEM-1 NC.4 OUTLETS PARK FEE Y N
3800,Lab C.)
policya GAS FA.SYSEEM-OVER A(EA)
Coma ny BUILDING DIVISION FEES
I ICertlfled copy is herebyfhthekd. CREASE/INDUSRL WASTE INTERCEPTOR PLANCHBCKFEE 207 l
CenBled copy,V filed with the city IropMbn division. �(, Z P
CERTIFICATE OP"I-MPE]ON FROM WORKERS' GREASETRAP PAID3-16—`CD SI-f
COMPENSATION INSURANCE
thepemdt V(or orehundred dollus SEWER SANITARY-STORM EA.200FT. Date Recel 11l
(Ihlssenbn neN eat be completed B
($103)or leW ENERGY FEE Y_ N_ d,ed
I eurtlfy that in the perfomunee of thework for which thl.permit b WATER I-IFATFR w/VENT/p.CcrR issued, !e
le U not empby any person In any manner w u to become wbjea to the WATER SYSTEM/TREATING
worsen Comperoatlon Law.of California.Date PAID` ibq()
Z 0
NOTICE APPLICANT:IL after making this Certificate of Exemption,you
NEW RESIDENTIAL PLMB. 9QFT. Date Remi 1N
H N should berm wbjet to the Wmi,,ra'Comp,.tlunmbro pvlaof the labor TOTAL: W •7
Code,you mast forthwith comply with well,provbbro or this permit shall he
W > deemed revoked. 2UILDINC FEE SO
aF3 CONSTRUCTION LENDING AGENCY SEISMIC FEE ' . DO
I herebyarfirm that there Is a commotion krding agency for the perform, TorA� ELECTRIC FEE
7 Z ant of the work for whkh this permit h trued(Sec.30 Y/,Civ.C)
00 lender.Name PLUMBING FEE
LL F Lemite Aaaresa QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
W I nntfythat l have read this appBcatbnard state that theabow lnformadm
6eorreet.I agreebeomptywuh all tltyaid county ordlnatmand statelaws PFRMTEISSUANCE FEES PAID:
} N Mating tobullding corotrunlon,ami hereby authociae representative ofth Ls
F Z city to enter upon the above.ar�mmned property for lrepeabn purposes. ALTERORADDTOMECH. —Date Reed NI
— (We)agree to cave,Wm
eNfy an el Pem Peep hsrmithe City of Cupertino AIR I1ANDllNC UNIT
against[liabilities, coh m
,)udgmentgetssod aperseawhitayin wyw.y..e (TO 10,000 CFM) SUBTOTAL:
against said City In mmseguent of the S.ming of this permit.
AIR HANDLING UNIT(OVER Ia,o33CFM) CONSTRUCTION TAX
Slg.mruof AppBcant/Contrxlor Date OUI LTSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplleam or future building eavpart start or haadk havrdous HEATING UNIT(TO 100,000 BLU) Date Recd HI
material as defined by the Cupertlm Mumdpal Codc,Chapter 9.1;and the
Health and Safety Co i!,healon 2S32(a)7 DATING UNIT(OVER 100,000 BTTJ) TOTAL: I
Rill
l TOTAL-
Yes Mj No
IBmt appilont&r contawldmgo¢Vpand by the equipmera Area devim VENTILATION FAN(SINGLE RESTD) ..SI$$Ij/{NCE DATE
whkh emit havbous air eonlamW nor.a defined by the Bay Area Air to
Qua10.y Marogemem7 BODER-COMP OEB'Oft 100,000 B'R)
4nYn No CdA
.ifem.dmen anularlateequlremenbR&33an 255M..95of BO GACOMP(OVR1m,000BT Y 1 5199U
the011lMt Heath&SafetyCode,Satlbrontlyhveatand t5 tis
undewrdy to noise WOdingdoe no the quiyhave.taunt that it met NEW RESIDENTIAL MECH. SQFf.
responsibility to notify the occupant ee the reyulmments which must be met
pante ce,n,lrll!ateeo''roa-„parKy. L p CIS Ot Ptl,rr}inp
Preen authodsd agent UDate ISSUED BY:FPOJ WJ'c uc,L
TOTAL:
OFFICE COPY