19997 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PrvectIds tllkelm a� PFIMIT NO.
ddrta:
Building A1� C
2
. 19997�►� �� s3 W
rcr• arse: /� E�,.��ca ort.
4�PC. P CITY OF CUPERTINO-BUILDING DIVISION
ContranW.Nacre: Lk.N. APPLICATION / PERMIT 10
BIIILIX aBCTMCAL.M.LWINGMECH LAICAL CATEGORY CONTROL I
Archtlen/FaRlnKlr
le.N.
2- - - BUILDING PERMIT INFO
QrY ELECTRICPERMIT FEE
Add— 66q L, � ` c PFRMITISUANCE
LICENSED CONTRACTORS DECLARATION o
I hamby.(firmthat l am licensed oder provisions.fCh.piet9(.c. APP,IANCESRESIDE1,111AL JOB DESCRIPTION
ingwith Sectloo7f100)ofDivlelon3ofthe Busireeand PmfeaNevCede,and my -F{�i�( ,�-\, -
llar�b�ln�n��funl�force
E�and affect.
�� __ PANELS ' `` ` �-r _
Date LC.ntrad.r_KalmanMechanical
ARCHITECT'S DECLARATION
8 0 Z I understand msed y plane shall be uas pubbe record& OVER I(W AMPS SQ.PT.FLOOR AREA S/SQ.FT.
g
Licensed 1'rdwbv1 SIGNS FdJ=TRICAI,
OWNER-BUILDER DECLARATION 5]'FCJAL❑RCUR/MLSC
1hereby.fnm m rthat aeaempt I.the Contractors License Law for the
FSE Q following newer.(Section 70313,Business and Profeelons Code:Any city or
county which requires a permit tomnatmtl,ahertroprove,demolish,or mpair TEMP.METER OR POLE INST.
y .nystrumrre prim to lb bsuance,abo requires the.ppuont for such Fermat to TONER DEVIIXS
K ole.signed statement the he Is laon d puesuant to the provbbv of the
Contractor'.License Law[Tisassm
9(comerel with Section 70000)of Div
+Si O�^ nbn 3 of Hie Bu Now and Prdrsinv Code)or that he b exempt therefrom sodF SWa1MIIC POOL ELECTRIC, VALUATION,
the hub for the eleged exemption. Any violation of Section 7m15 by any WTLEISSNTTCHESFlXIURF_S
00�� apphontfora peroomsrt subjects the applicant to.civil penalty d not room than
I" t
five hundred ddbes(S.SOB). NEW RESIDENTIAL ELEUTR SQFT. STORIES TYPECON'STRUCHON
I,sa owner of the property,ul my empbyees canis wages es offered
fo
mmprosatlon,wllldotk wmkand lite Nructurebmt uaeodedor offered(or �.
Od (Sec7plytos oi.Mipmpeby Cade:The(bntr.ctorshe melaw
flls� dxsmt.aach oanowvrof Pmugh hisonlldsorimprmvprooided that
-uch OCC.GROUP RES.UNT13
0.0. Imamwhoda eris amrkhMse Intended
Msowne.If,ho ee, praise dthat gor
ImprovemeMsart wt NtendM oroffered imitate.If,however,thebulHingm TOTAL: ,
Mprovement bold suithill.nays.rafcmnpletbn,theowner-0uiiderwlll have
tllLpirden of proving the he did not bund or improve for purpose orvle.). QTY, PLUMBING PERMIT FEE
LI I,as owner of the property,aercWelvely contracting won Peeved "F1ODD ZOVE 'V'IJare,
PERMIT ISSUANCE
mntnciun m construct the project(Sm 70K Bushes aral Praf®bv Code: .
The Contractors Llmnae Law does not apply to an owner a property who ALTER-DRAIN kVENT-WATER fJT,U r _
hand. or Imp.theme , and who mMraeb for such pto)ob with. FEE SUMMARY
f�coss)licensed puesuant to the Convict.'.License Law. BACK FLOW PROTECT.DEVICE
IJ 1 am eaempt under Sec B k P C for this renin
- DRAINS FIDoIt RODF,AREA,GOND. SANITARY Y_ N_
Owner Dale RCCFRT 1
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
®l hereby.Hlrm the 1 have•certificateinto of.seem,i.Pyth. a,(Sa RECEIPT
38W,Lab
Workeri Cvmpewtlenlvunnaa.artBled copytherto((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARR FEE Y N
3Policyit c)0610040779 RECEIPT e
Comppppppaaaaaa ray a Sao 1n5.. C� G! FA.SYSTF OVER A(EA) BUILDINGDIVISIONFF.F.S
�erllned copy b heed with Me eity CREASE/1NDU9ML WASTE INTERCEPTOR PLANCHECKFEE
Ced Wed copy b(fled with the mY inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR.SANRARY STORM FA.70(IF7 Date Rct>=i ted
(Thbaectbn need not bo completed tithe pemdt b fmoro hundred dollars
($I00)ofythut
I WATER HFATER W/VENT/EutTR ENERGY FEE Y N
certifyBy Hb rise perforrtunaef the wak forwMeh this pemdt b issued, —
I.hau nM employ.ray peesan in any canner m u to become subject to the WATER SY67}M/TREATING
Woken Corepen atbn Taw.of Califcrnia. Date PAID
0Z Applicant NEWRESTDENTLALPLMB. SQFT, Date Re¢ei t((
Z G NOTICE TO APPLICA T:If,after nuking this CerlHlate of Exem bn,you
should become subject to the Workers'Comperuelor provbbe of the labor TOTAL:
N Code,you m me forthwith cannplywlth such proWabna or this pemat"I be
deemed revoked. BUI DING FEE
W-Fn CONSTRUCTION LENDING AGENCY - - SEISMIC FEE
Il I hemby.fnrmthat then Is,a construction knding agency for the perfornF ELECTRIC FEE
Z dna cfthe workforwhkhthis perunkbbsued(Sec 309I,CW.G) TOTAL:
U O I<�der:N,me PLUMBING FEE
LL 1<edcre Addrms QTY. MECHANICALPERMIT FEE
0 W Iarl"at l have read this appuutbn.M vewormeim0 statethm lheaboMECHANICAL FEE
S iscorrect.I agrectocomplywhhan cityard coanlyordirunms.nd cote laws PPRhvr ISSUANCE FEES PAID:
} ay toenter
nupon
ohereopertyfor ori inspection
n rtprerntativn ofthis
1"' N
city Wa)a nertosheabove.mefy,and propharroLinspe Cit purpose.. ALh7t OR ADD TO MSH
Z (We)agree to cove,WemN(y,and keep F.nMew the CNy of peHhn Date Recel Ip
U agaiwtnabWne,pdgmenb,mk..Mexpenaewhkhmayin.nywayam a AIR HANDLING UNIT(To to,"CFM)' SUBTOTAL:
-
against said City In coneequerae of granting of this Pemid.
MR HANDLING uNrr(OVER 10,aoocFSD CONSTRUCTION TAX
Igrulum of Appno t t a IA FLHiAUSr HOOD(W/DLXM CONSTRUCTION TAX PAID:
HA]ARDO Silding Apa DISCLOSURE
0000th, shoed by the urtbulidingoecvpan ode, hapten .h,andthe HEATWGlJM7(TO 100,000 BTU)
rruterlal as defined by the Cupertlro MuNdpal Code,Chapter 9.17,and the Date RCC¢I [N
Health and Safety Code Section 75532(x)7 HEATINCUMT(OVER ID0,0DD BMTOTAL: Q (�
MY. . No
Will the applies M or
him building oovpant use equipment or device VENTILATION FAN(SINGLE RESID) JS'j§WATE
which enat haardous air mnlamWMs as defined by the Bay Area Air ��"'w/+�R�V�a -
•
Quality Management Dalret7 BOIIER-COMP OHP OR lWX1(]BTU)
4Ye No
bveread the harma materials requirements under Chapter 6.95 of BOILER{OMP(OVER IMAM RM) JUN 2 ti 1990
the California Health k SafetyCode,Sectluv 25505,25S33 and 75536. I
uodan.od that lithe buudingdoes rut currently have.tenant.that It is my N'EWRFSIDENLIALMECH SQ.FT
rvponamuity,to notify the occupant of the requirements which moat be met City Of
CUaa""D
primtolss..ofa CeHlflov of Parry. /' a�f .--.MMI Vt Wagif�
,Ownerar suthorirN agent Date ISUEDBY:
TOTAL:
OFFICE COPY