20468 I� APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idendfinatlon PETthOT NO.
Building Address:
& 20468
�� r �—
eme: one: .
c H AR F CITY OFCUPERTINO BUILDING DIVISION /� c 2 ct CNS
Contrctor,Name: Lin.N. APPLICATION / PERMIT !_
BUILDINGELECIBICALPLUMBINC-MECHANKAL CATEGORY CON"IFOI.a
ed/Engtruem lk No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
sane,. Sl�RA70G'R•-$'u(yq/7 (,�: S'r PERMIT ISSUANCE ❑
LICENSED CONTRACTOR-9 DECLARATION
l hereby aH4mthat l amlkmsed under pmvwnuof Chaper9(commeuc APPLLkNCESRES[DENTIAL pg�9 ION
Ingwth Secilon7C=of DlWslon3ofthe Bue and Pmfes Codgand
Ibemebinfullforeeandeffectp PANELS
Lkenx Clamp-74LkY 2 L/'�Z03
Date - CoNndor a U
ARCHITECTS DECLARATION 101-1000AM
7. lundeiabrd my plans shall be used a public record. OVERIWOAMPS SQ.FL ELOOR AREA S/SQ.FT.
O[ SELBCIRICAL
k U Lkcaed Pdembal s
<<�nC,�abet OWNER-BUILDER DECLARATION LCIRCUI.I./ML`X
7 I hereby affirm that l am exempt froan the Contractor's Luemelaw fa the
6,C�F^ (olbwing rtawn.6ea1m 7015,BusNae and Profmbru Cade:Anydtyor Tp,�METERORPOLEINST. -
F 47� mu my whkA requlm a permit tecomrud,alter,lmpmve,demouah,brrepalr 11 �
���6 anymm=mpdmtola.- me,.bomguirestheappbo tfwr ch pemdt to � DEVICFS{4-nn
E- U file a Ngned statement that k b Ummed punuant to the p }}loru•o(.tla
Ou. Contractor's LlcerueLaw(Chapter 9(mnmenclng with 5eNvtT70W)�of lRvl- y}y�MNd�=CpglC
bn3of the Bu,lnemCede)NdtahoEeobermertfmaed
VALUATION
ldPxrcAny,
N WWthe bub for the; MI
SeCbn 7m15 by any pUp{,FIsS1VI.ICFQSFlXCIIRES
applinant for a permit subjects the m
i tivil penalty a not mom than
E fav hundred ddWe(kCOPr. ` n NEW RESIDENTIAL ELECIR SQFT.
1,aowner ofThe property,- eny rnpbyeeswtthwagetr
sasthnwle STOWES TYPECONSTRUCTION
mmpernatlon,will do the wc4i,and thee,lruaur,is next Wended or dfered for
$ D sale e&,7041,Buslnm an Profeesbns Code:The Contracto%s Liame,Law .
(# does not apply to an owner of property who bulldi or improve+thenen,
�$^ who done such work himself ce through his Aremplcyees,provided that
w OCC.GROUP .RFS TINCTS
Improvemerman not intended oroffemd'for sale.If,however,the building � TOTAL
impmver MbaaldwhlnorerarofcnmplMt ,theownebu/Id-r willhav
L1y.'.?urdenof proving thathe did iwbu8d.rlmpmve:, ofaile.). QTY. PLUMBING PERMIT FEE
LJ L a owner of the property,,m es bud lily c�nt g wkh IbrnnM FLOOD TONE AI'IJ
mnmacton to mnstroe the project(Site 7044,Bush ember Code: PERMIT L6UANCE
The Contnctors I.Ire�law den nes apply to an own of property who M�-DRAIN k WATER(F�
Wild. r Impr thereon,and who mMreee for such ptopets with a -
'qa1r_`tmW Ilansed pit n,umt m the Contndnra Lineme Law. FEE SUMMARY
U I,m e:rmp order Sec B 4 P C for thea reawn BACK FLOW PROTECT.DEVICE OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,ODND. SANITARY 'Y_ N_
,\
Owner Dale RECFII'I'a
WORKMAN
mthat COMPENSATION DECLARATION FDCfUfaFS PER.CRAP Z2, _
ty�yll hereby affirm that I have•artlfican of consent to self-Irwrrt,m a Sp I00L TA% Y N
tt afleofWoricers'Compvwtion Iruunn¢ora ce"ied copy thereoftSee. RFGI]PI
3800,Lb G) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Copolicy
ay GAS E.A. OVER4(EA) BUILDING DIV
lswN Fes
CMNed
entry b hereby h tfJ,hed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified entry b rueed s with he nity lapectbn al.•won.
CERTIFICATE OF EXEMPITON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-cSANIpARY-STORM EA 2XFT. Date Recei t#
(TMs sedbn need nes be completed If the permit b forom hundred dollars
(f1DD)mlem.) WATER HEATER W/VENT/ELCTR ENERGY FEE Y_ N
Trent hat in employ
performanceof the work for which this stabled to
Wm1u not employ any person In any manner at a to bemrre wbject to the WATER SYS EM/TREATING
Wmkeni Compens,tbn Love of GlBomla.Date PAID
O Z Applicant NEWR sImN LaLPLMB. SQFC. Date Recei t#
Z O NOTICE TO APPLICAM:R,ftemaking this Certificate of Evempttm,you
should bemme wbject to the Worker'Cumpematlon provbbns of the Labor TOTAL:
~ fA Cade,you must forthwith mmply with such provisions."this permit shall be
LU O deemed revoked. BUILDING
CL CONSTROCTION LENDING AGENCY SEISMIC FEE
I hembya(flrm that then b a mvtrudlen lending agency for the perfomf ELECTRIC FEE
UO �m of the<edr.N�rkfor which this permit b issued elec 3(W,CN.C.) TOTAL: 3Y PLUMBING FEE
LL F LeMer,Addnn, QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1rnttByt elhavemadtN applleatbnandeatethattheabeve Nfomutlon
bmnccc. PERMIT ISSUANCE FEES PAID:
W relating to building mvlrudion,and hereby authorioel
e reprentzofthis
N dty to enterupm the above-nambrcd Property for Impabn purpose. ALTFRORADDTOMECH.
Z (We)agree to cave,Indemnify an d keep harmlem the City of Cupertino Date ReceJ t#
V agairot liabilities,Pdgnems,mesad evpemes which may In anywnya.n - AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: ct9
againstidCltfthe
yin prrmd.
-2 5--9d ARC I-uNDunc invrr(OVER lo,oaacFM) CONSTRUCTION TAX
Sigamm of Applinnt/Contractor Date / E(HAUSr HOOD(W/DUCD CONSTRUCI70N TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappbcant or future building oavpart mere or handle hanmlous HEATING UNIT(TO t 00,000 BTU) pate RCCeI t#
material as defined by the Cupertino Mu mctpaI Code,Chapter 9.1 Z and the
Health and Safety Code Scaflon 25537p)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
Ye No
Ill the appllomm turtbuilding occupant use equipment or dcv es VENTI LATION FAN(SINGLE RESID) - 1 MANCE DATE
which emit Mots air coma MV Mae.deft red by the Bay Arca Nr OCT u
I Qua llty Ma agement DWrict7 BOIU. CDMP QHP OR I KOM BTU) J �(3Qo
1 Ye F�Na v
Tuve read the Et>vr�ous materials requirement,under Chapter 6.95 of BOB.FR-COMP(OVFR 100,0008TU)the California Health k Safety Code,Sectlons 75505,75533 and 25534.1
urdeaaa does that lithe building donot currently have a tenant,that It h my NEW RESIDENTIAL MECIL SQ.FT. rQf
retporulblllty to notify the ocapam of the requbem ertc which rust be net
prim
7tgt"p/ cd Ipove
te ofoc =y.
Owneraauthm .gnrt � ZDoti 'TOTAL ISSUED BY:
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OFFICE COPY