21118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY DT18'
BuildingFrisian Identification / O
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`j-000I� CITY OF CUPERTINO-BUILDINGDIVISION I�Ir b�
• �•t .�_ 3 SI APPLICATION I PERMIT G 1 L
1� sari BUILDINGFI6CIRICALPLUMB[NC4AECHANICAL Gl}]CARY CO
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C� f» Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address �3r�
LICENSED CONTRACTORS DECLARATION PEMMISSUANCE I05 �I
I hereby affirm that l•erOcnned under prwldmuofChapter9 APPI.IANCE4RESIDENML �g
IngwllhSrdnn7000ofDMdm3oftheSudr andpm(wtm cocie,W
Line DESCRIPTION
is In o ad effect.
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LYL LkensedPMeesbai SK:NSm ECMUCAL r1 -.S T
7Hs< OWNER-BUILDER DECLARATION SPECIALCDICUIT/MBK: L� J(
O7� IhembydOrmlhatlamoempefmnWCodrattoel License lawfineha '
7❑ folbwing mafi7(=11 . -ZBualnea aMiiofe LCade:Avydlym
P eco ntywhkhrequlnvapemdttoa et,dter,improvrdermhah,wmpalr 7FMP.ME17•R OR POLE INST.
y� myAo mpnortoitsbwaaraborequbetheappH=tfwmchpemdtto POWER DEVICES
Ec Ob a signed statement that be b Seemed pursuant W the provbbm of the
Cart License LAW(CWpter9(mmmeneing With Sagan 700Dl of Divi. SVDWNGPOOL ELECTRIC
• 3dtheBrrma
udad Ro(e Cde)arlhnhebve
empethend..,A VALUAMObass, �
the bafor the dkgd emmptWe. Any viddbd n SSection �
7MI5 by any �,�F, ,BES 9
appllmnlfora Permitwb(edstheappllranitoachin pealtydnatmoreth•n Q
Ove hundred
❑LasaW er of 0500). NEW RESD)ENTIALE.ECIR SOFT. STORIES TYPE CONSTRUCTION
aowmrof c,thow eety,ormyempkryen vtlehad d as ehebwk
compensation(See.
Ikedra elwwmk,ad ion G du The Cr Wedd or o0emd for
seal Dor data not apply Wan
anowner c(propemywho build,w ad Pratrseba Code:The Camprowa LeeseLicense law 1
i $^ whodoewrhworkhlmeUorthrmghmsownemplaym,prwMdthatweh OCC.00Ol1P RFS,UNpB
Impnwemedaam WbLtendedoroReredfmak.l4however,thebuiMingm TOTAL (•�
improvenembsoMwkhinomyearofcompleliMtheamner-bu WerwMhave
t"rdenof FavingthatlwdM wtbuddorimpruve Tmpurpo•edade.). Q7y, PLUMBING PERMIT FEE
U 1,e owner of the property,am exclusively mmrading with InsteadFLOOD DONE APN
matuat to constrict the prood(Ser 70K Business and Profession Code: PFRMITISSUANICE
The Contndoem Unum Law data rust apply to an owner of property who
build,or Imprma therms,and who conlads for such pposta with a ALTEILDRAPIA VENT.WATER OW
�(�anMN Bceaed purwwtsetheContr dors Llreae Law. «FW DEVICEPRCTECT FEE SUMMARY
LJ I am exempt under Ser B k P C for thin sawn
S Owner pate DRAINS-ROM ROOF,AREb COND. SANITARY Y_ N
WORKMAN COMPENSATION DMURATION ItHou"R
of
hereby affirm that I have a mnlfimte of consent to•eB4mout,or a FD TUIMSPEITRAP SQiOOL TAX Y_ N_
38MIA Crknar
eWCampeaUmlmmamnBerw
ledcWthf(Ser ��B
3BO,habj GAS EA.9YSIFM-1 RJCII
IOV .RI9 PARKFER Y_ N_
Polky B eR
Co0BUILDING DIV
ISION FEESyRId copy b hreby furnished. CASIA.bYSfA-0VEdffA)
GREASE/RJDUSIRLWASMINTERCEPNR PLANCIiECK FEE
❑Cenllled copy 6(0d With the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAeE TRAP PAID
COMPENSATION INSURANCE SEWggylNITARYSFORM EA.700T. Date RL•txri ��
(Ihbsedlonned rw1 be mmpldBthaURA blmaahundred ddian
(fla Wally
alWATER HEATER W/VENT/E.BCTR. ENERGYFEE Y N
Imcast em t In employ
he any domrnm W the wm7ran a in b cornhin Funds is Weed, —
1 shag nor empty any person N any wanner t e b become subject m the WATEISYSIEd/TREATINIG
Worked Compenealbn hawnof GBfamb.Dab PAID
Z 0 d CETOAPPLEANT.$aMmki.glbb Ce ifiaWafEwmVdan,ym NEW RESIDENTIAL PLUS. SOFL DIM Rxei !g
shcotdbemmembOd tithe W.,keWCoMea imp,.,bkn,ftbe Labor TOTAL-1
N Cde,ym rmat forthwith comply wKha ch pwvbbamthi•pendt shall he
W > darned remkd.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL 1berebyaBtrmthat them b a mnMrutllrn lending spray Patherform. ELECTRIC FEE
I )MOO
Z armofthework forwhkhthis pemm b lewd Dee.3097,Cls.CJ oe TOTAL 0
0O Leaders Name PLUMBING FEE
LL )- IandeesAddrem QTY. MECHANICAL PERMIT FEE MECHANICAL FBG
O W Imrtlythml haveradthbappllmtionand eat as .
LL bcomxt.i dgetocomplywlb aBeOyand muntyordWancesand rtatelaws PERMIT ISSUANCE r FEF$_• IPAID.
N reWingtobulMing construction,and hereby authorize representative ofthls -1 \'NI�—
F Z city eat"upon theabmmemelomd properly for inspection purpose. ALTERORADDTOMr�i DAA !g
I.I Me)agce to!v! EdevWtyand harrrdas the Cly ICupertW
agaEmW tky' menti, •and ewAkhmayinwywayaccue AIR HANDLING UNIT(TO 10,11010CPM) SUBTOTAIA
agalat e n ofthis pend%.%6 aV (00AIR HANDLING UNIT OVER 10 CFM) CONSTRUCTIONTAX
Sigamre mm/Cmereetm r< EKHAUSTHOODIW/DUCD CONSTRUCTION TAX PAI :
A9ARDOUS MATERIALS DISCLOSURE r�
WDlthe applicant fume building occupant store calvandle hazinious HEATING UNIT CRI IORWO BTU) DateRL'cel !g
materiel as de0md by it,Cupertim Mudctpal Cade,Chapter PAZ and the
Heath andSfetyCde Scour 75533007 HEATING UNIT(OVER IDIUM BTU) TOTAL: I
❑Yen M No
Will the ipplkam ar fatmebuildingaccupant use equipment or dahe VFMII.ATWN FAN(SLNGLERESID) ISSUANCE DATE
which emit hazardous ab communiamsaade0nd bylle Bay Ams Air p 1'T
• sillyy regemem OlatdNo FAIP BOII.PR COMP OFOrOR 10(000 BTl)) ,
Ye No
W mthe Hadt en&Salo Codemateri,Book=requirements MiCS,2 vdend2S k95 of BOILER{OMp OVEt 100,000 BTI!)
the Californiab Healh45afdgdata socia TSR19,ar abreast
that it NoV 2 1990
understand that lflheb the
dost not the
hoes which that b bony NEW RESIDENTIAL AffCFI. SQ}T
rorpordNBOya ndlytha sccnpad oflha mptirememswhkh mart be and
prier to Instance da Certificate of Occupancy. ((''`` Ci. ty Of(Sroir"Pai
OwnermauthmlrNagent Data ISSUED BY:VIQ `V
TOTAL L
OFFICE COPY