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21115 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Suildhan Project Identification 7 L-45T. PERMITNO. Building Address: [']1 ' I D �Q S o r rs"s If 21115 ne Gene: ee AMINO T GWeLf CITY OF CUPERTINO-BUILDING DIVISION A-- ^I.-q nctofa Name: -.a e'7 Q • ��� 3,a;Nrc APPLICATION I PERMIT A -�J CLQ g��n.lCmTr.si_p(,�gING,MpCHpNICAI• CATEGORY CO C J ' Na Lin ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addrnc LICENSEDCONTRACTORSPERMITL471ANCE W W LICENSED CONTRACTORS �,GT 11, ffbmtluI lam licensed under prwWamdOupter9( AN7IANCESRP�FMIAL TOB N Ingwllh5ectbn7000IdDhde W r3 oftheBudnsaMRufe WmsCode,and rM Iketo andefat PANES �r FD , t1 Jr fJaa!1.�CUPTOWDAMPSARCNITECI'S DEC RATWN NI-1000orZ my pban eM11be usedss =Uc=c Nam&— SQ.FC.FLOORF.{ARE7 fa/SQ.FT. Ekmmedprdeanbrul SIGNSELISCTRICAI. �'7I11 '7L-K,71 DWNER-BUILDER DECLARATION AY#l'tJ y+ECIALCQtCIR'y M19C ' 1G IherebyamrmtiutI mmemptfromthe CnN ALkemelaw/orthe / L.&LL© 6AP— L8. 0"I R L^� folbwing awn.L4ctlm Ml5•Broin and Pn&mib Cody.Any dtym V 7'FMP.MECmtOR POLBINBC. ewntywhkhrequbmap.M*Wc whuMaIW.E.pr dem lid,wmpalr SD anydmrtumprbrblblmmnckaborequimtheappilcenlf"suehpermitb file a signed eatewnesm t that he Is licensed punt be the provbmbof the POWER DEVICES O$ 1� Cost es License Law(Clasping(mmrmndng with Section 7000)ofDIW SWIMMING POOL FLECIEC I�Z 07 s100 o(lhe Business and ProfeaslonsCode)urthat he be exbmpithecefromad VALUATION �r..111 the bash fm the dbgea exemption. Any ,vldalbn d9edbn 7031.5by any �� TCHESFDnIMM apPUnatioraperndtm*jntstheapPUe toadvilpmSydnnnnrethan 0 � I� Rr (Ivc,�undeed dolkn(f500). •NEWRESIDENT1ALFd.ECTR M.FT. 4 as man,of the property,on my employees with wage u thio" SrOEES TYPECONSIRU170ON mmpensstlmr,willdotiewcekadRhessroctuce bmtintenbd"offend for �^Ir d0 ssk LSe,'S 7014 Seats.and Profesebm Cade:The CovenamYa License Law1. $ dean not apply to an owner ofpropertywho builds or lmpow,theme,and whodmmchworkhim U"thmghhfs wnemptcyean,pr kWdthatmeh Na �•�� impmvememar se nom t Intended of&red f"sale.16 howermthebullding" TOTAL O Improvementksoldwithinmymrofe mpldkmtheo cone budderwgllave theiburden of proving the he dM rad build"Imp.for purpose ofeale.L QTY. PLUMBING PERMIT FEE jj L as owner d the Property,am exekstwZy ng with licensedIO.ODD TONE APN contract",to mmlmd the project(9e470K Busimsa dProfession Cade. PERMIT(MANCE ^1 e�` The Cmtndoe,License Law dean nae,apply to an oven d property who ALTER-DRAIN kVENT-WATER(EW •ar builds or 1 es rovthereon,and who contracts for such p� N jewith a Smmed pumantmtheCmaadds License taw. BACK F7.OW PROfBC7•DEV[Q FEE SUMMARY 1 am exempt under See B A P C for thin mean • Owner Dwo DRAINS-FLOOR,ROOF,AREA,GOND. SANITARY Y— N— WORKMAN COMPENSATION DECLARATION RI3Cm NB ❑I hereby affirm that I lave a oedMh d camel to sel4lnare,"a FDfRmFS PER TRAP SCHOOLTAX Y N senlficeledW"ken'CmnpermUmlmurancewamnBldmpythemfQee. gic®T 38MIabCJ CAS EA.SYSTEM-1 WC{Ol7iI.E15 PARK FEE YI Polity,# CAS EA.SYSTEM-0VER 4(EA) RRCE9R B Carry BUILDING DIVISION FEES Credited copy b herebywith thahed. CREASE/WDUSI7ti.WAME INTERCEPMR PLANCHECK FEE Cedllld ropy b(14d with the ct1Y Inspection division. CERTIFICATE OF EEEMPrION FROM WORKERS' ICREASETRAP COMPPaD ,3 COMPENSATION INSURANCESEygyyUdITARY-9TORMEA.EDP('. Date Recei t# RNesectbnneednot bemnpleted Ulla peen@b/momhuMreddoOan ENERGYFEE Y N W ImedlessJ WATFRHEATER W/VENT/ELECIR IcenffyWtoy he my person in myhewoekan an bthin permit blvd, — — I dull not empty m/peaws f mbl winner at, to become subject to the WATERSYSIFM/TREATING W"ken'CmrgenWbnfatvso(CaSfoeb.Dsse PAID Zawl'lIC6'cer,t10 AI'1'I.ICANEIL cher maldng lhbcedtilnb oftkempikm,ym NEW RESIDENTIAL PLM#. SOFT. Data c00 tg N shmidbemnmmbjMWtheWmhen'Compemlbapr istom a(the Lab" �tey0 Fftro Cd4yw rend(mthwith comply with such Provish m urthb Pan*$hall be L W 7 danmed naked. CONSTRUCTION LENDIG AGENCY SEISMIC FEE. IL Z 1berebyamwethat then b a oinstrudlan lending apWor the pedomf TOTALELECTRIC FEE �, O ancone.N.Name hf"whkh Nb pemdtbbsued 6e43D97, N.CJ 7a O LL ders O Lenf IedehMdress QTY. MECHANICAL PERMIT FEE PLUMBING FEE O W Imnifythdlbavemdthbapplkatbnad Wwthnlheabminfamrdlm MECHANICALFEE bmeat.lagmtocaiWlywithaBckyadmuntyodina amdmfelaws PERMIT IAUANCE 1-1,0b FEES PAID _ �\A►�dQ IL missing to building construction,and hereby nuthatches repmenbtives dthis F Z city to enter upon the above-menthand property for Impaction purposes. ALTER OR ADDTO MBCH. Date RlCel t — (We)arm beam indemnify an d Peepmd ha0eas the City Cupertino agaba Us b llea,pdgmmb,msssad nwhkh maylnany nyaanue AIR HANDLING UNIT Tf0 10,01DDCFM) SUBTOTA agaWts sequene ( e cel dthls prmlt 1 1�._ AIR HANDLING UNIT gWFR IgWOCFM) C NSI'RUCTIONTAX Signature t/ConlrM" t �I—jJ EMtJSTFKXro(W/DUCI) CONSTRUCTION TAX ID: 11DOUS MATERIALS DISCLOSUR Will the applicantorfuture building occupant mom or handle bgssrdws HEATING UNIT CM 103,ODD SIU) nakrbl as defined by the Cupertino Municipal Code,Chapter 9.17,and the Dade Recal ttt 1 Health and SadetyCde Salon 2SM(a)? HEATING UNIT(OVER 1OUM#TLB ❑Yes m arc No TO L: L14t3. Willlheapplimntbulldlegoovpamusenplpmed ordevicss VENDLATIONFAN(SINCIERFSID) ISSUANCE D which emit haadm W mnnmwnt,ss defined bythe Bay Aron Air PAIR • alltymmsipmol DistrW7 BOR.ER-COMPOHPOR100,003R•TL)) Yan No w mad the has ommderbb requircmenbunderChaper695 of BORER-COMPS)VER IgDp00 BM NOV 2 rt 1990 the Califamb Hankh 6 SafetyCoae,Sedbm 75505,]5573 and 75536 I understand that lfthe budding does not mrrenlly have a tenant that it Is my. NEW RESIDENTIAL MECH. SQ.FT respormubfiity to notify the aempnt tithe requirements which mat be met prior to leuanse daCeNfkateo(Oaorpanq. a Bf Cllnftl}il+� Owner"authorized agent Dale TOTAL: s ISbT7EDBY: OFFICE COPY