21839 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Ruildin Pm'ed W'entifeationn/ !oi/ PFRNWENO.
Building
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drv: ,�,.I'^' %•�, /' •y 7li(n - 21839
Owners EKY X< IoEr-21ap CITY OF CUPERTINO-BUILDING DIVISION ,
APPLICATION / PERMIT 9
BUILT➢NGMECTMCA[,PLUMBINGME LAICAL CATEGORY I CONTROL/
AmhXxt neer._ Llc No
�aT QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFRMIESSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby Wire,that l am tkensed under provWme of Chapter 9(mnvrrm APPLIANCESRESmEN[7AL ]OB DESCRIPTI
ON
Ing with Section 7000)of Divialm 3 ofthe ButlKaand Pro eslcrosCade,and
ed.
Ilam b1.fa
In ilrte foand df ' PANES /r
I c Clan Lffx
Date Caturactor UP TO 200AMPS
ARCNTTECI 5 DECLARATION -1 AMPS
q 5/SQ.Fr.
q��uu«7. I uderttand my plan shall he used u public nerals .OVER 1000 AMPS SQ FLOOR
k �jLimrued Professional SIGNS —
6 OWNER-BUILDER DECLARATION SPECIAL T/h78C a 1
E'�G Iher.bya/Oren that!am exempt from the Comramrs LiarueWwle Ne
Fq- f.Bewingreason.5ectlm�7015,Businessant Profmbru Cade:Anydtyor ,
<i,C countywhk mlqulreape toconsbud,alter,Impm ,den Wh,orrepdr
K ',SSS�6 anywueure Dint to its fad°rcgalw rcrylrestheappBunt fmauch permit to POWER DEVI
K 0 U file a signed statement that he b Beenaed po,,a.t Io the pr.vbbra of the
Co.t cxriLicense Lao,(Chaptm9(mmircMngwith Segbn7000)./Divi. yy�UgNGPOOLF7ECCRC VALUATION
do
F,�OS n3ofthe Rueben Ord PrdmbmCode)orthathebermptt refmmard
the Wsb for the alleged )muthean. Any violation of Sealant nor me re any OUTLETSSWTTCHFSFI%TURES ���
6X fiveapphc�mtfora permit srbjtt[s the applicant boa dvilpwlty and mnrctlun - J (`
0E-11, area dollars ISMbeer. NEW RESIDENTIAL ELECCR SQ.FT. STORIES TYPE CONSTRUCTION
�n .72-
F-1 1, .wren of the Property,or may employees with wages s offered
woe
C 6 mmpeee.tim70K will Roaloss wakand thesWcte:TheC Wedel o icensedfor
S D ale(See.7011,to an
Ad Prdmbra1ho The or Imp ore Cleve Ww ,
don not apply roan wvner of mth.gys on emplolmprwnthert.vand
c. whodmmchwoh M1lmseBmthwgh M1bownemployeq provided tM1atsch OCC.GROUP RES I1Nfr5
Imprmr.rds arc not Intended oroffered far ah,.If,however,the building m TOTAL
Improvement beold wNMnomyearofcu pletb theowner-bu erwi0 have
tIoCItarden of proving thathe did not build or improve for purpose ofsab.). QTY, PLUMBING PERMIT FEE
"L u owner of the property,am eucontracting nting with Planed PLOD ZONE APN
mnteu ar,to metmd the pmlact(Sm 7011,Busbm ad Prdesla s Code: PQUvEFF ISSUANCE
The Cordndors Llee.Paw d.e not apply to Aa owner of property who -
builde or Improve therm.,and who contra for such pi,)ects with a ALTER-DRAW&VENT-WATER TA)
optisemr(a)Bemin!pursuant to the Cmtradm'a Licence Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec B Is P C for this reason
DRAINS FLOOR ROOF,ARF-,COND. SANITARY Y N_
Owner DimECL nrr, R� /
WORKMAN I""aCOMPErSATION DECLARATION FDtTURES PER TRAP SCIICOL TAX Y— N_
'❑I hereby orMn that I have a Imorate d cmrnt to oself-Insure,there. ora RECEIPT/
3SM,Laeo(Workeri Camperaatlmlmurmaaaartl!int ropy therm(6ec. GAS EA.SYSTEM-I ING10ULETS PARK FTP Y N
3500,Wb CJ
Polky/ CAS PA.SYSTFMUVER I(EA) RECEPI'N
C�nr ny BUILDING DIVISION FEES
ItLs_1{l(/i`rLRee ropy b hereby filed
the cr. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
dNed ropy b filed with the dtY Ivpectlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFA TRAP PAID
(f — gyp
COMPENSATIONU NCE SEWER-SANTEARY-STORM EA.2()FT Date' Recei to /((� 'y-
Nseedbnneed net he completed Rtthe
Prrmlt b(macre hundred dollars(Sl W)«Im) WATERIitATFRW/VENT/ELECTR ENERGYFEE Y N
]o-troy employ
any personhe i anye of nee work so as to b Ws permit b bunt, —
I shag not employ Ary person In any manner at s to become eubjed to the WATER SYSTEM/TREATING
Waheri Compenatbn lawmd Gllfomb.Date PAID
_Zz = NOTICAppheant NEWRESIDEN1ALPLMB._-_SQFI. Date Recel tit
O shoulCEearmxo SCAMheWorsIll.fierrmbomperCtiecpreof Fiempter.you
should become svbjM b the Workers'Comperoatbn prvvbbro of the Iabar TOTAL:
F N_ Code,You most forthwith comply with such provlslaro or this pemat shall be
cc > deemed revoked. BUILPING ELE1 —
W O CONSTRICTION LENDING AGENCY SEISMIC FE
d Iherebyafli that there is-mrotrudion lording aMmY,for the pedorrry
TOTAL, ELECTRIC FEE ,qD
o = enaafthe me /or whldrthio perMtb ed(Sec.3097,CW.CJ �� 70
LL O Indere W mr / PLUMBING FEE
LL F lend rt Addrna�7Z/ QTY. MECHANICAL PERMIT MECHANICAL FEE ,10
O W IartPtyth gree to
mplyvvead apallelt aadc stacounty
thrtthe cess and lomatlm
1 lscoingt Iailding amply wNh andtyad munryardlnanaenta estebws I'FRMITISSUANCE
r raring to building and hereby hereby mth«b rtpreenta[hv of this U) dy to enter a Pon the abwcmentbad property for Wpecton purpose. ALTERORADDTOMECK Date Rebel [it
— (We)Agra to save.lndenudry n d keep harades the City of Cupertlm
egaimElabWtln,p 'eseav leh maylnan wayamue AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
agawteaid Cl gdtMs pa�lt. MR HANDUNG UNTE(OVER IQOOOCM CONSTRUCTIONTAX ,g
Signature of ant/Ccnr to EXHAUST HOOD CW/DUCT) CO CTION AD:
tAZARDOUS MATERIALS DISCLOSURE �1
Will the epphant or futue,bu0dingoccupant state.dandle HEATINGUNIT(T0100,000BTU) 'Date Recel tit
materials defined by the Cuperbm Mu Ndpal Code,Chapter 9.13,and the
Ilealthad Safety Cade Sedim355334)t HEATING UNIT(OVER 100,00)BTU) - TOTAL: 6
Fl Yn M N
'Ty ill the eppllaN orfuture WOding actupaat use equlpmens or dev{m VENTILATION FAN(SINGLE RF9D) ISSUANCE DATE
which emit harardmWs air aorta mnets s defined by the Bay Area Mr
Quarry Ma nagereent Dbt�o
t BOIIRR-COMP OHP OR 100,1X9 BTU)
Yes F�N
hove read the bxaoxl materials requirement u oder Cha pier&95 of BOILEILCOMP(OVER TW,000 BTU) EB
the California Iiealth&Safty Sm
eCode, laro c
75505,35533 and 7553!. I r 1- 1991
1991
ude and that if the building don wt amrently have a tenant that it b my NEW RESIDENTIAL MECIi. SO.F7 ,
responsibility to notify the ocapant d the requirements whishares,mast be ares,
prior to bsuanee d a Certlfiate of Oreupancy. ng ra" e r .5
Owner or authorlred agent Date ISSUED BY:
TOTAL
OFFICE COPY