23795 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuMin Project identfiation ' PE MITNO. 1
f Bulldir,g Address: &
Ilf 3 G- =%:Is c't�cls E � �L rC'3 23795
¢ one: A=CA'iiON SUHIMII IAL DAm
gf,lhprL. JLIG Nv. CITY OF CUPERTINO-BUILDING DIVISION
Cm'traeor'e Name; APPLICATION / PERMIT l9'-lLr"l
V'Q' /Kn BUR.DING-E DCTRTCALPLUMBING- EC NICAL CATEGORY C
Ited/Englraer. IJG No:
�� "` I 2-y QTY ELECTRIC PERMIT I'EE BUILDING PERMIT INFO
Tnd4.SC) PFRIATISSUANCE
LICENSEDCONTRAC1`0R5 DECLA TION
I hcmbyaBlrm flat l am licensed under pmvW«aof Chapter9(arnmenc APPLIANCESREEDENITAL pBD N
I.le;Ikon forean DlWect. Ne Butlreseandlhofe®IoneCode,and
ory Manx b In n force and R,a PANES .
Lloeue Claw LIG1
Dale Contndor
ARCHHECTS DECLARATIONOVER 1AMP'
q�q�uu nOit
z ]urdershrd my phroehaBhe used wpubllcrtmrds 000 AMPS- SQ.F^f.FLOOR AREA $/SQ.FI.
!i o� Licensed Profenbral SIGNSELECTRICAI . O
1-Q,, OWNER-BUILDER DECLARATION
Pathe SPECIAL CIRCUIT 111 J
Z O' a Thereby afRrmtFatlameaemptfromtfa Corrcnnor'elfoerue law (t
(S -
Z qqqq following maeon. emon 70115hsmi
,BuseaProfewloes Code:My dty or
vy muntywhkhrequb apem tomsbud,Otenimpm ,demo h,ormpsir TZ1W _
< anyst Mmpdortolla arc,alearequBn eappBrant/«such p,
rmdto CIS
O O 04 a signed statement than he b horsed pursuant to the provb In.of the
ww{{�� Contract/.L.Icerae Law(C apter9(mmmencingwithSedbn70W)ofDIW-
F,3oJ sion3ofthe Buslnew andP mfe Code)orNsihebeaempt NeremmaM Lfl.ECIRIC VALUATION
.•33 the buts far Ne al4ged eaemptbn. My Wolatlon of Sedbn 70115 bj any O Swt.IrF)FSED,T,MU, 1
applicant for.permit subjects theapplicant to.civil penalty al not mortthan �� l
O. flue Farlandadlue .
I,as ownNEWRESIDENTIALELECTR SQFT. `STORIES TYPECONSIRUCFION
�n ❑ owner of the
pr.property,or my employes with ended u their door
1-. mmpera dlon,700 Bo1l do iocthewwkanathewude:The
ormmed for
Law '
4 p6 n4 CSapply to an owner
df property Cade:The CoManora uarae law
dmnotapply tock 11 ofpropertywho WRds or ploy ,ovdted that
�S^
who dce.such wohhlmxU«thrwgh wownemplgees,provided that such OCC.GROUT' RFS UNITS
Improvements art not Intended oroHcred for.ale.If,however,the building or
improvement bald within oneyearofcom Idbn,theowner-bullderwBl have
tl�-+urdenofprovingthathedldrotbuBorimprosef«purposeotsale.). QTY. PLUMBING,PERMIT FEE
I I L u owner of the Property,am esswNcly ox�trxYing with Iberued HOOD TONE APN
mntradon to mrWrun the project(Sm 7044,BuaNewaMPdewbu e: PERMIT ISSUANCE
The Cordndor.Llarm Law don not apply to an owmer d property who ALTER-DRAIN k VENT WATER(FA)
builds or Imp.Neca
on, d who mrmadn f«..ch p5ojecL wd - -
h a -
�VL1�de(d Bceneed posuant to the Contndo:.Llan.Law. BACK How PROTECT.DEVICE FEE SUMMARY
L,J 1 im eumpt urdcr Sec B &P C for Nb reason
. Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECID'f
❑1 hereby•/llrtn that I have a certificate of cansnt to xB-Nesrt,«a EXTl1RES l'FR TRAP SCiBOIX.TAX Y_ N
. •oert PARK
RECEIPT
fWorker'CompeuatlonluuruaoraanBled ropy thrrmftsec. — N
' 3800.Lb LsbCCO GAS EA.SYSIT]d-t INC-4 0VILE15 FEE Y_ N_
policy
If GAS F.A.SYSTEM-O E 4 CIA) RECEPT I
y BUILDING DIVISI FEF9
Cedltied ropy is hereby furnished. GREASE/INDUSIRL WASTE IN]l]GII"IOR PLANCHCC E
CeNtleO mpyb(fled wlN the city lnpedlori division.- 1[ I
I CERTIFICATE OF EXEMPTION FROM WORKERS' CREAM TRAP PAI V /y.
COMPENSATION INSURANCE S4 co
(hlseedlan need not becompleted Bthe permit leforom hundreddouars SEWER-SANRARY-SHAM EA.W)FI. 07
Recel !N
�.' (9100)arlesJ WATER HEATER W/VENT/ELECTR EN FEE _-
I ll not employ
anyhe pcoroo in of the weaneer forwto bon pertNt is to the
(5q
I stall not empty uy peroan In any manner w u m bemma subject to the WA1TR SYSTEM/TREATING `i
w«ken'compeuatbnLawx err Cabromla.Date PAID
= Applicant NEW RESIDENTIAL PLMB.' SQFI. Date Reoei tN
Z 2 NOTICE TO APPLICANT:If,after making this Certificate of EumpOan,you .
should become subject to the Workcri Corr motion provisions ofthe Labor TA
~ N
Code,you moat forthwith comply with such provisions or this pertNt shall be
Wj deemed revoked. L
DFNQ 11CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.Ulan that there b a mralrudlm LendNg agency for the perform ELECTRIC FEE
Z ance of Ne work for which this permit b beued lSee 30Za,CN.C.) T
Q0 IcMcr.N. - - PLUMBING FEE '.
IL - Lender.Addreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1om fythvd
at I love mad tate that the,.bove,befornaRon
bmrrtd.LagrtetocomplywhWdlyaMd ntyord n¢s dAatelaws PERMIT ISSUANCE FEES PAID
I,r N relating tobullding construction,and herebyauthertre repnncntattvn oftw
Z cityto enter upon the abov rmntbnbpurposes.
rad property for bupen ALTERORADDTOMEM.' Dale Recei tH
(We).gree to sale,Wem fy.n d keep ha m the City of Cupertino
V agaWtllabBltb,judgmerda,men and nperan which mayN any wayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
d aga fret said City in mn.eqoi ens of the grant ing of Ni.permit.
i,, ALZ L-IAErDI.I,NC UNIT(OVER 10,000CE10 CONSTRUCTION TAX
Sigtaturtof Apphant/Contrador Date EXI IA HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE O/
WIRthe.ppli Mr fuWmWldingoccupantetomorMndkha dour I-EATINGUNIT(TO1W,000BT'U) Date RCCCI f)t
I materLd.,cleRrud bythe diro MuNdpal Code,Ch.pter9.11,ud the
f - I Icahn and Safrty Ion 25532(x)7 HEATING UNIT(OVER 100,000 BTU)
RiftYn NO
iftthe appBn tore bulldingoavpent use ryuiprrcnt ordevbs VENTRATIONFAN(SINGLE RE-%D) ISSUANCE DATE
whichemithavrdw ism 'mivrR...de0ned by the Bay Arca Ah,
Quality Mewgemer ast 7 BOILER-COMP OI-N OR I DO,"BTU)
F Yd No PAID
F 1have read then .matedw req.irerrcnts u nder Cha pter 6.95 of MOILER-COMP(OVEt 100,030 BTU) d 1 D
the Califoenla Heabb&Safety ode,Sections 15505,5533 and 2-56M. I
understand that if the buBdl don Trot mrrent haveatevnL that itbmy NEVJ RESIDFNTIALMECH. SQ-Fr.
'July ((a� '/
rcaporalbBdy to ratify Ne pard o[the mentswhichnr.tbemet N "' 8 19. 4
per a Cc to
CITY o
nt Date TAL; ISSUEDBY: -i RSV
kOFFICE COPY