22953 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identlfleatlm PERMIT NO.
Building Address:
�3 \Y%C- . 22953
rc eros: yAS�5NQ'A-slip°"t' A
Q,. CITY OF CUPERTINO•BUILDINCDIVISION �y
tradara Nam. LIQNm APPLICATION /PERMIT
110�1brara•s— Otib 3%%SBLUUXNC-MW CAI.PLIMMIrA C "W-AL CATEGORY, CONTROL F
ALIQ N.
OTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
LICENSED CONTRACTORS DECLARATION PERhff'I755UANC8 1:1 E
I hereby affirm that lm Seemed under povblonaofChapter9(cwnrnui APPLIANCE' RERDENTIAL JOB N
IngwithSedlon 7090ofOlvidonl ofthe Buslrwand Pmbaalom ,and
Br Is f.fuBfomandeffect. PANELS _
License Cines 1.re.Y .,].
Date Comacim �� '` C)
ARCHITECTS DECLARATION 7014990
OZ Iundendand my phmaballbe used an public remora OVERIUMAMPS SQ.FT.FLOOR AREA B/SQ.FT.
Llxmd PcofmLarcl SICNSELECTWCAL
OWNER-BUILDER DECLARATION
IherebyaOhmtNllmexemptfn theComnctmOs Lke lawfwthe SPECIALCBtCTR'1'/MEC
r�°°°JJJo following teuar.Reellm 71111A Bnalnm and PmfmWu Cede.Mydtym
oatntywhkhrnrybmapmNebmMmttaBeylmpmve,da llabcrrepalr '' ORPOLB ANSI'.
t anymelu
OmPrWwubibimaabrcquimtheappU=tfwmchpemhro POWER DEVICES
R 81 foe•dphnd statement that he b licensed purmmt to the provisions of the
G61 It�� Cmbadore License law fCNpler9(mmeenMgwith Section 7000)of DM.
�J 6WIIaAIIbIGPOOL IBFCTEC
don oftheBuabmand PeofmlwuCode)wm
that hebexemptthfmmand VALUATION
�'.•77
the Into for the alleged eeamptlm. Any violation of Srnbo ms by m
I3� appBwnt two pem*asbkdetinappBeanttoa civil pmnyofnot marethen OUTLE158TN7c Es-FOmntjE;
f[MInendred doll.0500.
as owner of the property,w my employees with wags as their sole NEW RERDEM7AL ELECTR SQYr STORIES TYPECONSDUXTION
5r compercdlm,wmdotework,and thermatmebnot Intended m offend for
t$ sale 05tQ 704 Babm and Premium Cada:The Coatrecier.Llmme Law
K R dam net apply roan owm of property who builds w Imprtwestheter,and OCC.GROUP R6 UMTS
6666 whodmmehmrkhlmwlfwthrmghhlsownemphym,pr idedthatsueh
Improvememmro intendndwoffuedfwsmk.l4ha r.thebulMbgw TOTAL
improvementhaddwithinomymrofeompldbRtito n-buWerwNhave
1 rdenofpro•Ingmdbed[debuddarlmpmvefwpurp aisale.). QTY. PLUMBING PERMIT FEE
LI L m mater of the property,am exclusively contracting with licensed FLOOD'dDNe APN
contoctonbmmruct PEtA97'ISSJANCE
the Prokct(S-.704 Bodamand Pmfemk=Code:
The Cordndoh Liam Law dew net apply to an owner of property who \S-
budd.w Improves thereon,and who mNncts for such pWpft with a ALTER-DRAIN4VENT-wATFR(BA)
n984aderWilmsed putsumttathe Cor adds License Lour. BACK FIDWP�'BCT.DEVICE FEE SUMMARY
L.f I am oemp under Se. B S,P C for thin masonOUTSIDE PFFS
• Owner Deb DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION P �. r SCHOOL TAX Y�®7F
QI hereby affirm that I have a certificate of consent to eelf-bsuw,w a �a
cadincatemworkm'Compeneaaonlrsurmce we codified copy thereof0ec. RECFNTI
35m,Iabca GAS EA.SYffEm.t INC4oumm PARK PER Y_ N—
Polity a GAS EA.SYSTFMOVER4(EA) DINGRBCMDI F
a�mReny BUILDING DIVISION FFFS
LDTJQi CLseedBled a"herewithhy the city GREASE/PIDUSIRL WASTE BTEIR:SPTOR PLANCHECK FEE
dated oapy b filed with the mY Inspection dblatm.
CERTIFICATE OF E7OMPrION FROM WORKERS' CREASETAAP PAID
gSATION NCB SEWERNRARYSIORId EA 700T Date Recti QB
OMsaect the b(worchundrnddollan
0100 WATER I'MATER w/VENT/MMM ENERCYFEE Y N—
I ffythat blhf for Mich thin Prig is based, — —
IW TlamCemploy nn as to benne asb(eat to the
-ATE(SYS1PtAm(EATINc PAID
O
Z Z A load NEW RFSTDE1,117AL PLMIL SQ.Fr. Date Recei tR
O a kat of Pxmptbryym
F N ahonld w bone Werke mdlonprovlom o((the Lelr TO'PAL:
Cada hwahmmpiywlthwrchpmvbbrewthbp.,n*Wallbe
� > dBUILDING FEE
'a C •CONSTRUCTION LENDING AGENCY SEISMIC FEE
I berebyafflrmthet them is a construction londingageacy ford perfornt,
Z anceefthe workfwwhlehthbpemmhe bound Dee309/,Clv.C3 TOTAL ELECTRIC FEE
V O land ee.Nam a PLUMBING FEE a\
LL H Iender.Addrea _ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
IondilytlutllearanslthbappBcetbnardetatethattheabwebfonm I=
O W
bearmot lapftW VlywlthaBdtyandmuatyotdlnanceseMmwiam PFRMTTI$UANCE FEES PAID:
} Wndating tobuilding coMmction,and henbyauthoriwmprmnbtimofthb
F Z cnylo emiruprn the Abnre-meatkmed pnspedyfw lnspetllonprrpes, ALTERORADDTOMECiL Date Reeei !M
� — (We)agree W seat,hdharmlesslly an d Exp harmless the city y Cupertino
age cat WbWUn,frdgmem,a 5BDd espenses which my lnanywaymmer AIR HANOUNG UNR(TO mm cphO SUBTOTAL:
Chyle of the granting of this
AIR HANDLING UNIT COVER IQDOCBO CONSTRUCTION TAX
SlgnsNre of Applicant Coamelor Ones EWAIJSTHOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or feum building occupant stare w handle harardoes HEATING UNIT CEO IMAM BM Date R9cei t#
cas eMdefined
l as by the Cupedim Municipal Cade,Chapter 9.17,and the
lbppilamwb
althand Sa(elyCodee SShedbn UM(a7 HEATING UNIT OVER I%=BTN TOTAL:
y.m.,
mmbu0dingocedpantuwequlpmemwdevim VFNIIIATK)NFAN(raNGLERESID) PSWFU DATE
which emit mmsus air coolandiume a defined by the Bay Am Air
alBy Management District? BOEFRODMPOHIPOR70R00STU)
IT. 9 No
ve and the Fara nesmandate requlnmenb underChepter 6.95 of BOEFR-COMP(OVER 103,099 BTU) NOVI)I1�
lh.Callfam Health ASafetyCode SeSections25Sm,75533 and 7557IT 8 1994.1 YY
understand that lithe building dean not currently lave a tenant,that it is my NEW RESIDENTIAL MUM gQ.FT
respmWllity to really the occupant of the requirements which mat be mm CIIY LIF wF'EHIlow \p'A ]
phew b imam of a Certificate ofOccapany. Vf� .
Owner w authorized!agent Date
TOTAL: ISSUED BY:�
OFFICE COPY