20043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bu lldln Project l enlfleation PER.WT NO.
Guiding Addme: �>tido �;--s,-7
Soo200,43 ,.
3
me. A
Ownern) - p CITY OF CUPERTINO-BUILDING DIVISION
Confessor's Name: Dc.N. APPLICATION If PERMIT
Ardhea/Fit L]}r., BN[AINGFI.ECfAiCALPLUMBINGMDCI IANICAI. CA7FLORY CONTROL Y
gime. No:
/ u� t Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
I&L
Addrma 06 `SS 60 S PFRMITISSUANCE
LICENSED CONTRACTORS DECLARATION , W X D
lF mbyatflrmthatlam Hcmaedurrderprw of Clupter9(om.unc APPLIANCFSRE4DENTIAL )OB DF RIVDDN
Ingwhhsctbn700Dof D m3otthe BUM. and Profe msCode and my
lice a is In full fora and effect. PANELS
Liceme Clam Lk.a 227562 - / 1p
Dde_6,22�_Coetntor Ka mil an hlan�ian1C31 PW6'1,yo Wqj
ARCHITECT'SDECIARATION M-10IGAIMPS
"rZQ Iundoretard myplars.hallbeteedaspublicremrde. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
F��f" Lkenwd Pmfenbnal SIGNS ELECTRICAL .
Q uF.�n OWNER-BUILDER DECLARATION SPECIAL CBtCN7/ML9C
Z t, G Ihartbya(B rm thatlamvemp froanthe C.rdnctors LlavclAw fa the
following rn,aon.(Section� 70315,Boex.and Professions Cock My a ty.r
t:. TEMP.METER OR POLE INST.y county which require,apermHtommtrvq alter,lmprove,demollsh,.nrtpalr
QQQ anyetruaum prierto lot ova ance,also requirea theapphaet forsuch permit to )OWER DEVICES
p 5
file a elgned statement that he is llanued po..t to the provi,lom of the
3°- Contractor'sLlcene lAw(Chapter 9(commencing with Section 700D)of Divi- SWIMMING POOL ELECTRIC
F, O d.n3o/the Busmen and Prdessbn Code)orthathe L,eaemptthertfromaM VALUATION
$ y.' theGab for the alleged easnptbn. My violation of Section 70315 by any
aPpuantforaperm sub}•aetheappkc ttoadvllpemhyofna=mthan �' 1CF�SFI%'T'UR6
6 � fhm" rdrtd ddWa($SM. NEW RESIDENTIAL ELECTR SQFI. STORI6 —=CONSTRUCTION
�n Lf I,as owner of the property,or my employee with wages a.their ease
k comperselon,wnl clothe work,and the untentre is rot Intended or offered for
❑ rale 5n.7016,Bue re,and Profealom Code:The Cordnssol.TJorme haw
don out apply to an owner of property who builds or Improves thereon,and
Ca• who dos ach work hArtmelt athmugh his own employm,provided that wch OCC.GROUP RE&L/NIIS
Impmvcmer uI ee rmt ietend.d...fitteE for nk.If,however,the Wild Ing or TOTAL _
improvemeet Gadd within oneyearofcomplet em,the owner-bullderwW have
t1qpardenof proving that he did not bund or Improve for p,rp.of k.). QTY. PLUMBING PERMIT FEE
LL e,owner a the Property,am eacfushveky contracting with Ilarued FLOOD LANE APN
PERMITISSUANCE
contractors to construct the project(Sec.70K Buen .nd Pm(ealnm Code:
The C.Nractor'a Lbenue Law does our apply to an owner of property who
Wilda or Improve thereon, and who mmram for ouch pnojeaa with a ALTER-DRAINk VENT-WATER
cpIpctor(illLLrned pumunt to the Contractor:Llan.1.a w. BAIX FLAW RtOTCCT.DLYICE FEE SUMMARY
LJ I am exempt carer Sec B k P C for thls_reason
Owns
DRAINS A,FLOOR,ROOF,ARECOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION
RECEIPT A
ARATION FD(IURES PER TRAP SQIDDL TAX Y_ N_
®I hereby ffirm that I have a certificate of cnunot to self-bnRrrt,or a te,a
certWoteofWorker'Compo Omlmuranmma¢ ifk eDpythert.fl$ec. RECGAS FA.SYSI79.1-1 INC.{OIIILE[5 PARK FEE Y N
3800,Lab G)
Policy{�—��(T(�,��L�+�-��-�(�34077 9 GAS EA.SYSI731d-0VER{(EAI RECEIPT.—
Com nY—YiGLL.laTd_ BUILDING DIVISION FEES
�L4lcertNed copy e,herebyth the city GREASE/WDUSIRL WASIE INTERCEPTOR PLANCHECK FEE
i Certined ropy Ie Hid with the city Inspection dfvielm.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONldfftNSURfE SEWFRSANTTARYSTORM FA 2()0FT Date Reeei IH
TITI,eMbn need not becmnpiaeautha pemdt dtorone h.narta a.uan ENERGYFEE Y' N
(8100)rt fess') WATER FfEA 1ER W/VENT/EL.EC TR
Iartuythe
oyany rtrawniaorthe work
tso.t I,eeomh this em,ui.I.00ed,the — —
I shat not empty any penin b my manner ar ore m become urbject to the wATTR SYSTEM/TREATING .
Workery Campen.atl.n IJws of G Wornla. Duh PAID
NEWRESIDENTIAL.PI.MB. SQET.
Applicant
ZZO Noncbco APP(TC.wr:e Workra'Co pe,certn pro
bE.s of
y.�r Date Recei tit
H N .Mould become subjeetto Ne Worken'Compewtlm provbbm of the labor TOTAL:
CC Code,you nw.t forthwW comply with each provlsbm orthla permit Nsll be
j deemed rooked: - BUILDING FEE
coNsraurnoN LENDING AGENCY SEISMIC FEE
d G Therebyellrm thet the.b a mmtructlon lending agency for the ped.mo- ELECTRIC FEE '
� Z anes.fthewonkforwhkhthlaper tl,te.red(Ser_W,Cv.C� TPTnL: � PLUMBING FEE
(� O I.ender.Name
LL I– Ieoderawddrtn QTY. MECHANICAL PERMIT FEE W MECHANICAL FEE
O Icertlfythatlhave read fhb.ppucatbnard nate that Aheabvve Wormatim
(1 kmrrnS.PagreetocemplywithaudM m
tyauntyordbunmand statelawa PERMITWJANCE FEES PAID:
>_ N relating to building mrutroction,and hereby auNmtr repro.nive atof thh
H Z city to enter upon theabu.cmentbned property for inspection purpose ALTER OR ADD TO MECIL Date Recti [#
V — (We)agree to sae,•,Indemnify an d keep harMem the City of Cupertino
.,erred Babiutk..judgenents.ma.and eapemrawhkh meyln anywayamue AIRHANDLINC UNIT(TO 10,000CFM) SUBTOTAL-
against said City N mnsep ence of the greeting of this permit.
1p ' � �.�5,^A AIRHANDUU
NCNIT(OVERl0,Im CFM) CONSTRUCTION TAX
Slgretum of AppOant/000..mmmtffFarctt�...rrr Date 7s1 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAAAADOUS MATERIALS DISCLOSURE
Will the.ppBcant cefuture bu0ding.ecupo,pore or handle lsvrdou. HEATING UNIT(TO I00,D00 B'DJ) Date RecCI lq
mahrUl as defined by the Cupertino Municipal Code,Chapter 9.1;and the
I k,hh end Safety Code Section aeon 75531(e?
HEATING uNTr(OVER tW,IID RIs) TOTAL: D
❑Ye, LJ No
Will the applicant orfulure building.eevpant um equkpmem orde4ces VENTILATION FAN(SINGLE RISID) IS, ATE
whkheMthavrdws.ir mntaMvMe+e deOned Fry the Bay Arta Airff FF�R77�1��
Qu Ilty hUmg.meet DL❑arla7 BOO FR-COMP PTfl'GR 100,0(q BTl1)4 p h; ad theh rad we LL q l m ns underCGper 6.95 of BDILERCOMP(OVER 100,"BTU) JUN 9 6198u ,
un Gklfnniaat Ifth building
atin Code,not correctly
h ..a tenant,
tfot I
understand that if thebu0dingdm not mrrtnuy have atenanl that ltlsmy NEW RFSIDFNf1AL MECH. sQ37
rvpomlbfltym
to notify the orpant of the m(ubmew
ewhich nest be rout WVof cumfi
ng
print to issuance of.CrrtlBao. Omn ancy. '
I'yYt�,,. 6
Olvn..ormthonbed agent Date TOTAL: ISSUED By..W�C
OFFICE COPY