24360 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN UNLT I'IAMII N
Nuildln Project Identification 24360
IfullJinBA '903 S�,e._t"/"onJ /�-/f/'d•�1 a ,
A'
nrr orate: ^'
j F0/2, fouce 3766) CITY OF CUPERTINO-RUILDINGDIVISION
Con ator'+Na /)•),as a,�'j,`/ /�/L11c�N9, APPLICATION 1 PERMIT
IES ///'TS IV A_/ 7 3'{"ES—�_ BLPI.DING-E[,EC'MICAI,PLUMBING-MSCI IANICAI. CA'IFL'ARY COMAOI.N
Architect/Engineer: I LIe No: BUILDING PERMIT INFO
'PTY-'�:;ii'`';3:ELECTRIC PERMIT ,fef:�i`, !W FEC . RCr'-1'f.(7rdI�F1
Addm++: S'�J 4si2� PERMIT ISSUANCE m� u
LICENSED CONTRACTOR'S DECLARATION JOIi DISCItO'T ION.
Iherehyaffionthal l am licensed under provisions of Chapter 9(commenc APPUANCISSRESIDIiNML
IngwllhSretlon70DBoflNvbinn3olthe Buelnn,and l'rolnnlensCode,and my N
PANUS
license la Ia IuJ�a� �r�sd effect.
Ucens Cla++(�pI LLIr.I_39v MO2 ANTS �1/
Dale �'���a—Contractor_�•yT *.StiN R• 7�1-laN1AM15
"WRCIIITTC 9-I).0 RAT N —OV FR I0W AM15 FQ.pL MOOR ARIA SISO Pl'.
CO 7 I understand my plara,hall be used as public remrdx
O O SIGNS ELECTRICAL
Licensed I'micwtonal
S OWNER.RUILDER DECLARATION SPECIALCIRCUIT/MI9C
�n I hereby affirm that l am exempt fromthe Contractor',Llmnm law for the
following mason.(Sectlon 7(PIIS.Business and Profession,Code:Any city., TrNj',ME7[R ORI OLF.INST'.
counlywhkherqulre.aperMttocoratruct,alta lmprovgdemolsh,arrepair --
any structure prior to ib b+uance,abo requirearae applicant forauch permit to POWER DEVICES _
U file a signed statement that he is licensed pursuant to the provslom of the
04I-� Contra&or'+L iterate law(Chspter9(mmmenclngwlth SeObm7")of Divi- SWIMMING PDOL IILECfRIG VAI UA
El the baxit ho Buainm,and...remion, A.y,,i.I.tbm bexemPtm I.5byand
••]]] the Mab for the omit sit eectsth a Any t tolac.n of SMIon ent m try any OUILGISSWI"Iti111S19%'1-Jitl!S /a 7S I D D
p� <�
applicant for prrMtaubjeet+theappllcora too civil penally of not more than
five hundred J911an(A9fNB. NEW RFSIDINTTALFLECTR__SQIT SIOWIS lYl'C CONS'IRIICT'Q)1x'
1,as owner li the properly,or my eucture n with wage, rthele dfo /
UTO compensation,wllldosx.ml kand theatructure boot lnlcnJrJ or elfrnd tote —
,o rale(see 7(R4,Rnamn,and,rote,I.v Cade:Tne Cnmmcter'e Lmeme law — _ —
g .h.do,,.rhtoan owner.,p rough whoW mploymprovprovided tatsuch
and
OCC.GR
RIiti.UN119
r.'^ whodonsuchwod hlmse de through owne.if,ho a praise uilding or —
ImprovesrcntsarenotIntendedprofferedforsale.thhowever, deer ill have TOTAL:
it rden nt Towigsold than he did notfW Wild
orImthee for purpose of shave --
tfr�arden.fpmring that he did not bund or Improve rate purpose of sale.). Q1v. `t'• PLUMBING PERMIT �1 � FEE IrL000%ONIi AI'N
Oat,a, or,of the property,am exclu,Ieriy contracting with licensed PERMIT ISSUANCE
contractors to emtruct the project(Sec.7184,Business and Professions Code:
The Contractor's License Taw does not apply to an owner of property who ALTER.DRAIN&VENT-WATTR TW
Wild, or Improves thereon, and who contacts for such project.with a FEE SUMMARY
cactors)licensed pursuant to the Contractor's loose Law. BACk WP*ClTFgT. 'N E —. r--, n r� nOUTSIDE I
ng0.t.[t am exempt under Sec. B k P C for this mason •. SANITARY Y N
• Owner Urate DRAINSR
.FLOOROOF,ARRA,COND. RECEIVE
WORKMAN COMPENSATION DECLARATION FT(IURE§-PER TRAP � I i SCIIOULIAX Y_ N_
hereby afit.that I have a rerllfiesm of consent to eeir.lesurs,or a •• RI!CEIVIN
crHlllcal,m Wurken'Cmeperession hs-mnrelmacerllRed ropy Rmmuf(Sec. GAS EA.SYSTEM..INCA TI -T _ PARK ITE Y_ N_
3RW,lab C.) /O/J �}�T DIiNGPIM
38M, N �y1 Q e CA PA.SY.SfG1- "' BUILDING DIVISIONI'Iif.9
Caa "...
Cenlfled copy b hereby furnished. GREASE/INUUSf ItL WASTE '1' 2 R I'LANCI I`C'CK PGE
Kenified copy et filed with the city impaction division. /a J
/W, CERTIFICATE OF EXEMITION FROM WORKERS' GREASE TRAP _ i t AI
COMPENSATION INSURANCE SEWER SANITARY-STOW EA.ZVFT. Date I�CCCIeI#
(fhisnectlonnerd not he completed lithe permit bforone hundred dollars ENERGY PGG Y N
(9100)or less.) WATEII I IEATEIR ENLP.0 W/Vf/EIR —
I certify that In the performance of the work for which cols Permit Is issued,
I aha 11 n.t employ any person In any marc er m a.to become subject to the WATIRSYSIEM/TRGTTN'G PAID
Workeri Comperesti.n law a of Ca[if...Is.Date Date RCCeipl#
0 Z Applicant NIWRTSIDINTTALPLMR. SQ.(T.
Z O NOTICE'IOAPPLICAN'f:ILaRer makingthls Cen111amof Exemption,you TOTAL:_
should become subjCd to the Workers'Compensation provisions of the Labor �..
� LI) Code,youmost forthwith complywithsuuhprovplomorrhl,permltshallb Ul1ILQING[15—.--�.—�y�
deemed revoked. SCISMIC FGG
W CONSTRUCTION LENDING AGENCY
CL O 1lorebyafnrmtluuhem b.constmciion leedingag,ccy for the pedortn" — TOTAL; ELECTRIC PEE
7 Z ante of work forwhichmb permit J,b,ued(See.3097,CN.C.) PLUMBING FEE
O O 1.rndr,'.Name QN. MECHANICAL PERMIT •' FEE
IL F I.ceder'.Address MECI IANICAL FEE
0 W Icenlfythat l havem.dthhappllcatkm.mI ataethattheaWvetnfm.tIon pPRMI'f ISSUANCE. FEES PAI D:
1 i"mood.l agree to comply with all diyand county ordlrancn and date laws
N relating rebuilding construction,and hereby authmW,mpm,rm.tive+of this AI TFROR ADD TO MFGiI.
F Z city to enter upon the above-mentioned property for Inspection purpose,. Date Receipt#
V _ (We)agree to.ave,Indemnify an d keep harmiess the City of Cupertino AIR HANDLING UNIT(1010,MOCIId) _ SUBTOTAL: _
against llaM1illlin,tudgm• co+Uand expense.whlcherayin.eywayacerue
�_eeeInst+ayl
City ran o of lhe.Rn Ing of ml+prrmlL AIRIIANDIJNGUMT(OVFRIQ(DOCfM) CONSTRUCTION TAX -_
�6> CONSTRUCTION TAX PAID:
Signawre of Ent t/ . tact., Ix,ie IXIIAUS'f1100D(W/DUCT) -- —
fl OUS MATERIALS DISCLOS RG IIpATINO UM'C('101IXI,D111IFIL) _
Will the applicant or future building occupant store or sedlehaaard.us Dale Receipt
rwtrriala,definedbythe Cupedln.hlunlcip.ICodq Chapter9.11andthr IIG'fING I1M'f(OVER IOO,fXD il'flJ) TOTAL:
Ilrabh anJ Salrty Cal rrr��S,,nalon 2953Ra)7
Yea 00NoVPN IILAPION FAN(SINGLE RIiSID7 I$ /�, CGDATG
Will theapplicant or own,building occupant use equlpmentordevices / 1 If
• which emit havardous air c.niamlnanrs as defied by the)lay Area Air IK)ILER.COMPOI IP OR I(h)PM II'f U)
Quality Management District?
4FEBY. I—TNu BOILER.COMP(OVER 111000 13111)) FEU 1taps`e 1993
hivread the bazar u,rwterlab rrqulmrrcnt,undrrCMpter 6.95 of
the ifernla Health&Safety Cade,SedJon,B.SOS,75M3 and 2434. 1 NEW RIiSIDENTTALMECII. SQ.IT
understand that if the building does not currently have a tenant,that it 1.my IINU
nsPonaibildy to notify the occupant of the mqulmment,which must he met CITY Ur to Ur'rli
prior to l„uance of a Certificate of Occupy nay. /��.N.,����
Ownrner awhorbed agent Date 'TOTAL: ISg1JED try �"-�P!
OFFICE COPY