19974 F, � T_ _
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Prv"M Ede Ilkallm_ A.J.O 1'EIt1.11TN�. 9 9-71
Budding Addmsa: 1 f19
U
rcra a,rc: one;
QV _ CITY OF CUPERTINOLBUILDING DIVISION
. Coni g[7L \ oo�N.�� II.No. APPLICATION / PERMIT
`�,3' BNIL)INGELECIRIG4I'LIUMBINGMECHAMCAL CATEGORY CONTROL
A111t 1Gglneer.
"' 1 G-5t rr. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtu lob C 5 - PERMITISSUANCE ® - ❑ ❑ '❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am teemed.oder proeid. fChapter9(mm a APPLIANCESRESIDEMiAL JOB DESCRIPTION
Ingwlth Seebn7000)ol DTVIYoo3ofthe BusitKasand ProfalonsCode,and my
Ikenx is in lullfor¢and effeeL PANELS
Lkxnac Class LILY
Date Comnc[or UP TO 2DDAWS O U. 1I r
ARCHITECPS DECLARATION '1000 AMPS �•—
�]. IwderanMmyplauehallbeuaeduPublict— s, OVER100AMPS SQ.Ff._FLUOR AREA S/SQ.F7.
[O N
U LlmmdAb
ed Prnal SIGNS ELECTRICAL
QLUu OWNER-BUILDER DECLARATION grpCIALCIRCNT/M E R
pF, S 1her7L fi rm than am eeeeopt from the Conneofs Lknae law for the
/ollowing neaaon.(SeoUmi 9015,Bualnu and Prof ado.Code My dty or
7IIAP.METEi OR POLE
F myOmMhrequl, IUP alttommtrue,antheaprove,aemoilah,orrtpalr
any nmeurt tatent its Issuance,hoes e d p....t to the forau em,of t e POWER DEVICES D TE / )r
le 40..V Be a aigned»stemma that he la r 9(coup pursuant it the don 70Dm of the YI�R G ' �t
Ou.0 Cont3forS License Law(CFapler9(mmmerthghelNSeciptthe0)of DEW- VALUATION
aF..30�n elon3o(the Businm and Prole�bm Cade)orthrt helaexempt th<mlromaM SWBdh9hG POOL E[,EC"1"RIC
the bub for the alleged ea pfion. Any ,lolation of S Ioi,,pJ 9015.by any 'apph¢ntforaper wbie theapplkanttoadAlpe hyofna moretlan OVILEISSWITCHESFl%7LRES.
0. �4 five hundred dollars SM. nC 7 CLL I r .
❑1 uowneroftM NEW'RESIDENTIAL EIFLL_[R SQFT. STORIES TYPECONSTRUC1'ION
, Property,army, emture inwnhwagesu theremob
k7 cok CS1_tion,wuldothewvk+nsions ruaunbmt Wardedoroffemlw �`�
9 ❑ soknot 70µto anvuandfprosalom Code;The CoMnGofa therms Taw
g$
does od.sixytouowrcr dpropertywho Wlmaorlmprovntherms,and OCCGROUP RES.UNITS
0. whodxwch am nor,meen orthwghhbownemplgm,pmtheedddiog re
Tmprovemerdeanrwt intended o, fe roplden,th,hwvever,the 4mfldbrw0J luo TOTAL
Improvement Taaold wnhlnorcyurolcomplelbRthe wvner-builderwW love
n oty,f proving that he did ret baud or Wprovc for purpose,of sale.). QTY. PLUMBING PERMIT FEE
L owner of the Properam essWW
ely contracting with IleneM FLOOD ZONE APN
cmn to mrmtme the project(Sec 9014,Business and 1'rofoanbm Code: PERMIT ISSUANCE
The Contraeori License Law don not apply to an owner of Property who , ALTER-DRAW k VFM-WATER ff.V
builds or Improve themon, and who coni for such pio(ees with
�yat(aeo,(,)Bmr d purwut to the Cuntriemh Lice.Law. FEE SUMMARY
LJ 1 am exempt under See k P C for this rtmars BACK BLOW PROTECT'DEVICE
DRAINS FLOOR ROOF,AREA,mM). SANITARY Y_ N_
Owner ate RECEIPT 0
WORIQIAN COMP SATION O pp"NREq ppR TRAP SQi00L TAX Y_ N
❑1 hereby affirm that I have•¢rtIB¢te m m mel/-Inert,ora RECEIPT Y
oett111¢te o/Warkeot Commw
pe .aon Lr ¢a oertlfld copy tt,ereof&c.
380,Lab C) GAS FA.Sri"ITM-t INC,40(JTLEIS PARK FEE Y N
Y GAS FA.SYSTEM-OVER 4(EA) RECEPI'N
� y BUILDING DIVISION FEES
CenlOM ropy b filed th the c" GREASE/WDUSTRL WASTE IKTRCEPTOR PLANCHECK FEE
�CenNed mpybllkd'Mth the tlty lmpMbn divWan. '
CERTIFICATE OF C(ENI'TION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR.SANITARY STORM FA 2()�C Date Re(ni til
(fMa mesion need out be completed If the pe,mn b f¢ora hundred doRan
($lao)oryth WATER HEATER W/VENT/ELL= ENERGYFEE Y N
Idl nor lhrtoto the pernoin of 0ework w as
htwpemiltcIs lasued, —
1.hal ont cmpem any Peron m any nanner ao u m hemme subs to the WATM SYSIFM/TREATING
Appli 'eempematwntawanr Caluomla.Date PAID '
Z Z NOTICE NEW RESIDENTIAL PLMB. SQFT. Date Recel til
O NOTICE TO APPLICAM:B,aper makingtw Cenifl¢te o/Exemptbn,you
.F ehmld beonr sub}aT to the Workers'Compemrtbn prvdabm ofthe l. rbo TOTAL:
CC (n Cede.you fonhwnhmmplywilhwchprosMiomorthbpemdtahallbe
deeed revoked.
W CmCONSTRUCTION LENDING AGENCY SEISMIC FEE
BUILDING FEE 1% cx
CL IherebyaBirm tluttMebamrmtmnlmrkMingager�cy(orthe perfomm ELECTRIC FEE
� 0 once o/the rorkfor whkh thin Perron b Issued(Sec3M],Civ.C.) TOTAL.
LL O I<rdee.Adde PLUMBING FEE
LL F Lenaera Adareu QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW I¢nl(ythat l have nadtwapplletlanand elate that the above lnformaHon
IL lemrrect.]agreeto comply wnh aB d[yaM muntyordWnresand erste laws PERMIT ISSUANCE FEES PAI D:
Y mialingto Wiwd gmrmtmemandhenbyauthor .presentative of tib
F..
ALTFRORADDTO
Z cry to enterupon the abwo-menOorcd Property fce WpeNon purpoen. M13l31
V — (We)agree to nave,indemNfy an d keep har ilm the City of copertlra Date eeel tN
aga lam Ubiltiea,Ndgenenta,coma a M eapemn whkh ovy,in any way aecme AIR HANDLING UNIT CFO 10,000 CFW
SU TOTAL: I
agabu4 maid City Jr,consequence of the got permU. / O AIR HANIXL NG UNIT 10,000 CFM) CONSTRUCIIONT
rteture of P1 G 1a,�,�a� /'�4///aJD�yF..`�y',� CONSTRUCTION TA PAID:
Signature of ApplHAZA wlsrveferA' Date FXFiAl15F HOOD(W/DUC"D
HAZARDOUS p DISCLOSURE
Will tenial an appned by teupertioingomrpan ocle, hhandle hanricuesdthe ]iFATINGUM7(TO 10,00 BTU) Date Recel tN
material.Safety
Code
Cupenloo MurdtlpalCoda Chapter 9.1 7,and the
tlrxnh and Safety Cede Seelon 75537p)l HEATING UNIT(OVER 1 W,00 RM TOTAL:
❑
Yen No
WOltheeppB¢ntor uW mbo0dingarvp..tuuegdp..tcrdevkcs VFN11ATION FAN(SINGLE REED) - ISSU DATE
whkh emit haaMous air contamW nts u defined by the Bay Ana Air
Qu❑a lhy Ma ragemcnt Deatriet7 BOILER-ODMP DFB'OR 100,D00 BT(1) - LI
No
I havne nM the huard.1oute,ul.main menta under Chapter 6.95 of BOII.ER-COMP(OVp210,000 BTU) P ny y fl%L�•1
the Califamla Heaith k SafetyCod.,Seelom75505,25533 and75534.I I; n. J lL
underataM that lfthe bu0ding dorm not mrtently have.tenant•that it b my NEW RESIDENTIAL MECH. SQFr.
rapomibllfty to notify the omuparn of the requirements which must be met city A�
polo,to lswarce of a CenBkatcc V nIACTI1TtDof O.Nney. �
Owner or authorUN agent Date TOTALISSUEDBY: " "`"_ ']
�t
: �
OFFICE COPY