20011 APPLICANT TO FILL IN INFORMATION WITHIN REP LINES — USE BALL POINT PEN ONLY
Kuildln Proert Identification - PERMT NO.
Building Addrnc 1 �. C16 �- . ,.. 20011
"a.-IS-00 cD , 6
r. ane: TIM MB77T=M
CITY OF CUPERTINO-BUILDING DMSION
° to s 'arta: APPLICATION / PERMIT O�D
3 r 7, OLMNNGEL=CALPLl1MBINGMECHAMCAL
CATEGORY CONTROL.
AnGttet/Fs neer. L1e`N'
QTYELECrRIC PERMIT FEE BUILDING PERMIT INFO
Add. �a ( :av SF PFR?ATISUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflmntlutlam Vcmaedurderpro Wb ofChapler9(comnen APPLIAtxICESM
RESIDE7AL _ tris rir CRII'IU
Ingwith5ecdo 7CMofDlvwm3oftheBuMl a dp fe,em Code,and Tr
11.IC n fuBlope apd�ect.sq lZ PANELS
'1
ARCHITECTS DECLARATION 1ERIOD ANI
PS
OZ Iundentand my plamahaV be used are pvbVc records OVER 1000 AMPB 9Q.FT.FLOOR ARTA 5/SQ.FT.
0° L1¢rucd Pd�lanal SIGNS ELECTRICAL LED I M
Z�
< OWNERex fro DECLARATION SPECIALCIRCUIT/MLSC P
F, .hereby affirmSatiamexamprframt and
Imi.lons Code,hew f¢the TE .
7 3 followln reason.(Section and I,Improve,
Cade: h, d or
6zt.� R y �' TFFMP.METER OR POLE A'ST.
r� cwntywhldi regulonEna s permit nce,rooreq i athe.p m.tfor.&prmit to
1 any structure prf¢to,tthan eE,lia.aoulrst tto the lorsuch permit t e POWFRDEVICES
rG � Ole a'slgned statement than k b Ikxnsed pursuant to the pmMalom of the
�w Cnntntor'aLkeroeLw(Chaptm9(co.ruffigw1hSetbn7000)ofDiv1- SWIMMING POOL ELECTRIC
�O abn3ofthe Butine.amd Prd mCode)orNathe6e rrLptthemfmmaM VALUATI
the basisfor the alleged exemplo.. My vldatlon d Se tlen 70115 by my
appliantfor.permit sub)eta theappkant too Wil penalty of out more than OlTILBISSWHCHFSHXTlJR7'S ,
five hundred doll..(SM. NEW RE9DENEIAL EI.KTR
�n ❑I,as owner of the property,or my employees with wage a.their sole SQ-Fr. STORIES TYPECONSTRUCTION
romp..non,will dothew¢k and the.trudure brut Intended or offered for
Orole not
70 apply
to an
a rofofesbro Code:Tk or imptloh Larue law
f$ tan ret apply roan owner of property is b emplrimpmovidedthatrod OCC.GROUP RES.KNITS
C whOdaaauchw mffitte df or ugh hlammle.I hone er,theedthrtach
improvement arenatbdndnd earofco for sale.IL however,thebuldingw TOTAL
r Improvement bsold whhinorcye.o/canplelbRlheownerbullderwW love
t rEenofpmvingthat he dm notbuildormyrovefeupurporeof.1c). QTY, PLUMBING PERMIT FEE
L a.owner of the property,am exclu.nely atr
mating with llrm d FLOOD 7Dt[JE APN
PERIvIT 156UANCE
onem.mn to mvtrun the pmj d�70M,Bu.lness ami I mfembv Cade:
The Comeatori Lice.Law don one apply to an owner of property who ALTEC-DRAIN 4 VENT-WATER&A)bu Bds or improves thereon, and who comets f¢welt projects with a
opiRder(O lice eed pt to the Co ntrator.License Law. FEE SUMMARY
U 7 am exempt under Sec B h P C /or this reason BACK FLOW PROTECT.DEVICE
• Owner Date DRAINS FLOOR ROOF.AAFA,COND. SANITARY Y_-N_
RECEIPT,
,,1� WORKMANCOMP� SATIONDECLARATION
yl!herctiy affirm that I have a¢mftcate a caruent to self-Iwrt,or a FT),7UfaFZ PER TRAP SC 1001,TA% Y_ N_
rt�l to afWorken'Compevatlanlwrintt or a certified copy thereof Eke, RECEIVE
3B00.11er,r•a GAS EA.SYSTEM-11NC4 OVU.EIS PARK FEE Y_ N_
1'dky, ort ro �00 . RECEIPT,
�Lny IT eQmP GCS EA'SVSTQA OVER 4(EA) BUILDING DI VI SION FEES
CrAl ed ropy b by fumbhnd, l GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE .
di ied ropy b filed with the city lespeetion dlvlelan.
CERTIFICATE OFE(EIAPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER,SAMTARY-=RM EA.fi(/T. Date RCUCI tN
(Thlasetbn need era be complied ifthe permitb for one hundred down
(510o)alesENERGY FEE Y N
.) WATIR1fEATFRW/VENT/EL13cTR
I f or le Wt in tha pcdoman¢of tha work forwhlch this pemdt b loaned,
I shall not employ any person he any manner ro as to become wbfc t to the WATER SYSTEM/TRE.ITTNG
worl er:Compen..tbn laws of California.Date PAID
0 Z Appllunt MB
NEW RESIDENTIAL FL , SQF1'. Date Reeei tp
Z O NOTICE TO AI'PLICANT:IL after muldng this Certificate of Ew.ptlen,you
thadd become abject to the Worker'Compewtbn provbbmoftbe Labor - TOTAL:
~ N Ccde,you mrd/¢thwlthaanplywlthwchpmvb morthb pemdtshallbe
LU > deemed.1uni. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffiren that there b-romrut
tion lending agency for the pedoen ELECTRIC FEE
Z arm ofthe work/or which this permit Is loved(Sec.3097,CW.C.) TOTAL
L) O lender.Name PLUMBING FEE-
U. E- Lender:Add. QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
O W 1certilythat l haverad thbapplatbn and Ratethatthe above lnfomadon
bcornxt.lageetocomplyw .UdtyaM=ntyordWnmmd� telawn PFRMH'ISSUANCE FEES PAID.
>_ elating to building conatrution,and hereby authodo,erc+ vn
pentatlofthis
y dry to enter upon the abovo-mmtbned property for Inspection purpose. ALTER OR ADD TO MECH.
Z (We)agree to save,.1rocernify an d kee humlea.the City of Cupedbio Date Recei tH
(') .ViutbablRtles,N U,amt.a an wdnloln yin anywayamue AIR HANDLING UNIT(TO 10.00)CFM) SUBTOTAL:
ed
ago x e_3j
AIR EIA NDLING UNIT(OVER 10,0q CFM) CONSTRUCTION TAX
9gv n�i — p onYrator Dam �usrlioOD(v/DUCT) CONSTRUCTION TAX PAID.
11AlA R DOUS MATERIALS DISCLOSURE
Will the applam¢futum building occupant atom or handle ha ardws HEATING UNTT(TO100,0001ITU) Date RCCe] tee
material s de0nad by the Cupertino Municipal Cade,Chapter 9.17,and the
Health.nd Safety Cme 755374)? HEATING UNIT(OVER 10MM BTU) TOTAL: 0
❑Yea
Wllltheappllant¢ uturc 1,u0ding.,.t..,ulpmentordevkn VENTILATION FAN 6I1,GLE RISID) LSS RAIL) DATE
which eMtFavNauaa rasta mbumeas defined by the Bay Area Air �tdJ fl{t'L
Qualtty M..gemen la? BOILER-COMP OHP OR 100,0(0 BiY
Ya
have rad h om
t re enbunder Chapter 6.5 of BOILER-COMP(OVQC 100,0008"U)
teeUfmbHealthhSfetyCoeStbm25505,25533ad25534. I JUL 31 1990
undmiand that it the tIuildleg dm no rmrtly have_#tenant,that It 1.my NEW RESIDENTIAL.MECH. SQFr
resp.milbilityi.,509heceeopa t nqubam swhkh mut be met
pri¢to la of dilfa pa nor Ctt•I ('a nrr, ,rHr1
Pune autharlrN agent DateJ( - (/��T(� •��/>�
TOTAL Ot ISSUED BY: -- ✓ r "^a��I
OFFICE COPY