22951 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pam Identification PEJUd1T11'O.
Building Andreae 22951
Name o q our CITY OF CUPERTINO-BUILDING DIVISION
l�tJea....mo..�ce�
eraoreNamr. 'Tp LIa.N� APPLICATION /PERMIT
• - 3585\ BtnLMNC MBCDDCAL-PLUMMW-MBCHANKAL LCATEGORY, CONTROL
A}�Ren/Foglneer. I.k.No:
KNZ3 VM C-53 L a on ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITL95LANCE [:] ❑
LICENSED CONTRACTORS DECLARATION
1
1
emebyaBhmthatlamBcmwduaderpmblauafClupter9( A"UANCESRMDEMTAL ]OBO®CRWTRIN
Ingwlth5enbn7ODD)ofDivWon3oftheBusi a aMPmfedmCodrandmy
theme is In fug fors and effect. PANELS
LbxmeClass Llaa Cz) O \ QTS
Date Generator
ANCHITECTS DECLARATION 701-IOOOAMPS - FLOOR
G
{Qu 67. luderbndmypbmshafibousedispubge teondA OVERIOMAMPS DI � S/SQ.Fr.
E� Limmed Pafewhmal SIGNSELECTRICAL . El FAL E
Isn OWNER-BUILDER DECLARATION SPECIALCIXCN7/ML9C
�t; IherebyaMmthatlameuu"fmmtheCau eaLkemlawfmNe E R
gal pppOq folbwing rtaeon.healon 7E1 9mins ad Pmbwbm Cdr.Mytlty or
Pg 7 aauntywhk requbeapemnmmnama,dhr,bnpmvydemobl orr"Mr TPAD'.MEItRORPOLEIN31'.
7
aft
POWER DEVICES DAT
5 fib•signed statement that 1.b Seminal Formant to the ptovlsbm of the
slmallho lld..aicense w(Chapter9(mrmrennngwnh Station ADO)o(DWI. SWBdA4NC 1OOLEFI7EC'
elon3aflheBusbessad Pro(erbmCade)ocelot hebeaempt eherdrmad VALUATION
the bels fs the alleged emmpti n. My violation of genion 7011.5 by any O(T LITISSWCIC ES-FDMIRES
applicant fora permit subJcmtheapplk•ant tea civil penalty dace morlhan
nv,�mdrd talus Dg00). NEW RESIDENIALELBCTR SQFr. srolIIES TYPECONSIR(ARION
L as ower of the property,or my employer with wages an that,sole
mmpemagon,will dolheworkadthe nnulun bra Wended m offered for
sale bee 70K Bum ss and Pumeaiom Code:The Camrdors Leeme Lw
td danatapply WmowerofpapereywhobuiNswlmpmvesthae sod OCC.CROUP RES UNITS
==Pp
hlsownemployess,pewidedthatueh
Wpavememsarsotbteededoroffnedformle.U loom ver,thebtildings TOTAL:
improvemembsldwhbiaomysrofeompLUagthe a erbuilderwEhow
the.burden of paving that he did cwt build or kmmpave fa purpoa of ab.). QTY. PLUMBING PERMIT' FEE
LJ L m owes of the preperty,am exclusively contracting with 14emed FLOOD TONT? APN
contractee to comMcoct the Impect(So-70%Business and PafemicasCode: PFRMITEMANCE
T1s ComtaGera License Lw dm nor apply b an owner m papery who
builds or Improve,thione,and who common for such p(ejeon with a ALTELDRAINk VENT-WATERff )
. 4U
Seemed purmnttot a Cmteonrs Llsme Law. FEE SUMMARY
Lj I am ercmpt ands Seo B k P C for this ran BACK FLAW PROTECT.DEVICE
Ower Das DRAINS FLOOR ROOF,ARBA,ODND. SANITARY Y_ N— .
WORKMAN CCMPFNSATION DECLARATION ABCFST/
[JI herby affhen thin I leve a omrte m lBtom nl he sebbsor,s a FDffURF8 PER TRAP 5CHOOLTAX Y_ N_
rml0mem Wskm'Compemumlenlummrsocemacemtifkd copy thema((See. RECEIPT 9
36MI, bC) GAS EA.SYSTFM-T INCA our ers PARK FEE Y_ N—
Policy
RECEIPT 9
P EI GAS EA.SYSTEM.OVER 4(PA)
ey BUILDING DIVISION FEES
cElfid copy is hereby furnished. CREASE/IVDUSIRL WASIR IN1lg(CPl'TOR PLANCHECK FEE
to trilled copy b filed with the my inspection dlvidm.
CERTIFICATE OF P3iEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7D�T. Dene RMI tB
ONssetlbnnasd nor becompleted lithe permitbfsonehundred dollar
1310111)celess3 WATER FIE,\Tl•RW/VEM/ELBCTR ENERCYFEE. Y_ N_
I certify flue N the performance of the work for which this permit Is hawed,
I shag nor employ soy poem N any manner so an to become abject to the WATER SYghM/7RE\TINC
Worker'Compenatlen lawsmGEomb.Date PAID
Z O ANO CE TO APPLICANI:q after making thinCenBkaleofEaemaptibon,ym cant NEW RESIDENTIAL PLAfE SOFL Date Real #
WcoM become subject he the Wonder'Compeeamim pavbbe orthe Labor TOTAL:
U) Code,you mutfMhwith complywltharh pmvisbm sum permit dullbe
W 7 de mad revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL C the aEmelhat then b a construction Lending a TOTAL 7 Z woof kfmwhichthbperdubbsedMea3O9�ClvCJ a\— ELI-CI'RICFEE
CY O lsndeh No PLUMBING FEE —
1- lenders Adelman QTY. E
LL MECHANICAL PERMIT FEE FEE
OW Iceai"at l have read tit p ce nd dadethatlhe above infomutbn
OL bmrrn.lagreetoean withall eftya county eminanmand note laws PFSMrrINUAN*M FEES PAID:
} N datingtobul rualm,aed kr Authorls repreemativor ofthb
1- Z city t
to
fee Inspection Purposes. ALTERORADDMMECIL
ale yr Ind and P hamde s the CRY of Cupertino Date Recei t#
U agalmetsab t d n e mthis
�dichmyinsywayaeeue AIR HANDLING UNITCCOIO,000MO SUBTOTAL
�4 AIR HANDLING UNIT(OVER IgWOCFM) CONSTRUCTION TAX
r Appllce /Cantrnor `T..Dare EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSURE
appor fumy building occupant sten or handle hasmom HEATING UNIT CIO 100,000 BM Date ROcei t#
1 as defied by the Cupertino Municipal Code,Chapter 9.17,and the
Rhamd Safety Code
Section 7SM(h)? HATING UNIT(OVER 100000 BTU) TOTAL: a —
RNo
OlTlbeipPIIm turn building occupant on equipment or devkm VFNTLATTONFAN(SINGLE RESID) 1SSPAl� T 'I'E
which emit haramme air conbmWms as defied by the Arm Say AAir B'-KT
altlyy Management DblrktT BCEIER-CDMPOHPOR IMAM BTU)
an No
• wrulthehaaamsma dalsmqubemenbunderChaptff&95of BOILER-COMP(OVER1Wp00 Bno NOV8 1991
the California Health A Safety Code,Sodium 75505,75533 and 75534.1 M"` ate
undetected that if the building doss nm surely have a tenant that it Is my NEW RESIDENTIAL MECH SFr ('—
rmpombllRybmdilythe mvpmdNemNWmentawhich emshenet CITY UI- GUPLONJ�
prior to Issuance Of flor
aCertlte ofOaupanry. \ecQCS`B'/�9J
Ownerorauthorixdagent Data I�TIEDBY: �[J
TOTAL:-
OFFICE
OTALOFFICE COPY f