21736 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm d Identification �'- Cj PERMIT NO.
Building\dd\:R) ',V OP \-A I I t,- C_o J�c P i,r�...) �A��� 21736
CCiY OF CUPERTINO-BUILDING DIVISION
Contract.u.Name: (� Lic.No, APPLICATION I PERMIT
UO G-�} BUTLDINGFI-Fi`IRICAGPLLIMBINGMFLf1AMCAL CATDMRY CONTROL/
- • ArehXect/F gircer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
Add. PF]NRTI$IIANQ ❑ ❑ ❑ ❑
LICENSED that ED CONTRACTORS DECLARATION
I hereby aHlrmtluofI)MMmacdunder pressandoffesdon Code,ad APPllANC6RE9DEh'IIAL JOB DFSCRD'f10N
bgwithsectbn force ar Dlvfect. (the ButlnnsmdProfesdovCode,and my
Barra Is N full/ore.and effect. PANELS
License C"-B.Llca �-7 \ - I L
Date Contractor UP TO 2DOAMPS
TOOOtiM� J V�
ARCMRECTS DECLARATION
pQ2 l understand try plans shall be used as public records, OVER I000 AMPS SQ.FF.FLOOR AREA S/SQ.FT.
d Ltomsed Professional SIGNS ELECTRICAL ✓4
OWNER-BUILDER DECLA)IATION
6 IheabyaRinnthatlamemmptI.the C.Mmet r'sLicenselawforthe 9aECIALC[RCUIT/MLSC �� 1
following ream.FeaHon 9031 S,Business.rd lhofslov Codr.Any city or 'ITR
mu my which requires a permit to constvct,aller,Improve,demolt.h,or repair
TEMP
'
�[ ilk et utlurcptementaLwaKgalm licensed
pnthattot he p ovedopeof to TOWER
K L file a d ora statement that he(Chapter 9(coon pursuant to the pmvbbv of the
O7 ContraR1,11.kenssandPr9(mtrurcncing with Section
mmptth000)of Did- VALUATION
t,�oQ tlobzslshe Buelnele and lxempt vCof,Aclhat Wbesemptthnefromard
•salt tte boats far the permit
su )couthea Any Isolation of Section does
m re any � � /h (�
(g5 60 .ppgontfara permit ubJab the applicant toss dull penalty dnct moa than 0U7LE7S tix'�
E tiv ndred dollen(x508).
NEW RESIDFNI7ALFT TR
I,as o r of the pmperty,or my employees whh wages u their sole �'�' STORIES TYPECONSTRUCTION
< mmNe ti , ldothewakandthesm=m OMm eMd or offered for
p eek CS,,70KB.J .MPrtf.a .Cade This Contradoe@Umns Law
does not apply to an owner of property who Wilda or Improves themor,and OCC GROUP RIES.UNITS
who d..&work himself or through Nsown employees,pmvbcd that such
Improvcmenu am cot Intendedoroffered for sale.If,however,thebullding a TOTAL:
improv mem Isaam wlthlnorcyearofcompletbn,tk ownerbullderwW Fay.
t risen of proving that he did cat bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LJ 1 as se
owner of the property,am exclusively contracting with licend FLOODMINE APN
mcnactws to construct the propot(Sec.9036,Business and Professions Code: PFRMR ISSUANCE
The Contractor's Lbsrue Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WArrR ffNN
builds or improves thveon, and who contracts fee such PP" with•
&or(&)pFEE SUMMARY
ry➢tfaaved pursuant to the Contractor's Llave Law. BACK PLOW PROTECT.DEVICE
LJ I am exempt under Sec B 4 P C for this aeon
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Avner Date RECEIPT 0
WORKMAN COMPL'NSATION DECLARATION pTXNItF_S P
MI hereby affirm that I have a certlDate of consent to wLf-Kure,ora ERTRAP sQi00L TAX Y_Y NRECEIPT_
certificate ofWorlums Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INC4OTILEIS PARK FEE Y N
38 W,Tab C.)
Policy I RECEIPT It
CoG• GAS FA. -CIVER6(EA)
BUILDING DI VISION FEES
Wed copy 6 hereby furnished. GREASE/INDUSTRL WA INTERCEP]OR PLANCHECK FEE
Cert Bled copy b filed wish the a ty inspection dfWJon.
CERTIFICATE OF EXEMPTION FROM WOR K MS' GREASE TRAP PAID
COMPENSATION INSURANCE sEwER-SANITARYSTORM FA.200FT Date Reeser l# 1 S O
(This section need not be completed Bthe pemdt b(o ons hundred dollar
C$lw)«Ima.7WATER T-DA7FR W/vpxr/ � ENERGY FEE Y N
I certify that In the perfor .of the wokIssued,for which Ws permit Is Issued,
I shall not employ any person N any manner o as to become subject to the WATER SYSTE,(/TREA.III
Woken Compensation Laws of California. Date PAID
PP Date Repel t#
Z O Applicant NEW RFaDFNDAI.AMB. SQFT.NOTICE TO APPLICANT:1l after mwklry tits Certificate of Fxmmppttion.you
Hy shmId become sub),et to the Workers'Compensation provlsbvofthe Labor TOTAL:
cc _ Code,you maust forthwith comply withsuch provhbv or this permit"I be C{gO.SU
W > deemed avotrd. BUILDING FEE
IliCONSTRUCTIONLENDINGAGE.NCY SMIC FEE 7302.
Z Iherebya(0rmtlutthen Isamvtmdtmleldingagemyforthepedann TOTAL ELECTRIC FEE 10.35
ane of the work for which this pcmmNNttIs Issued bee 3D97,Cl,C.)
(� O Ierdeea Nanof l(k, PLUMBING FEE
LL M 10.35
1eer'.Aaae;a T QTY. MECHANICAL PERMIT FEE
O w b I certitythat i have read this appBaJonard state that the above lnbmnaticn MECHANICAL FEE l O. 3
correct.]agree to comply with all cry and countyordtnanroand state laws PERMIT ISSUANCE FEE pAl I O
y N rdatingtobulldingmwdlmi,aMkmbyautharluapr nuts oftMs CI
r city to enter upon the abo,mentbred Property for Inspection purposes. ALTERORADDIOM }L
Z
_ (We)agreeto save,todenwfy an d keep harmiese the City of Cuperttro Date Recc pt#
egawt WbWlles,jadgmew,costaaM expenses which myln any way amore AIR FIANDLING UNTT(I'010,000 CFM) SUBTOTAL:
against sold City In ressequence M the granting of this pemdt.
AIR HANDLING UNR(OVER 10,000CFl) CONSTRUCFIONTAX '3Z5.01
L irate f' CONSTRUCI70T/IX{'AID:
Signature o(A pliant/Con t a Date FXI U[1ST HOOD(W/DLCO
tIAZ.1 ROOUSMATERIALS occupant Mom
URE
appnrut the
upbuilding omipalCtloa hhaMkh,and
HEATING UNIT 1710 100,000 B'IV) Date Recei t#
m.Ith aore defineSfdy Code
Coon tino 255MurdcipalCode,Chapter9.12,and the
HeaHF ant Salety code session 75532(a)i tffATING UNIT(OVER 100,000 cru) TOTAL:
C Yes W
BInut hazy cdapplicaMa tore bulldog as defintuse I he[Errant Area devim VENTILATION FAN(SINGLE RESD) ISSUANCE DATE
which eMt haumern ab camnntlruMeas de0ned byint Bay Area Ab
Quality tdavgemeM Del rkti BOILER-NMP OI-�OR IOQIXU BTU) PAM
Yn ❑No f
havenead theleap& Safety7. ode.brtyulamenbundea Chapter695 of BOILGR-NNU'(OVER 100,000 BT11) FEB
the Californiarstand Heald A Safety coda sanbv ctly h 7e.tc and 253d. I 7 1x39
.p.ataMtiutl( tify, the occupant
oft .requirhaveathih thatb met h'EW RESDFNIIALMEIN. SQ-PT. 114 `J�
roor to enityto maltythehcteof of the requleneMswhich revel be met
prior to Lvuana o!a Certlllote of Ocavpanry. ,
C .�. �..�.n 1W"1 CO . -7 - r—
Owner or amh red agent v Date ISSUED BY:
TOTAL
OFFICE COPY