19644 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildim Pro'M Identlfintian pIXM1BT NO.
Building Addr.: 19644
1` � , 1�
rcr. sone:
4&
�YL-ft&jT C1/C/' 3— 3 CITY OFCUPERTINO-BUILDING DIVISION
as RL a �+0�r ! ?7 �j68N9L APPLICATION / PERMIT c� RZ�I�
BUILDING ELECTRICAL-PURABINGMCHCI ANICAL
A Nee/Fspgr��er. 1��
``* CO
0 ` SI QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmss,' jq_ ,W Jy C4 PERhA TISSUANCEy�/ � ❑
LICENSED CONTRACTORS DECLARATION X' E-1 El
Ibereby affirm that 1 en 11cenaed under provisions of Chapter 9(commm< APPLIANCFSRFSIDENTIAL JOB N `
I Ing with Seclon7D)0)ofDld>fm 3ofthe Buslnessand Pmf.ImsCode,and ION
��U U
11¢11 I In full f and dfect. �I-/ � PANFIS
Lkxn CI �Llc/ V-----jAM ' -
Date Lic,0.Contror
ARUP TO 2DOAMPS
CHITECPS D C TION -1 AMT'S
1 pp�ww7Z ]undamtand my plans shall be used as public records OVER IODO AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
Licerue,d Professions SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFCIALCBiCUR/MLSC
X, IhertbyafBrm that!am exempt frumthe Contractors License lawferthe
7.9 following reason.5octlon 70315,Business and Profeebm Code:Any city or
O G 9q TEN[P.METEROR POLE INST. .
anystm mpm to pemme,am buMilliheapawe,demohah, er to
Q any alsucturt tatemelts the he 6atcenseddreslheappother forwchperfNt a POWER DEVICE
V Bb s signed ummurLa that he b r 9(co d encong t on the pm 70DO) d the
Contnciors lJcemelaw(Cha 9(mmnrncln wMSectbn7D00)afDlvl-
re" alon3oflhe Buelneaand Prd�nsCode)orthai'heb ettmptthertfromaM SWM.MPNG IDOL ELECTRIC VALUATION ;T
the bags for the eleged exernours. Any vlda0on of Section 7(1315 by any { -,A
/D
applleantfor•pemntt.ubfacbthe appBrantto•ciWl peakydna more than OUTLEISSN77C Fl (p G(fa' (.l
fiv hundreddofi es(S500).
r $ N I,as owror of the property,or my employees with wages as their oris NEW 2bSID EL i TYPE CONSTRICTION'
eumpematlon,wthdotle work,and the structure b rot Wended or offend(or
�' o s,ld(son.7ON,a,.ir�esa and I4of.bm code:T1s Camneor.u¢nse law R
$$ dh.d apply ,kho if pth. hM, eWl.y.,p.W,dth.t and SCC.GRO R}S.UNTEi
W po a wchworkhlmtmdedhroffe �ow le.l hove move dthatwer `J
improve. M are riot Intendedorr&cc f¢sa4.t however, Mer WIngor DATE
I Improverrcnt bsoW wlthtn oroyardcomplelWMthe awnerbullderwW lure
tljtp+rdenofpmvingthx he dM not Wild or Improve for purproeof.ak.). QTY, PLUMBING PERMIT FEE
LI I,as unseen of the property,am e.hod eiy—11-8 With IbemM FT-ODD ZONE APN
mntmclors to coneua the project(Sm 7DN,Busln.and Profmbns Code: PERMIT LSbUANCE
The Com id.e.Lloene law dues not apply to an owner of property who ALTER-DRAIN k VENT WATER ISM
or Improve thereon,and who common for such pSote.with a
c7➢t(aaor(s)Beemed purewnt to the Contraad.Ll¢ve Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_J I am exempt under Sec B k P C for thin neon
DRAINS-FLOOR, OUTSI DE FEES
FDR ROOF,AREA,CONE). SANITARY Y_ N—
RECEIPT Dns RECEBT.
WORK MAN COMPENSATION DECLARATION FIX.NRFS PER TRAP SCHOOLTAX Y_ N_
❑I hereby aRlrm that I have•mobficate of convent to opythemo ora RECEIPT a
380D.AfiLaleofWorkere,C�m`npemallmisunnm as¢rteled mpythereof(Sec. GAS EA.SYSTEM-1 WGIOLTILEIS PARKFEE Y N
38]0,Tab CJ Pos,�3?/oZ RECE7Pro
Pdky s
IT.y GAS EA.SYSIFM-0VER4(EA) BUILDING DIVISION FEES
t �Ccabled ropy Is heed with the
olf e- mpyblllLd with the ctty lmpMlon division. GREASE/INDIISIRL WASTE INTFRCFT'NR PLANCIIECK FEE
I6-Yo
1 CERTIRCATEOFID(EMPTIONFROM WORKERS GREASETRAP PAID -1i90s �v
COMPENSATION INSURANCE SEWER-SANTTARYSTORMEA70�T - Date Recel t#
(r orleebn need na be compined Bthe.erode b(ororc hundred dallam
(f100)orfy 0h) WATTRHEAT11RW/VENT/Fl.ECTR ENERGYFEE Y N
Ill nor cop In the person In dthew¢k forwhichthispemWis trued,
I WB not employ any person b any manner at u to become subject to the
orWATIItSYSTEM/TREATING
Applicant ompewtbn Laws California. Date PAID
Z Q NOUCETO APPLICANT:If,after making thio Cealflnte of Exemption,you NEw RF9DEIYSIAL I'LMB. SQFI'. Date Reoef I#
should become subject to the Wor4en'Comperse Wn provlsmnsof th.Labor TOTAL: 6-
N Code,you must fmthwhh comply with such provl.lens orthb permit shill be
W Q deemed reveled. BUIL12ING FEE
CLCONSTRIICTIQNr LENDING AGENCY SEISMIC FEE
I hereby affirm 7 that then b a mmtructlm lending agency for the perform - ELECTRIC FEE Z ,nmdthewnrl for which this permit bw
led(See TOTAL
31N7,CW.C.)
O PLUMBING FEE
Indere Name -
LLf Ierder.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
l O W I¢nlfythrtlhawmdthbappB tbn&Md tethrtlhcabovelnfomutlm
IL IamrmC.lagrteto complywhh aB dtyand muntyordlnananand pnelawe P'ERMITISSUANCE FEES PAID: r
>- relating to building mmlructlm,and hereby authorlae representatives ofthis I,
2 city to enter upon the above-mentioned property for inspection purposes. MTFRORADDTOMECH. Date Recd t#
— (We)agree to e,bdemNfy an d keep harm!.th.CKy of Cupealro
aga b i 1' ,mst.ud expenses whkh may in any way.ceom AIR HANDLING UNIT CFO 10,OW0 CFM) SUBTOTAL:
ag I of the gn ming d th.permit.�� /LSV AIR HANDLING UNrf(OVER 10"CEM CONSTRUCTIONTAX
Slga rc r puex/Cmlrxr¢ Date E)HAUST HODD(W/DDCT) CONSTRUCTION TAX-PAID:
HA7 RDOUS MATERIALS DISCLOSURE
Will the applicant arfumre building oavpant port or handle ha>aadous HEATING UNIT(TO 100,0DO BTU) Date Rttei t#
.terlal.,&f1m�dbylhe Cu blw Munlet lCode,Chapter9.17,andlhL
Ile.hhand Seety GdMue ; 3IWi I.IFi1TINGUMT(OVFR1W,00DBTl-0 TOTAL: ?6-
c;Yes Nb
Bl the applicant bit lldlng oavpart use equl proem or dmiens VENTILATION FAN 5INGIR RFSID) Ill Mf3lSF DATE
whkh coot havrdaus air comaaNvnts as defined tM Ara Mr AMr i-I"1-YLT
QnINy Maaugement District? ROILFhOOMP OHPOR IOW,((10 BTU)
Yes ❑No
have read the havrtlowmalertals requirements under Chapter 695af BOILER ODMP(OVER 1W,DOO BTU) jtj f,)1� 3 1990
IM Ce forma I teeth 4 Safety Cade,Sections 75505,75533 and 75534. I
uMd rdtlutifthebuildingdoeswtwrrentlyhaveatenanithatlthmy NEW RESIDENTIAL MECH. SQTT.
respons@BRytod.ceriottvpamdtp.ocy. remema whkh rtwrt be rant City of rl���
pilar to Lessons d a Certlfiate d Ocvrparry. YIY
Owner or eahorlud agent Date TOTAL: ISSUED 0Y:
OFFICE COPY