20012 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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I am: one
CITY OF CUPERTINO-BUILDING DIVISION m C tr� /1 f���
c bads? Nam: En.No APPLICATION / PERMIT l�
� BUILDINGaBCTRICALPLUMBINGMWL MCAL CATDGORY CONTROL,#
A Ited/1sgt L
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— bC tf L—S&1ajtjs S F PERMITISiUANCE ❑ ❑ ❑
ILI
LICENSED CONTRACTORS DECLARATION
Ihercbyafflrmthatlamllceroedurdepr wv ofChapUr9(dxrwac APPLIANCESSRFSIDENIIALBDE9CRIl'f ION
tngwith Sedbn7UW)of Divm3ofthe Bua and PmfeW C� e,and ((�� e
11¢nae is In fu doffed. _P
PANESa..4^ �-I—
uL1.La
Date (
Date Cnje/wontdor 4 UP TO 20DAM25
ARCHITECTS DEQ TION 1-10DO&M.I5
q�v M7 1 odentand my plaroshel be used n public records OVER TWO AMPS FA R INJ g/SQ.FT.
c� Licensed Pro!®brat SIGNS ELECTRICAL P U T E R
L
�<� OWNEReBUILDER DECLARATION SPECIALCIRCUIT/ML2
Lf,<Di Iherebyafflnn that I am ERDErom eLARATIOsLl¢nelawforthe
qq b ntywhkhren.Lgedape7 5,Buan c a to rofp 4oroe=d hny dryor DATE
F �ry county whkh rtqulrnapemdt to miWrud,alter,Improve,demoLLeh,or repair TEMP'METLF OR POLE AST.
OE 7 any rtrudurc amore the he It abonq!puna ttothet rmr ehpemdt a
mea agreed rmtememw( he b BrenaN purling[to the provhmro of the POWER DEVICES /\
F,�05q Contactor'elite?ue dPC1up1er9(mmnendng .bevmptthem)dDNI-
sbn3efth<Buslnmsand Pra(essbro Cade)erthat hebemmplthertrromaM SWQ.ftANC IC)0[.ELECTRIC VALUATION
4 y.' the basis for the alki,ed exemption. Any violalan of Stolon 70115 by any
appll¢nt for a permit subjects the applicant to a dvll penalty of AM more than OUD%ISSWIICI4SFIKIURES
fivdundnd dawn M00).
A I,..owner of the property,or my,employ.with wages as their cote NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
ompewtion wRl dothe work and the structure Is not Intended or offered for
p sale(Sec.7046,Buebm aM lidexbro Code:TM Contndor'•Umroe Taw
5 dm ont applyto an ownu of properlywho buildsor improve thereon,and OCC GROLIP RFS UN175
G whodoe,suchworkhimeelforthwgh hlaownemployees,pmvkledthewch
improvemewanno tendedoroffer fmula.IL however,thebulldingte TOTAL:
Improvementha MwithinomrarofcomplebNthewvner WerwBllove
t rdenofproviogthathedd QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
1 u owner of the properly,am esclae ely camtradtng with II¢naed
mntradn oto mrotrudthe projed(Sce 7014,Buenee and Profembro Code: PERMIT 66l1ANCE
The Contractor's License Taw dem not apply to an owner of property who ALTER-DRAIN&VENT-WATER EA)
or Improve the¢on,and who mntrada for such pTopm with
")Btensed pursuant to the Coetndols Lken.e L.. RACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this reasonOUTSIDE FEES
® Owner Date #MAINS FLOOR,ROOF,AREA,ODND. SANITARY Y_ N_
REC
,..�/ WOR"AN COMPENSATION DECLARATION �4
CJI here af(Um that I have a certlfkate of cont to e<If-Iwrt,or a NR�I'ER TRAP SCIIOOI.TA% Y_ N
#Otero of Workr.
CwnperneLon Trounce or•terrified copy thereof(Sec. RECEIPT 4
3800.LES OI� 10 O GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE RECN
E -
I dky n GASFA.SYSTDA-ovER4(EA)
Com y BUILDING DIVISION FEES'
CerlN copy hereby mlah GREASE/INDUSTRLWASTEINTFRCEPTOR PLANCHECK FEE
crlifled copy b IBM Mth the dry iropMbn dlvwm.
CERTIFICATE OFIXEMPI'ION FROM WORKERS- GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 20D-T Date—
($1
ate RCSI lA
Rhbeneed n¢be completed Bthe Pe^^it bfororc hundred doRan
($100 f..)
ese.) WATERT�ATIAW/VENT/EE3.TR ENERGYFEE Y N
I certieify that m the performance of thework for whirl thio pemdt b toad,
I sha0 not employ any prreo�to any gunners oro become eub}M to the
wWA.HR SYMIMfT 4EAUNG
orker:ctenpeneatmn law.acawtew.Date PAID '
PP NEW RESIDENTIAL PLMB. SQFT.
Z Q NOIiCE TO APPLK:ANT:IL after making thio CertBlute of Eacmptbn,you DB1C Recel U7
N cissoid become nrb)ect to the wonken•Compenmatlm prvvlsbns ofth.Labor TOTAL:
Code,you nue forthwith amply with alt provhbro or this perMt shall be
W > deemed revoked. N
CONSTRUCTION LENDING AGENCY SEISMIC FEE
G FEE
CL Thereby affirm that then b•ooimtrudlan kMingagerry forthe pedorm- TOTAL ELECTRIC FEE
7 = ance,of the work(.?which this permit b homed(5ee 3097,Civ.C)
() O I<Mer's Name PLUMBING FEE
ly I- 1<M&.Addr QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O
O W te
I rtlfythel have read this+ppl4otbnard statethat theabovemmm
fouti ^�
IL hmrred.i.grtebanmplywitn.0 dry ad manrye�dma,�,ne ante l.w. PFRMTf ISSUANCE f ,Cb FEES PAID
r N relating to building mrotrodlon,aM herebyeathortam representativeofthis -
F- Z dtytoenterupm,the mentbradp for inspectn purposes. ALTER OR ADDTO MECFI. Date Rttef [M
V — (nod agree tau cowry an p �E _,
of Cupertinoagem[lhbWtfm g rets,met. ea n-viv.yacvue AIR HANDUNG UNIT(TY310,00()CFM) SUBTOTALgenated m the ntinit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SJj. Appian/Gontradar mt. F7(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Willtheappllnant or futurt budding ocmpant sort or handle h rdms HEATING UNIT(r0100,()DO BTU) DR(¢ � RCCCI tq
.tectal an deflned by tis Cuperliro Mu Ndpal Code,Chapter 9.lZ and the J�
ITna RhedSafety Cod Ion 75532()? , IAATA'G UNIT(OVER 100,00()BTI - TOTAL: Q a
n Yet o
Bl the applicant futon building arvp..t use equipment or devim VENTILATION FAN(SINGIR RFSID) ISSUANCE DATE
whic? haardwaa contaminant..+deRned by the Bay Area Air
• Quality Managementtrtd? BOILER-COMP OTB'OR 100,IXD BTU)
4Yes o
havertadtheh wemlc abrequOemnbundcrChaper495a! BOMEROOMP(OVER iwmBru) (
the Callfomta He. 'r.fety Cade,Sedbro25505,25.573 and 25534.1 JUL 31 1990
underaaM twtilthe Bding don na mrrently have atenanL that ltbnry NEW RESIDENTIAL MEM. SQ.17.
naporobBlty to pocv the ocmp."15t rrqumnx,5IwhJx1 must be met
prbrtot of Cent gamy. -d , ..!• ,�` , .
Y 7 3/�a Clh! ^"�
l�a
Outhodaed agent Date TOTAL: JQ'VT ISSUED BY: r II
OFFICE COPY