22373 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Projed Ideanrkatioa - PEMIr NO.
Ba1lt(Ing�Addr s. �/ E� Ien dor ern t4 i T e�h 22373
3'i 35
rc ase. ane: ,
CITY OF CUPERTINO-BUILDING DIVISION _
can raaa •"•aa Lk.Na APPLICATION / PERMIT 9-2--91
BUTLDIN aECTRICALr'LUMBINGM HAMCAL CATEGORY CONTROL a
Archtlect/Ggircer. Lie.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
I'ERM9TISSIIANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IhehSedWnrm lD) lM lm�xd ueBuM vWdTsrof7 onsC(oo do API'LIANC617ESmFM1AL J N
Ingwithtfall7000)dpvffem 3ottheButlnessandPro/eWonsCode,and y�� ^,
Iimnse hln fuEf ddfeR PANELS �t Y� � pIG}
Llv G Lk Y 4 �J►1'Y ,
Dae ARCot[MCT'� A!'14�t ✓1
qK ARCHITECTS DECLARATION OOVF1.R1000 M� Fr.FLOOR AREA/ I
NUO{a 2 I urderaand dry phro shaE k used ss public records. �. $/S]—FT.
< (W�j LkxroM Professional , - SIGNS ELECTRICAL
alel 0=1 am aBUILDER DECLARATION SPECIALCIRCUIT/MUSC rrl 1 1
E'y�G IhcrelryafErmthatlam<x=from the Coal raccor:Llanse Taw fm the T
��— following naami.LSMion 70715,Budnesarad Profenlans Code:Any city or TFMP.METER ORPOLE INST. 1 .
P co.ntywhkhmryWapermfttomr malter,Impmv demlWhorrepalr
anyatmdumpM tatbl arce,aLwnqul OeappBantfwmchpemdtto {'T� /�O/�
file a tlgned ratement that k h Iberued purasnt to the prowbro d Me POWER DEVICES P o%
04, Contractor:Lice.law(Chapo,9(mmmenMg arh Section 700D)of DM
30 s 0.fthe Buslnmand Pmfembna Code)orthat he b exempt lherefmmaM SWErA9NG POOL ELECTI(IC VALUATION
EI y.' the bash for the alleged exemption. Any violation of Section 70315 by any L E D I N
p applicant for a permit aubpM. Die applicant ha
ant to a civil penalty d not moretn � �"�
-ETCFhSFIXTIIRFS
!We hundred dolhn(5500).
�n ❑ w
I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL EFL"IA
TYPE CONSTRUCTION
t mmpenartlm,wllldothewvk andthe Nructun bwtlntenaed or offend for - 1
5' O sale(Sc7041,Business and Profeabm Code:The Contnaole Une.I,aw
f� doesrotappytoanownerofpmpertywM10 builds orlmpmvmtkrtoR and C. �
whodoaauchworkMmol!orthroughhlnownempluye ,pm WMthatma
Improvemealsanoatlntendedorofferedfvvle.ILhovever,the Wlldlagor - TOTAL rp
4nproveare,nt bsald w thlnoneyeardcompletbn,tkowner-bullderwW have
t rdmafprmdngthatkdm not Wudorimproveforpurpoaeofule.). QTY. PLUMBING PERMIT FEE
LJ L as owner Of the property,am excWlvey corru—mg wan BvruM PERMIT PIQOD ZONE M"'
m _
ntracTas to mroteact the projea(See.70K B.mcaaand Professbm Code: .
The Coalntors I.1¢roe Law dm not apply to as owner of property who ALS-DRAIN 4 VFI`FF-WATER am
or Imp. thereon, dna who contracts for ouch p,"wlth
qnjla<taaa)Ilanaea purnunt to the Cantncor:Lberae Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for thio re
uon DRAINS FLOOR.ROOF,AREA,OOND. SANITARY Y_ N
Owner Date RECEIPT Y
WORtAN COMP ENSATION DECLARATION FIKTUI(FS.PER TRAP SCHOOL TAX Y_ N
�heneby affirmm that I have a vrtlflrate d<oroent to self-Invert,a a RECFQ'f Y
mrtiBmeof Worker'Compenstllmlrwmcev•apeNffed ropy theoeof 0:ea. GAS F.A.SYSTEM-1 INC,4 OUTLETS PARK F4R Y_ N_
3800,Yb CJ Gl _put 1100 7 RECEQ'I'Y
y L�Wqu a�.,.i�C �s GAS EA.SY5FEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy is hen' shed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
GertlflM mpybfB<d with the dtylrope tion divWm.
CERTIFICATE OF EKOAMON MOM WORK ER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA.NOFT Date Reed tH
(Thies xtlan need not becompleted ifthe permit hfmone hundred dollar
($100)orfea") WATER HEATER W/VENT/EF.CTR ENERGYFEE Y N
1¢iant that Inthe perforrrunoo(tkworksorwhicheco pesubjbToed, —
I shag rV employ any Peron in any owner eo u b become aubjet to the '
Worker Compewtbnlawa Of California.Date WATER SYSIFM/TRFAnIVG PAID
NEW RESIDENTIAL PLMB. SQFT.
Applicant
ZDate Recti t#
Z !7 NOnCETOAPPLICl to
aRermaking
cunpe CertRlvtedoxs of the
,yw
ehald becomeabjett to the Worker'Comperoatbn provisions o(thelabor - TOTAL:
CC _ Cede.You nutlforthwkh comply with such provbbro orthb permH shallk
W > deemed mroked. III ITT Mr,G FEE
G CONSTRUCTION LFNDWG AGENCY SEISMIC FEE
I herebyafRrmthattkrcba esrotrution lending agency far the perform ELECTRIC FEE �QI
M Z anmofthe.o forwhkhthbpe til su d See3097,CIv.Q TOTAL v
02 Lender•"•ne PLUMBING FEE _
LL F Lerder:Address QTY. MECRANICAL PERMIT FEE MECHANICAL FEE
Q W l artltythat l have read thisappBvtlxnsM natethat the above information
C bmrnci.Iagtee to camplywhhWcityand muntyoodlnancnand etat<lawa PEtMIFISSUANCE FEES PAID: _ 1 qN
} N relating to Wilding cc h ction,and hereby authorb repreentatives d this ` e 1
city to enter upon the sWse-mealbrad property for bupetion purpose. ALTERORADDTOMECH.
Z
Z (We)agree to save,bolm
enly r an a keep li .the City of Cu pertW Date Recei tk
ago lost liaMlltlea,ydgmems,can a rd expenses which may in any waya.e AIR HANDLING UNIT(TO 10,000 CFM)
gawt)))da IryI
he granting a tw permit. SUBTOTAL:
;vg�// AIR HANIMING UNIT(OVER 10,"CFM() CONSTRUCTION TAX
SI�lure orP=='/CR
p t/Co r Sll EXHAUST 1100D(W/DL)M CONSTRUCTION TAX PAID:
lARDD MATERcupant t RE
Will the applicant
nedb orefuture pWino Municipal
orhandle
ur9AZa rdaw 1{FATWGUMTCFO 100,000 BTLI) Date, Recei ted
Heals hl a defined by the Cupertino MuNcipal Cede,Chapter 9.12,and the
Health Barely coQ�d<�U��J�'NtO 25S32(a)7 ]{FATWC UNIT(OVER 100,000 BTI!) TOTAL:
,illYee dvTa
the apptiv tune Wllding occupant ua the Bay ntmdevim VENTILATION FAN(SWGLE RcaD) ISSUANCE DATE
which snit haement aleamnMrorua u defined by the Bay Area w '
. Quality MLwgement Els 7 BOILER-COMPPEE'OR 100,000 BTI!)
4Yea No
have reed lelth& s mtle ,S equlrem05,2SU .d Chapter 4. I of BOL K-COMP OVER tN,00D BM
the Gldomhat Ifth&Safety Code,notcum255 ,ve atand75534. I
uMeontaM that lithe buildingdoes rad mmnty have atenanL that ltbmy NEW RI9DENilAL MECH. SQFT
"apo milhytondlytheoaupantdtherequimrnent wh M1muatbernet
P to lort va olOavparuy.
Owner or au ager Dae ISSLIEDBY:
\' TOTAL:
\ OFFICE COPY