21599APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
EuiIJh,g Project Identification
Building Address
% 06 3 /EvdiEu/ ql/E �r/GEeriiuo A 9s'O/
PERVIT NO.
.21599
ossa ante: - one:
y //f/E/Z IilG" �3S
CITY OF CUPERTINO-BUILDING DIVISION -
APPLICATION / PERMIT
BU MNGELLC RICAL.PLUMBINGMECHAMCAL
I :3 —W
(( '
Contrsctaraw .. � Lie. Na
1Arehhect/F
CATEGORY
CONTROL. L
V
g/wer. Lk. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PERMITISSUANIX
SIJ
LICENSED CONTRACTORS DECLARATION
I hereby affirm thatlamB me uMerpm m.ofChapter9(�
Ingwltb Sectbn7000)ofa islon3ofthe Busnessand Profnalona Code, and my
Macrae la in full for¢ and affect.
Dawe CassLit
APPUANCESRESIDENffAL
J09 DL9CRIPHO14
�D
PANELS
L1. qb
Dale G011ntTalr
h)
VIA,-
2' 1- 000
ARCHITECTS DECLARATION
I unlenaM my plane shall be used as, public meorda
Limeaed Professional
IOVERIODDAMPS -
9Q. Fr. FLOORAREA
! / j[J
S/SQ. FT.
9GNSELECTRICAL
L SrrECIAL CEtCUCr/MLSC 4 S O
OWNER -BUILDER DECIARATION
I hereby affirenthat I am aenipt frorntle CoMrn<[or's Lcense iLaw forthe
1 l e(-
i
ITEb1P.METFR OR POLE INST.
following reason.(Section M15, Business and Profession. Code: Any city or
mntywhldirequireapemdttowa Malter,improve,demo is orrepair
'
anyatructu,prior to lb lwance, also requ ire the.pplfont for ad pemdt to
file a egned statement that In, la licensed pursuant to th. provbloro of the
POWER DEVICES •.
SWD4WNG POOL ELECTRIC
I O ouTLE Svswl C FUUUREs i co
Contractor's License Law (Chapmr9(oommencing with Section 90()0) of Divi-
Won 3 ofthe Business and Professbro Code) orthat he is erempttherefmmaM
the basis for the alleged exemption. Any violation of Section 7m15 by any
applicant fora pemdt subjects the applicant to a civil penalty of nor mart than
VALUATION ,
0 D O
NEW RESMENTTAL ELECTR FT.
SQ
tv ndred dollars (SM.
"Ven.
L u owner a the property, or B7 employee with wage as their sole
oompensation, wW doth work, andthastructure is, not blended or offered for
sale Sec 7011, Busiruas.M Prof®ions Cade: The Contractors License Law
does eat apply to an owner of property who build. or Improsv thereon, and
who don such work himself or through his own empl gees, provided that such
STOR16
I^\
J_\ D
TYPE NN'SIR(J'ITON
f
- rP�
Imprewemena art not Intended or offered for sale. If, however, the building or
Improvement beold within one yearofoornpletbn, the owrter-builderwlll have
TOTAL:
4�� r
QTY, PLUMBING PERMIT FE
t"mienofpmvingthat edklr WUdorimprovefacpurposeofsale.).
Ll L as comer a the property, am emhuNeiy oontracUrg with licensedpFgMR
mntr.cmn to construct the pmjed (Sec 7011, Rostrumand Professions Code:
pL00
TE
-
ISSUANCE
- -
The Contnctorb Lianas law doe not apply to an owner of propertywho
Wilda or Improve thereon, and who contracts for such pipjees whit a
c�3Tactar(a)Baneed purw.nt to theGmtnctofs Lherm Gov.
LJ I am ...pt under Sec B k P C for this rano
ALIT]( -DRAW h VENT -WATER TiV . Gb
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, ODND.
S N —
RI EF1'
Owner - Date
WORKMAN COMPENSATION DECLARATION
F-11 hereby affirm that 1 have • certificate of Consent to self -Insure, a a
Cnpensximwneaa
Workerio rinsrtl/iedc�pythrrtsec of
38W,�C
Pdky a
I FOCRJRES PERTRM' '(�
Y Ea Ncertifig
S F.A.
' GASYSIIM-I INC./OLlHEIS '��CX)
PARKFEE N—
E� .
CAS EA. SYS LTM-0VER 4 (EA)
C,,o,,,������mppppppa ray
BUILDING DI V ISION FEES
�CertBled copy is heed with thehed.
Certllied ropy la filed with the city Inge eject divintm.
CREASE/WWSIRL WASTE INTERCEPTOR
PLANCHECK FEE
I
F �• j
GREASE'IRAP
CERTIFICATE OF"OOPTION FROM WORKERS'
r � �j
PAID .1 Oma(
COMPENSATION INSURANCE
(ITIS s<ctbn need eat be cromplored lf the permk a faow hundred Golan
Date Reed t#
SEWERyS ARY-STORM EA 2DWr.
wATFR IEATERw/vENr/F3Er R
ENERGY FEE Y N —
atm)alea)
N m
I certify that the perfonrioe of the work for which this pemdt le lasted,
I shalt not employ any penin In any manner to as to become subject to the
Warkerv'Compen.atlanlawsof Cnlifoma. Date
WAM S-YSIFM/.TREATINGPAIDw^s3
L 7 7
_t:7
Apphont
T:
NOTICETO APPLICANIf, alter rruU g thisCertlflateof Exemption, you
amldbemme.ubjc tothe Workm'Comperoationpr lomofthel.abor
NEW RI3DFNTIAL P(MB. SQ}T.
Date Recd t#
TOTAL
r Zj•
Codc, You mat IorthwRh comply with such provlabns artha pemdt shall h
deemed revoked.
coNsrgurnory LFrInNc AchalcY
—BUILDING
E 1z
d
-
SEISMIC FEE
/ 1
I herebyaffirrn that there is a construction lending agencyfor the perforrry
raceofthewarkforwhkhthlap<rmitaam (S 3D97,ClV.C.)
Ierdcr's Name
Landers Aeert,..
1mnifythat l have read thisapphatbn.M sate that theabove UdornWlon
-lamrrcR.Iagrteb<anply wlthaBcityaM muntyaedln.nceand state laws
. TOTAL / Q7
6
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
�7 �r
PERh4IT ISSUANCE - C4 0
MECHANICAL FEE
2 .�
FEES PAID:
relating to building (arutrUdIM and hreby suthrume representative of tha
city to enter up.. the above-mentionsd property for Inspection purposes.
(We) agree to save, Indemnify an d keep hamles the City of Cupertino
Against liabilities, judgrrena, cussaM expenses whkh may, a anywayscwe
g.hot CRY In na of the granting of thinpermit !
�� /pL
ALTETt ORADI)TOMECH.
Date RCCeI t#
AIR HANDLING =(TO 10,000 CFM)
SUBTOTAL:
-
APR HANIwNC UNIT (OVER IQOOOCFan
CONSTRUCTION TAX
S na reof ApphcAnnt//Cmtmctmcta D,t�LL
EXHAUST HOOD(W/DLCD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUMT00100,ODOBTIn
Date Revel t#
WUlLheappl<Mr fuWmn ddingo pantstonorhandlehav ms
mtterialas dellrad by the Cupertino Municipal Code, Chapter 9.1Z and the
llcahh.M Safety Cade Scalar 2ra537(a)7
RYee NN.
01 the Applicant orfutum Wilding oncupantuse equlperent curt
which eMt hvrdous air contaminants an definod by the Bay Arca Air
HEATING UNIT (OVER 100,000 BTU)
VA�OTAL,
VENTILATION FAN (SINGLE RESID)
155UAttI DATE
BOILER -NMP OHP OR 100,0ID BTtq
QuaWy Management District?
4Yn (z No
haw mad the F r�auanecrialsrequirtrrcnbunderChapter6.95of
l AEI'
wel�l�
BOILER -COMP (OVER 100,000BTln
Ube California Health k Safety Code, Sections, 25505,2SS33 and 75534. 1
�as
Iai1N }Ly�i.i`�
NEW RESIDENTIAL MEIN. - SQFr
understand Hat if the Wilding don not currently have a tenant,that it Is my
74sd
ropomlbdUytonaifytheoecup.ntofthenqulr<mentawhkhmuatberret
pr ct.l uan¢of.Conlflatcol Ocarpany.
^
-
ISSUED BY: ~Mr— h[Fx+-�y-a-
Owner ass authWcd agent Date
OTAL
OFFICE COPY