22488 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY �7
Buildim pmjaut Identlfkatl® PERMIT NO.
Building Addms: 22488'
9O0 7 7 . i ✓/g o
one:
APPLIMMO=9=1,LATE
/ k- CITY OF CUPERTINO-BUILDMGDIVISION
^7
Lan'ore«•Name: a ZI APPLICATION / PERMIT
Yd! S BUrLDINCI EC?w PLUMBINC-MECHANICAL CATEGORY CONTROL!/L�
ArohllM glnec V .
r ELECTRIC PERMIT FEE BUILDING PERMIT INF
O
Addrns 1-. ( 71f (-3� PEILwTI9'1JANCE
1 LICENSED CONTRACTORS DECLARATION ,
!hereby alfirm tlat lamlken.ed urderprovWmuof Clupter9(mmmenc APPLIANCESRFSIDENIM,
JOB Dr9C N
In gwlthgen1an70DOot Dlvlalm3dthe Buslmuand ProfesemsCode,and
L nee lalws lora and e.8 .PANELS �OO�•
17�`.. J
Lkuns Chas Lba ,•l rVI-
Dao Coennor
ARC111TECTS DECLARATION 271-1000 .
pQq�v+W9
0W 77 I uMereand my phm stall be used as public record. OVER TODD AM75 .E7.sF10QR AREA �(./9�.F[.
k L� Llansd Prolmloml SIGNS EI.EC[RICAI. ��c7/ y1T'IL'7`T'l� Q7(l-C,. �
t�Q� OWNER-BUILDER DECLARATION SPKIALCIRCUIT/Ml9C o ( ( T
r�,5 1 hereby aff rm m that I am exempt frothe Cax
omraetor'e IJnLaw fa the 7
7 OF, folbwie9-scan.(Seal.70315,Bush.and Pmtmbm Code:Antl or ` ';• 7
OM®� y ep TEMP.MISTER OR POLE INS). Ig.
'P5 cnuntywhkh mryitena permtttommtrun,ilter,bnpmve,dfunaeah,ormatto S p
y any-Impurepatert.eent that
eis abonsed pu mant to the fmwium of
te POWER DEVICES Q
K � Ne a signed statement thrt he b llarued punswnt to the provbbm of the
ECwt Cantradors Lkeme Law(Chapter9(mmmeneing with Seetbn 70M of Divi- _mss 00
t sen 3 of the Buslnm and ProlmbroCade)or the he b exmpt therefrom SWIMMING POOL ELECTRIC VAL yT
t Q •] the basis for the alleged exe�tbn. Any violation of SMB.]0315 by any / / / Try
'I a Z[/
�� applicant fora permR wbjens theapplkant to a tivll pemhydnnmorethan UII.ETSSWITCF�SHXTURE$ l/ a LV. -�( ¢S T
$� Ev hundreddolians0500).�]1,uowrcrdthepreperty,orrtryempbyenwithwagnastbebok NewRESIDEN7LALw.FSZRSQ}T, S10W6 I TYI'ECON57kIKTK)N
t76 compensation,wllldothe wofa,ancithestruelumisrot Wended or offered for
5aO vie Lm 7011,wm o •MPmfmbm Cade:The Cordnn0f.Clams-Law r
s �3g whodoesu&worn awrcrdthroug yisenvo ldsorimposv.thereon,and
whodce.wchwork hlmmeBaNrmgh woven emplo/ees,Pmvlded that sucL C �'
improv nbareren Intendedorolfered)resile.If,however,thebulMinga
t"He edbsoldwHM1Ncamad raolcumpleian,mowner-rpIderwlahave
tl"L., dpm of the pbdldrnt WBdorlmpmve r«purpose !teen). QTY, PLUMBING PERMIT FE
u[as owner tr the property,am a 0K Bu y eas eulung wBb!)scared NE APN
The nnntocomtmnthLawdoesruxapplytslnmaMPrdeaebmCode: PERMIT ISSUANCE ATE a Z
The Contntlols Llarue law don oat•PPH to.n owner d,pmperty who ALTER-DRAB)4 VENT 7 WATER(EA)
heilds or Improves the en,and who contneb fa wch pto)em with.
c'maet a q hened pursuant to the CmMaeor'.Lk �erTaw. - FEE SUMMARY
LJ I sen exempt under Sec B 6 P C for thla reason BACK FLOW PROTECT.DEVICE
OUTS I OF FEES
Owner Dee DRAINS.F P,ROOF,AREA,CONI). SANITARY Y_ N
RFTEIT'T
WORKMAN COMPENSATION DECLARATION
M
❑I hereby affimt that I have a cenlfhte of connent to seB-Inure,or a FDCNRES PER TRAP �+ SCHOOL TAX Y N_
mmfiwe ofwonkem'Compets tiro Iruunnee or.entified copy thereof($ec. RPLEBT
3800,Lab CJ GAS EA.SYSTEM-11NC.40IJD,ETS r PARK FFE Y_ N_ -
Pdky,a GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FE
RLCEB'Ta
t Com ny ES
Certified copy Is heebytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEB
I ❑CenNed mpybfiled with
the the city lmpenbn division.
GR TRAP 393.
36
CERTIFICATEMPE SATIO ION FROM WORKERS' PAID
COMPENSATIONhe prR isfE SEIVFR-SANITARY-STORM EA.210F1'. Date Reed t#
(ITbrannbn need
no be compleed BlFe perMt him era hundred doBan
a100)mlm3 WATERHFATERW/VFNI/ELECTR ENERGY FEE Y N 7 /0
00)orI the Nthe performanm o(Ne wakforwNchtw pemdt l.bwed, /b /•
1 Mon not employ any Peron in any manner o as to become wb(ea to the WATER SYS1EMnnewnNc
Wmkcn'Cmipenuatbn Lawsof California. Date PAID
_Z p NOTICE TO APPLICANT:If,a Sher coiling t w Certlfleate of Exemption
you NEIV RE4DFN77AL PIMB. 9] Date Reeei t#
• oeld become wbpet to the Workers'Compemation ptovislom of the labor TOTAL . t 0. -
~ N Code,you nsrat forthwith omply with wch provbbm or tom permit a .]I be
w ] deemed revoked.
I ,O
W - CONSTRUCTION LENDING AGENCY $ ISMIC FE
d IherebyalBrtnthat tMe b•comtmcllm lending agency for the perform T L ELECTRIC FEE
= ince of the worktop whkh this perMt b homed 6ec 3097,CN.C.I -
U Lender'.Norm r PLUMBING FEE
LLE, Lcnder'.Adden QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ianlfy Natlhave readtwsppllcatbn.nd ebtethat the above lnformatlm
bcorren.I cgnmtocomplywhall cityand murtyundhunan.nd rtatelaw'. PELMlr IssDANCE FEES PAID.
Nreleingtobuildingeormmntm,.ed hereby.whaUerepresentathmawthl.
f. z c4ytoenterupon the above-mentlarmd propertyfm Wpeabn purpoen. ALTERORADDTOMECH. '
(We)agree to vve,W emdfy an d keep harttlm the City of Cupeninu Date Recti t#
V agaWt lbbWtln,Ndgrneea,mats and expenon which my In anyway ao�rue AIR HANDLINGUMf(TO 10,000CFM) SUBTOTAL
ag.lmt dCLLyinc...cienedthe gewng of W.pemdt.
i AIR HANDLING ulvrr rovF3t 14DDDCFO CONSTRUCTION TAX
mture of Appgont/Cmtranm - Date EXHAUST HOOD(W/Dues CONSTRUCTION TAX PAID:
HALk RDOUS MATERIApant Mo L.OSURE
ria the appgcant the future, rtno Mu dpal Code, hFeer le hvardthe 1-fE1TwG UNIT(TO 100,000 BTI)) Date Reuel t#
, renis)as defined by the Cupertino MuNtlpal Cade,Chapter 9.1 2,and the
Heahh mai Safety Code Shim 75532(.)7 HEATING UNIT(OVEIt 104000 BTU) TOTA
❑Yn Nb
Will theappli ntm tore building occupant use equipment mdevimVENTILATION PAN(SINGLE RF9D) Cf ISSUANCE DAfE
whkh emit hazardous air mntaMmnte aa de0rcd by the Bay Area Air
QmW
Quality Manageent tritl7 BOILER-COMP(3I11'OR 100,000 BTU) PA I
Dy. F� p
Yn No
have read Nehvawernuterials requWmcnb under Chapter 6.95 of BOILER-COMP(OVFR t00,ON BlIJ)
the Califomh Heakhk Safety Code,Sectbm2tly have a tend,that 1 AN 0_ ���
' uM.nibHhy .that l iebulldingdoeanotcurtenilyhavea hint.thatltbmy NEY:RESIDENTIAL MECH. $QJ"T.
� nvpomlbBHy to ndify the oavpant tithe nequfmrrcnts whkh oust be met r
prlortot uanceofaeemBcatedOavparuy. I i CI�y- Ur CUN77
thu/ry
Owner or authorised.gent Date SSUED BY
i
OFFICE COPY