21117 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY k.0r/
Building Protect IdentificationLO l/ .ae L- PERMIT NO.
eullding Addree:
0 0 0 oe-vt :r 0 lr- 2 a .. 21117
n amu. /a��..n ssue: A
�y-KFJIJI� CITY OF CUPERTINO-BUILDING DIVISION ,/Q�' �� �
• N.m _ SSW
APPLICATION I PERMIT L
�l BUILDINGELECRUCALPLUMB(NC-MECHANICAL GTt]CARY CO
A r• �
Con ELECTRIC PERMIT FETA BUILDING PERMIT INFO
Addmx
PERbUTISSUANCE t
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under prwWmeafChapler9( APPLIANCM31ESIDEM7AL LOB D6CRB'170N
Ingwlth5enbn7000)0lDivWon7oftheBudrc andPmhMauCode,and ^' p '
Ikene bbAr ad d(ee. PANELS e
'bF
Lis k/
Dale CoeD�
ARCHITE[TS DE RAmon OVER00
AMPS
�7 IS' nlaM my plain sluBhe used YpubBenmd6 O�I(m AM1g gQ Fd[�FLODR�A.RfF�A F/SQ.FC
k iI$�Bal Lkxnaed Pnfnalmul S1GNSELECTRICAL
<<� t OWNER-BUILDER DECLARATION $kC(ALCIXMT/Ml9C L�CJ T
eherebyafdrmehelfameemp frmmthe CoeractWaLlonr lawlwtiu �'z� ('•�••f
l0lbwlry rason.�dlon 7811$Buerrs and Prdesskm Code:Any ely or \II}
5 muntywhkh requbeaa perms Wr --,alW.Iznpmvyde.Wi*wmpalr TEMP.MEDAORPQ.EINST.
fd anysWcbreprbrbheb mus .bsorequi theappaoudfwsurhpemdtw ppyygg DEVICES
(5 Ole a Ygnd statement the he b kcened puonrant to the provisions of the
Canlnutoh Lkenss Law(Chapholl(mm0rndnSmir Bratton 70W)d Divi. SWBdhUNGPOOLELECTRIC
�2 e1=30fth Budnnaad PrafesstoruC de)waha hebearnittherefromand VALUA71O7
•]] the mato Beeline alleged oempton. Any ,vlwmnn dseaton Imes by anyFrinURES
appBcentfmapermbwb)edatheappUb toaeWlpeukyofmm mthan OUT'EIS.SWITEMES.
Ove hundred delam C&NIE.
�n ❑L as matter ofthe property,or my emptoyinswkh wageaasthebsole NEW RESIDENTIAL In ECTR SOFT. SI'OWES TYPECONSMUCTION
< compensation,willdolhe work and lheerumtm hint leendedor offend fw
p
tole(Sec.70MWrunad Pm(enbru Code:The Cmarader, Icene Law
11, I
@ dem me apply In an owner of property who builds or improve therem,and
who dmaudrwmkhlmeforlhrough hbownemployme,pwlddthat much C.Zwup STB
Improvemwamretinlenddwof.mdfwsale.ILhowever.ahebdHingw T+Dr L W. .
Improvement lswMwithinomyurof n pld(aktheoener-buOdnwlll hew:
lis£purdenofpmvingtlWhe did not build orknIm forpuepoedelel QTY. PLUMBING PERMIT FEE
LI 1, we
as or of Property,Prorty,am eeehu vely contracting with Ikenad F1mD u1NE APN
mnteectemto construct the project(Sm 7014,Business and ProteabNCode: PERMITISSUANCE Al1la
l
The Comneprea License law dm M apply to an incur of Properly who buildsALTER-DRAW k VENT-WATER(EA)
opga tu improv"theme,and who menet forire such L w. with a .
appJIamauouldell mele,S erotheContradda Llmtue Cfa RACK FLOW PROTECT DEVICE FEE SUMMARY
LJ 1 am eremp oder Sm B k P C far thin reason
• OwerDore DRAINS-ROM ROOF,AREA, SANITARY Y EI_
RECEBT/
WORKMAN iatriuCOMPENSATION DECLARATION FDnuim&PERTRAP SCIRXX.TAX Y_ N_
QI hereby stinum tiW I love a nselBnsfe d tdllenl b arlLbaurt,w• RECEIPT/
38 MLab CJ ken'Compersstltonlrwmce me certified copy theml6ea GAS FA.SYSRA1d INCA OUTLETS PARKFEE Y_ N_
Polk labCJ
��/
GAS-EA.SYSIE 43VER4(FA)
^ RECEIPT/
cornparry' BUILDING DIVISION FEES
Cert
Certified copy Is hereby th tied.
❑ Nd copyb(fled with the ctlylnpetllOn dlWtlon. GRFAg/QJDV"1R' LWA4IE NITERCQ'70R .PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
CATIONINSURANGE yErp�•ART-STORM FA zarr.- Date Reimi t
GNasectbn nerd nm becom hecmmpleted lflhepemuN bfwonshudrd dollen ENERGY FEE' Y N
(fiW)w yth WATERHFATERW/VFNT/ELECM
foaam employ
a heperkmmInanyn wwkforwhkhlhbpemdecit.t e
1 ork ne empty any peen In any manner at n b become mbject to The WATER SYSIIId/TREATING
Worlicant mp¢nnwbn fawad Calllernb.Dau PAID
Z 2 AOnesTOAPPLICANP.IL&An mWng eMsCerWlow orEemmppt1bnyon NEWRE4DE1V77AL PlMB. SOF(. Date Reuel tM
Shonld bemm ssrb)eca bahe Workers Compensation pwbbns of lheL&bw IOTA
~ H Coda you rwefwlhwah complywlthatch provisions orthb permit hall beSO
Lr
deemedmmkd. I UDING FEE be r�
LU C CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Z 1herebyafnmthet there bacontmctlon kdingagency lorthe perform, .Rya, ELECTRIC FEE
7 anwdtheworkfwwbkhthbpmMistmdO .3M,Ctv.CJ
V O Le d.exName I f 115-0
PLUMBING FEE
LLH LaoderaAddme QTY. MECHANICAL PERMIT FEE MECHANICAL FEE W lmdaythelhavemdthbappOwlbnadmtethattheabovelnformallon
bmnee.Iagmebe0mplywkh aBctlyaod muntyodlonnanmd tltle tows PERMIT ISSUANCE 21� F IaA1D:
r N relalingtobulkling consbreion,and hembyauthwlre repuentalm oflhb J{��
F Z cltybenteruponlheabwe• entkurdpropely forlmpretonpdpma ALTFRORADDTOMBM a Date t
(We)agree to area,Indemnity an d Exp harmless the Cay of Cupertino
agabutW MOM eecoes "Pe mylnanywaya0me AIRHANDUNCUNIT(TOIQOWMC SUBTOT
aguWt sequenced a permit.
1 AIR HANDLING UNIT OVER IQ WCF.M) CONSTRUCTION TAX
SignatureA m t/Contactor Dat EGIALiSTFIC0D(W/DUCT) CONSTRUCTION TAX P ID:
HA7ARD0U5 MATERIALS DISCLOSURE ^rte
Will theappllord or home boOding wapntewewhedle haradmua HEA77NC UNIT CIO 10.000 BTU) Date ReLTI) t LI
modal n dA td by the Cupedlno Munklpal Code,Chapter 9.13•and the
IImhhad S3fdy,Cd,lra_-_SrledionlWO(a)) HEATING UNIT(OVER ILIUM BTW
Yo b�
TOTAL: a
Will Noun building oaupanluse equipment wdevkes VFNDLA7R)N FAN(SUJJGLE ItE9D) ISSUANCE ODATE
which edt heMdona air mlantlnsnb a de0nd bytheBay Am Ab PAa
• uuslay Management DblM7 BOBFR-ODMPOFNOR lOQ000 BTU)
I IYe f-1 No
vemdthe hara ous Code.S requlremnbunder Mmd2ffiM.mid BOILER-COMPODVGR IWp00 BTU) NOV 2 7 990
the GOtamth Heith bulking dean mcurr 75505,have.
and 7,tha144.I
maintained that ready the
of therrtuital as atmae•thalitbuy NEW RE9DFN'IIAL ML•(}L AFI'
ropons rilitYinnua ono a ready aauofoomperequiremeswhkh malhemel City of MfI1M
prlwbiruance daCediflotedOmtpray. y. Y
Owner or aulhodred agent Data
rornL: � 1 � ISSUED BY.. L_
OFFICE COPY /