19999 APPLICANT TO FILLININFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLYBuilding Pro P rND
Building Address: wed r
-12400 _ Cls ( 2
ra CU J CITY OF CUPERTINO-BUILDING DIVISION .�
eonverior'a Name: Ue.No: APPLICATION /PERMIT
® ATFx /Englrcerr� /l Lr BUfLDINGELECTRIGV�PLUMBINGMECHAMCAl CATEGORY CONIROL♦
Z L," BUILDING PERMIT INFO
k-
QRICTY ELECTPERMIT FEE
Add— 6 lS -ST, F trERhurlssunNw ❑ F-11:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Beevcd under pewieloes of Chapter9(commrn APPLIANCE -RFS)DENTIAL JOB DESCRIPTION
In 7000)of on 3ohe BAmand ProldonsCade,ad
license isle N11foce and off �
PANELS
D.tn_ Cbs/,_ /AQ �Ka I r
Date_(T _ 7r7i�7S Convenor Kalman Ma anical
ARCHITECTS DECLARATION 701-1000 AMPS
Q 2: IuM �
eand ryp6vshalllx used uPubBeerorfa OVE $M,R1000AMPS SQ.Fr.FLODRAREA S .Fr.
OdE Lkere I'rufesv
ial SIGNS E[ECIRK'AL
1<<% OWNER-BUILDER DECLARATION SITLTAL CBtCU1T/M19C
Q
Ihereby affirm m that l aexempt from the Comranorb License law for the
qq ult wingason
re .L5e'ctlon 7015h
,Buses rof and Pions Code:Any city ar
Lt'ly muntywhkhrequl apertNlromlulruMeter,lmprw demolbh,orrepar TEMP.MEfFR OR POLE INS(. x
S5y� anystv mpriortoibi mgaB requb theappBuntfmauchpert to
15 K << Ole a a1 ed statement that he b eeeeued
POWER DEVICES
y U B^ pumunt b the provWov of the
Contrad.e.Lice.Law(Chapter9(oommentlng with Section 7000)1 D1- SWIMMING POOL ELECTRIC
ebn3ofthe BudvaaandPMmbv Cede)orthsthebexemptthere(romard VALUATION
STI.•]I the basis for the alleged eumptbn. Any Wdatlon of Section 7(815 by any
ga <Z appBont for a permit subjects the appileant to a civil penahy of net mom than OIITLE S_SWITCH ES-FDCTURES
p. 0 flte xu ird dollars f,$.SM,
�n I,as owneraflhe property,or my e..pbyceswfth wagnu theirsole NEW RESIDENTIAL SQ'Ff' STORIES TIPECONMUCI70N
roma 5,e.7on,velddothewmk.andthe,Code: hrotd.aedoroffemlw
O role(Sec. ppkirteanowner PMe®Iov ho W ilk CodnnolaLavelad
Sg don noessu&w anowrcrofthroug h1sa nemporlmpmvetkrtotsuch OCCGROIIP RFS.UNITS
wM1odceswchwaffitse dedororgh hlso un .11ihcwn rwdedtheirgm
improvemed5arenetblendedo rofco pl ub.14however, Uder ldingm TOTAL
improvememGadd wdhlnovyvrofcomplNon,the vxner-bullderwlli have
t"raenofpmvingthxhedid notwudorimpmveforpurpoesofsale.). QTY. PLUMBING PERMIT FEE
u L u owner of the property,am e¢Waluem
ly ntraivIng with Ibenaed FI.00D?ONE APN
convsetms to mvtrud the projeet(See 7044,Business ad Profmbv Cade PERMIT ISSUANCE gsyx
The Contractor's Line.law dm net apply to an owner of property who ALTFR-DRAIN&VENT-WATER(PA) l.0
builds or imp.therms, and who rorReada for Such pTojeris with a
Natr+ctor(s)Licensed pursuant to the Contraries Licenr Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B &P C for this reasonOUTSIDE FrES
Owner Date - DRAINS FLOOR,ROOF,AREA,CONI. SANITARY Y_ N
WORMAN COMPENSATION DECLARATION 4
K
.:a hereby affirm that I have•certiliate of concent to aeff-Inure,or FIXT IRE&PER TRAP SCHOOL TAX Y_ N_
contlficae of Warkers'CompereationIrounces¢m.certffied ropy th,.QSsc. RECEIPT N
min,fAS ab C.) GEA.SYSTEM-1 INC40UTLE15 PARK FEE Y_ N
I'dlryl nl;ln GAS FA.SYSTEM-OVER4(EA) RECEII'1'e
Co ny W BUILDING DIVISION FEES
�Cenlfled ropy is heretumished. GREASE/WDUSTRL WASTE IMTFRCEPTOR PLANCHECK FEE
�CertNed ropy to filed(Red with the city InspectiondiWim.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEtiVEIy5AM1•ARY SCORM EA m(Ff Date Recei I# '
TThis section need net he completed ff the perm@ b forom hundreddollar
almloalo.7 wnrPR HEATER w/vFxr/ELECTR ENERGY FEE Y N
I centlfy the In the pedormemof the work forwIdch EM.permit le Issued, —
I Shall not employ any Peron In any manner so as to become vbjee to the WATER SYSTIM/TREATING
Wmken'Compenutbn La..(California.Date PAID
O Z Appheant NEW R SDENT AL i LMB BQFf Date RLroei 1#
Z O NOTICETO APPLICANT:If,after rnukl�thls CertBinh of Exemption,you
Should become subject to the Workeri Comperoatlon provisions of the Labor �ULDNGTOTAL:
N Cade,younuetfmthwhho piywthnuchpmvbbvorth6pemJ gibe
W > deemed(evoked.
CONSTRUCTION the vmoNLENINNGAcwCY SEISMIC
Q. IherebyafOmtFatlhert bsronntrurilon kMingagenry for pedorrtf TOTAL: ELECTRIC FEE
= Z arm ofthe wohfarwhlcM1thb permed bliued(See 309'/,CIv.C.)
U O knderaN. PLUMBING FEE Q
LL F Landes Address QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certUythat l have madthisgpl tlenand stale that the above bfmr,mon
fl broreeri.Iagereto comply, mty with all CRY and usordtnmoos and state laws PERMIT ISSUANCE FEES PAID:
} relating to building mvtruction, ed hereby authwU rtpmentaHvn of this
F N dty to emerupon the Sbove-mentbrcd Property for imperibn Pup.. ALTERORADDTOMIECK
Z (We)agree to save hdemnlfy an d keep hander the City of Co pertino Date Receipt#
I..� agaWt BabRltbt,pdgmems,mstsuydeap,vn which may In any way amu, AIR HANDLING UNIT IO 10,tDO CFM) - SUBTOTAL-
against said City immneq.e of the gas ming d lMS permit. AIR HANDLING UNIT(OVERI0,(XOCFM) CONSTRUCTION TAX
�S CONSTRUCTION TAX PAID:
gvtum o(AppB nt ntrador Date EXFiAUSi FRX)D(W/DLCO
11AlA DOUS MATERIALS DISCLOSURE
Will the pph.rt thefuture bu
prtirto goovpart xore or hhandk ha and
HEATING LINTT(TO 100,000 BTU) Date Recel t#
matcdal as dell red!by the Cupedlro Municipal Cade,Chapter 9.17,and the
t❑alt'aa SafetyCade,Seetloon2S532(a)7 HEATING UNIT(OVER 100,OOD BTU) TOTAL, O
Will the applicant a❑future building occupant use Nuipment or devim VENTILATION FAN(SINGLE RESID) ATE '
whkh emit hazardrnu air mntamharda aa defined by the Bay Area
Qu IRy Mavgemcet Dbirlri7 BOIERCOMP PHP OR I OUM BTU) I'ta• ,
®
&Yes No have read the ha:aemtedals requirements under Cha pier 6.93 of BOILER-NMP(OVER I 00,000 BTU) JUN 2 6 199
the Cam
lfola Health&Safety Cade,Sectbv 75505,75533 and 25534. I
understand that ifthe building don not currently have a tenant,that It Is my NEWRESIDFNTIALMECH. SQFr. .
responsibility to notify the oavpant of the reqummentawhkh must hemert MV ooe�tinP
prbrto Lvuancede CartlOatc /Oaupamy. W CLa VWL,
Ow-ncror authalrcd age Datet�C
'TOTAL: ISSUEDRY: .� �[
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