21979 .■rPL"ICANTTO ELL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Mottling Pnmldendfkaam P1MWTNO.
euOdWg naareer 6 21979
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CITY OF CUPERTINO-BUILDING DIVISION
Caomachm'• eoe: Ue.N. APPLICATION /PERMIT
Amhltea/&;sneer. Lk.Na BUTTE ELECTRICALPLIIMBINGMECHAMCAL CATEGORY CONTROL/
- ;
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: LICENSED OR5 DECLARATION TION
IERNUTISSUANCE ❑ O
El
I harebyeffiron tUmmi under provisionsCiup4r9(aor APPLIANCES-RESIDENTIAL
ngwthdlo-7DDD).fDi .3aftbeBuvndPmfsaCendrrTy 109 DESCRIPTION
Iane I,In b roe andeffen.LDlaooe PANELS
Ca LeYhCordra22J/ G
1
ARCHITEO'S MCIARATION -
�QZ IuMendand my plamahae beuaed as pubk mound• OVE210DDAMPS SQ.IT.FLOOR AREA $/SQ.FT.
�j LI¢rved Prdemlume SIGNSELECTRICAL
OWNER-BUIIDER DECLARATION SPECIALCDICIII'T'/MESO
Ibertbya0rm that l am exempt fon the Coorenorb Untrue Law for the
p p following;reason.5adlm 7015,luWer aM Profaaeum Cods Any tltyor
FZf'q muntywhkArequ4 apemJttooratruct,alter provsdemolbhormpalr TQ'IRMEI'FRORPOLEWSI'.
�`'0 7 any atruaurt fuel tolbhwrce,abrtdpursuant to antfa anions I t e POWER DEVICES
6 file a tlgned.btement that M b If¢nsed pursuant b the pmdalom of the
Q� Cormetor'aLkerue law(Chapm,5(commendng withSedlon7000).fmvi- `
g, orj don3 of the Buenees and Pd
mfeaabn Code)or the b •exempt themfmm andgWBgQBNG POOL ELECTRIC VALUA ON
the Ivab for the alleged exemplm My violation of Bastion 7015 by any D�S�.TC}DS-FIXTURES ^� 0�
apphantfor.pemdt subjeds theaspliant toe civil perahy,of not mom bet i
o Eve hundred dollars MWS. NEW RESIDENTIAL ELECTR SQFI. STORES TYPECONSTRIICTION
n1,as owner of the property,a my employm with wages as their sok
compenrBm,wit do the work and the structure b rot intended or offered for
� p
sale e'.7D34,Bualnm and Prdeaabro Code:The C.otnd.rs Umme law
�dr$ daemapplytoa ..(pmpceywbbWWorlmpmvathertosand OCC.GROIN RES.UNITS
0. whadom•uchworkhim lforth.thi..w .,pl y.,p.Wl that•uch
Impmvem,nte are not Intended orofkred forsale.If,however,the building m TOTAL
'Innprovementhsoldw hlnomyeardaomplebsih owner-buMerw Uhave
tl),I,iurdenofprovingthathedld nmtbuildorimproo,forpurposeofsale.). QTY. PLUMBING PERMIT FEE
LII,ae owner of the property,an exhtewty contracting with Ikmaed FLOOD ZONE M�
oonme,tme to coatrod the proJM(Se.7DK Bushes aM Pof.ions Cad,. PERMIT ISSUANCE
The Contractor's I.laroe Law does M apply to an owner of property who
lou Ude or Improves thereon,and wlo mNraN for ouch pp"with aALTER"DRAIN&VFM-WATER(EM
coN7edon(.A lu ensed pursuant to the Cmtndurs Llrtroe law. FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason RACK FLOW PROTECT.DEVICE.
Owner Dns
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT g
WOR)OVIANm,the COMP WSATION DECLARATION FD(TURFS PER.TRAP SCid TAX Y_ N_
` I hereby affirm the 1 have•¢ooraro of anent to o y theroo,(S
certlEole o/Workers'CornpewtlonTorrance ma certified copy thrrenf(Sec. RECEIPT N
3300,Tab CJ /• 2 CAS EA.5YSIYM-1 INCA OUTLETS PARK F'F£ Y_ N_
Iblkyl_�1��t0 y�I BUILDING
GAS EA.SYS7Eki-0VER 4(FA)
IPT If
Com BUILI31NG O1 VISION FITSGE� '
�eaniflad mpyb Certified copy it;filed withh the
hertbytGREASE/IN)USIRL WASTE INTERCEPTOR PLANCHECK FEE
he city
Impectlon dlvlelm.
tlty
CERTIFICATE OF U DY[PTIDN FROM WORKERS' GREASE TRAP PAID
COMPENSATION NSURAE
(hlsVlonndfidbclefft ebfooe hundd dollenSEWFR-SANTI7ARY-STORMEA 20() Date - RM'2t#
x100
I certify the
t.)bn In the performance of the weekh WATER HEATER W/VENT/E.E TR ENERGY FEE Y_ N_for wldch tFla permit issued, .
I.h U not employ any person In any mons,so as to bemrre subpet to the WATER SYSTEM/TREATING
Workers'Cornpensauonlawsof Cold h.Date PAID
O Z Appliargt NEW RESIDEV'nAL I'LMB. SOFT'. Date Rcoel Ik
Z NOTICE TO APPLICANT:If,after making this CcrtUlate of Eou
xempon,y
should becomeaub)ect to the Workers'Conpenutbn prov ..of the Labor TOTAL:
CC N Code,you mue forthwith mmplywith and pro,ialum or this permit shall be
W ' deemed revoked.
BUILDING FEE
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmib
tt there b mm&M
a mtroatling agerary for the perform ELECTRIC FEE
Z ante of the work I.,whkh Nb pemdt 6 lsared(5ee JOT/,Cl,CO TOTAL:
O O E<Mer'.Name - PLUMBING FEE
LL ~ L..Mee.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Inert vy that l have read this application and Bate the the above Information
4 hconea.lagroatoeomplywhhaUdty.Mcountyordlnanmand"t.law. PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authotive mpnnxnbwn ofthb
I— Z dry to enter upon the abov orantbrcd property for Wpealon purpom. ALTERORADDTOMECH.
(We)agree to sae:,Indemnify an d keep harmleas the City of Go pertlno Date Recd t#
V
against fielit4e,Irdgmens,"a aMapeamwhkh may In any way aaaue AIR HANDLING UNIT DO 10,0D0 CFK4) SUBTOTAL:
agaWtsald yin mw arm of the tinning d thla permit.
/`//il— AIR HANDi1NG UNIT(OVER lo,ODocFln CONSTRUCTIONTAX
7i i -'19-9 CONSTRUCTION TAX PAID:
HAZA
SlgraAt�irL fA' IoDate FXFIAU57 HOOD(W/DUCT,
AUROOUSOUS MATERIALS DISCLOSURE
WWthe appllarat afutta no eGoperundbg.aupantu.reorhaMkhavndous HEATING[IN17(TD 100,000 BTfp Dale Recei tq
Rea Itha r defircd by the Cupertlm Mu Ntlpal CMe,Chapter 9.1j and the
Health and SafMyC Ire]553IWt HEATING UNIT(OVER 100,600 BTU). TOTAL:
Y. Na
�1h enot eppUaru air
tum Wlnam oa efined•y the Bay Area
vFrrnLnnoN FAN SINGLE Rem) ISSUANCE DATE
hichemitlurorent airrini? NsudeTinged by the Ray Arta Air
yhbwgcmMDbtrid7 BO ERCOWO}RORt00.IXUBTU
,•i mad the h &Seel,Code, la.2553, under Chapter of vOILCIt-COMP(OVEt10,000 BTU)jdi'l [7
. andhHealth&SafetyCods SLabr 7tlyhvcatcnantt�3 and 54. I fHAR 2 •� 1a7aa1
a.TeistaM thio no'ebu Uding dm of the enfrementa hJ& that itbmy NEW RESIDENTIAL IvIECH 9QFT
porolbl to
acovpant.(the rayulremenb which r�ustMrrct I '
pnmt an Certlfkatc ofOmrpany. //rr��asaa
g � � � /
Of
nor autho agent Date 7 TOTAL ISSUED BYI\,
OFFICE COPY