20856APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pra eat Identllkatlon
B"fids°' Address: - o
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20856
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2X267S
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGF],�IRICALI'LI1MBiNGMkY:11ANICAl
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CCONTROL
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CATEGORY
.
'
Archhect/Engi¢cr: �� Lk. No:
QTY ELECTRIC PERMTI'. FEE
BUILDING PERMIT INFO
Address
PERMITISSUANCE
F-1 1:1
IFenbya(flrmtlutlamlkeneeduMerpm Womof Ch.plcr9(mrrm a
Ingwlthgect1on7000)of DIWslon3dNeBuarcmand Pm(e.eloroCodc,and my
er^a�cbi�n!^sail dl�. O�
DatejAr/�ContactorInn
APPI]ANCErRE9 L
)OR DESCRIPTION
l� j Rei
P
-1
i ARCHITECTS DECLAATION
R
_
Iurderaard erypbm.luBbeetsed'upubllcremda
OVERT
SQ. FT. FLOOR AREA /SQ. FT.
SIG CAL
Lkc4sed Professional
IA
SPECCUIT/
OWNER -BUILDER DECLARATION
IM1ereby affirm that I am eaempt frorn the Contractor'• Lleenselaw f¢ the
'
TEMP. OR NST.AW
f ntyngnhrequ aFon7 wRualn®alt Pro(nsbro Code: My dtyor
awntywhlch requUn a pemdt urorocnrct, alter, Improve dermlbh, orrepilr
'
anyaromrnpri¢toile!yuan¢,abonqulrvtheappB¢nt(orudpermNto
ilk a signed Namenent that he b B¢n.ed pursuant to the provbbn of the
CFS
Contracts 's License Law (Chapter 9 (ron
mrnctng whh S. 7000) d qvt-
VALUATION '
sbn3o(the Business and ProfembroCode)orlhrt hebeumpt the-fromand
the Wait for the alleged exemption. My vldatlnn dSMbn 7m I5 by any
app0ant fora permh subjecla the appitcant to. dell penalty of not mon than
J! -
pNTEAL EI.DCIR SQ. .
fivehundreddollus(SAO.
11, as ownu of the property, or my employees with wages u their Ante
E$
TYPE CONSTRUCTION
rompenation, will do the work andthe structure Is rot Weeded or offend for
'
ule (Sec 7014, Busircm and Pmfembro Code: The Cordactot. LI¢me Law
does not apply to an owner d property who build. or Improves heron,and
whodmuchwork himself orthrwgh hl.own empi.y., prwlded th.t suds
OCC. CROUP
RF5. UNITS
Improvemcas are not Intended crof(ered break. If, however, the building er
ImprovementbAdd wlthlnaroyesrafcompletb4theowrier-bullderwlllluve
TOTAL
"mvp
t Menofpingthathddnot WBdorlmpmve(wpore
urpofsak.).
1, a@ owner of the mperty, am exchuL—lvely ronir--, wRh i
eontnnm to rouee construct the project (S7D14, Busu m and Professions Code.
Cod
QTY. PLUMBING PERMIT FEE "
F1.00D ZINE
APN
PERMIT ISSUANCE
. DQ
The Contactor'@ L1¢v law does not apply to An owner of property who
builds or lmp.. themo4 and who mmnm fee udd projem whh a
ogM(Actoa(ai hoseroed pursuant to the Contractor's Lken@e law.
LJ I Am e.empt under Sec B 4 P C for this MasonOUTS1
ALTER -DRAW k VENT- WATER MA)
FEE SUMMARY
BAC{: FLOW PROTECT. DEVICE
UP RE 9
DRAINS FLODR, ROOF, AREA, GOND.
SANITARY Y N—
RECEIPT )
ow., Dae
WORKMAN COMPENSATION DECLARATION
❑I hereby a(lbm tha I ha e • ¢MBain of consent to @elf-Iwre, ¢ a
¢rci0ateof Workca' Comperoalmr Iwnn¢ ¢a ¢stilled espy thereof pec.
3800, Lab C.)
FOCIl1RES PER.fRAP
D
SCHOOL. TAX Y_ N_ '
RECEEE T 1
GAS EA. SYSTEM -1 INC40VILEIS
PARKFEE Y_ N_
GAS-OVER4(FA)
CoCam ray -
DING DIVISION
BUILDING DI VISION FEES
�CertlBeci ropy is hereby -
�certuiea ropy b !tics ledownes the sty Bwpemoh aivblon.
GREASE/INDUSTRL WASTE INTERCEPTOR.
PLANCI']ECK FEE _
GREASE TRAP
CERTIFICATE OF EXZZMMON FROM WORKERS'
PAID
SEWEFFSANITARYSTORM EA-70fET. -
COMPENSATION INSURANCE
(TMs uetlnn need not be completed Bthe permB b f¢ one hundred tlo0an
Date R.,eJ t#
WATER ]-�ATTx w/vFxr/ELEcrR
ENERGY FEE Y_ N_ -
(SI00>¢IeuD
I ¢reify that N the perfomw¢ of the work (or watch this pemdt b Awed,
I AMU not empby, any person In any manner m As to bamme subject to the
Workers Co open salon laws of California. Date
WATER SYSTEM/TREATING
PAID
Appliant
NOTICE TO APPLICAM: I, after making this Certlfi¢te of Exemption, you
DatC Re i t#
NEW RESIDENTIAL PIMB. SOFT.
TOTAL:
should become subject to the Worken' CompeevHon provision of the Labor
Code, you roust fe thwbh comply with ud provbbn or this pemJt shill be
deemed revoked. -
BUILDING FEE. 0,9
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby afflrrn that thea b a ronimctlon lending; agenrcy for the perform
.nee fthe work fee which this permd b Wimcl(5, 3097,CIv. C.)
Lender. Name
Iendet.Addau
1 ronlfy that I have read thla appheatbnand Matethat theabovc lefnmution
bcornal.Iagme tocomplywkhalicityard countyordlnanmand•atelaws
70TAL 0_W
ELECTRIC FEE
QTY. I MECHANICAL PERMIT FEE
PLUMBING FEB — D
MECHANICAL FEE
PEtMITLSSUANCE -
FEES PAID. -
nelatingtobulli eg construction, and hereby authortre representatives ofthis
city to enter upon the.bovcmentlorcd property for uspectbn purposes.
(We) agree to save, indemNly An d keep harmlem the City of Cupertlro
ALTER OR ADD TO MECI-L
Date RCCCI [# -
SUBTOTAL:
against Btlm,�udgmenb, outs and expenses which rtuy N anywayacnue
agobut said CBy In ronaequerce of the granting d this penult.
AINHANDLiNGUNTIGOIBODDCFM),
' •IRI-InnrouNc uNrr (OVER 10,cm cFM)
CONSTRUCI70N TAX
SlgruWn of Applicant/Contractor Date
ID(FIAUST FLOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC W SURE
HEATTNG UNIT (TO 100,000 BTU)
Will the.pp0anl orfuture building oavpant atom or handle hanadous
nutedal as cieloid by the Cupertino Municipal Code, Chapter 9.1 Z and the
Date Recd t#
HEATING UNIT (OVER 100,000 BTI))
TOTAL: �yy
Fk.hherd Safety Code Section=(A)7
nn Ym No
401the appilant¢ tum building omrpant use equipment or devices
which cent haardou@air mntamivnt. a defined by the Bay Arta Air
Q.ulxy Managemea DW rk47
Yes, ❑F� No
ihave read the haeAraou.materialsrequinmenbunder clupqlerG98of
the ilf
Caomla I leahh k Safety Code, Bectbro 75505, 75533 and 75S34. 1
VENTILATION FAN iSINGLE RESID)
-
IS
ISSUANCE
SUA{CNCE DATE
AUG 61990
ROMER-COMP (3EI' OR 100,000 BTU)
. BOIER-CO.Y,P(OVER 100,000SM
NEW RESIDENTIAL MECH. SQ.FL
uftd rdtlutllthebulldingdommwt ntlyhave.ten.n4th.titbmy
re,poroffiBity to notify the part of the requirement. which neat be met
prbr to lmuancc of a Certificate ofc panty.
j}y of CUP, Ila
ISSUED BY: C(h4•.O"'�N/
Owner or authorircd agent Dae
TOTAL
OFFICE COPY