20058 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Ideadflotlw 1•r� �3 p p pp�(pgT(�-O/A/, -Cl (��{
Bulldbig Address: Cola I UWZ\, 11 �� C 200VV
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n one:
r(2 T C_e"P CITY OF CUPERTINO-BUILDING DIVISION
tnaor Name: n '
3 3j .No: �j APPLICATION / PERMIT
BUf 1D ELDCTRnAL-PLUMBING-MECHANICAL CATEGORY CONTROL
Archhea/Engl^rt Lk.Nce
2
C- 131( 6 Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add—' .(Doll �SS b p S J PFRIATISSLIANICE ❑ ❑ El (�
LICENSED CONTRACTORS DECLARATION �I
I hereby afflreathat lam Bcmaed urde,pm Wormof Chapter9(cvamen APPLIANCES-RESIDENTIAL BDF3T;R�T10
Ingwlth5ectbn7000)of DlvlNan3o(the BuJ�sandrrolestlaroCnde,and /T (jam � DOP (--.y
II¢vse d(ea. �q PANELS aT`r^br a--C�
Llceme Cl..ae L Got —C V> H r c-Y
Dne �Co ZCI t/0 6—
ARs.hall CI'S DECLARATION 1E AMPS
q�q�uu z 7]. I uMemtard my phro sha8 M cart u pubes rec¢da OVER 1000 AMPS SQ.FT.FLOOR AREAS/�.FT.
E
Cd, Licensed Professional - - SIGNSELECIRICAL - J. L E D N
<<� OWNER-BUILDER DECLARATION SPECAL CBLCUIT/M15C
P�� owing reffirmason.
thrtlson exempt MS,Rsmnthe professions
Ll¢n,e Law for the PU TER
ro-F follawingkhregimap9 ttom tm aMr, fpm a eod hnytltyor TEMP.METER OR POLE INST. 4l
F muntywhkh requlrtaa perWttocorotrua,ilter,lmprove,demolbh,or rcpalr TG rj
< anystructurepH tolbL arcSalaorequl theopp8¢ntfmsuehpemdtto POWER DEVICES DAaG 57
Y Ob a signed statement that he b e¢nsad pursuant to the provision,of the
nE �1. Contractors Lkeve Law(Chapin 9(mmmenWgwith Seabn90LV)ofDM.
^; ..JJ77 ebn 3 of the Bu alnm and Prc(embv Code)nrthat he b exempt therefoon." SWIMMING IVIX-EI.ECfItIC VALUATION
the Wsb for the alleged exemptlon. Any Waatlon of Satbn 7MIS by any
<� aPpb..tf.r.per t.bjed thaapplk.ntt.ad ipe.itydf a.o thao D[717'&7SSWI'CCt�SSF7XfURPS
flvQundred dollars($500). NEW RESIDENTIAL FT FCR FT.
Lj I,am owner of the property,or my employees whh wages ae their sole SQ STORIES TYPE CONSIRLCTION
k < mmpennlon,wWdothe work,and thestrudure Is not Intended or offered for
5a O sale C e 9064,Busmen,and Prdmbru Code:The Cortradoes License Law
does one apply to N owner of property who builds or improves thereon,and OCC.GROIR' BE,UNITSEE.• who doessuch work himself or through his own employees,provided that such
Improvemcw art not Wtended oroffered(m Bale.IL however,thebuilding¢ TOTAL:
Lnpmvementismidwlthinomrarofcomplet mtheowner-b Werwlllhave
trl9krrden of proving that he dm not loved or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
LI{m owner of the property,am ercWelvely mntmm—g wkh I—nsed FLOOD ZONE APN
contractorsSec to construct the projed( 9044,Bushes and Prefeabv Code: PERMIT ISSUANCE
The Coarsctor.Lloen,e Lw does nue apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
AtBds or Imp.theeon, and who contracts for such ptojeens with a
ryptLiaor(a)ecerosed pursuant to the Contradar.L".Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
DRAINS R ,N
FLOOR,ROOF,AREA, SANITARY Y_ N_
Owner Date RECEIPT R
WORKMAN COMPENSATION DECLARATION FDCTURFS PER TRAP SCHOOLTAX Y_ N_
ereby affirm that I have•¢rtlBeste of consent m self-insure,ora RECD.i
certl to ofWorkers'CampenuHonlwrsnceai¢rtRlcd copythersof sec.
3800,Yb J OfO O r/ GAS EA.SYSTEM-I WG4 OUTLETS PARK FEE - Y_ N_
`( RECEIPT If
Com ny GAS FA.SYS EMOVER 4(FA) BUILDING���pppaaa y g BUILDING DIVISION FEES
I ICeANedropyhere tums
rHficd ropy 6 filed Mth th.e ctfrty Iropectbn dW Wm. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
b -
CERTIFICATE OFE)(hTEPTION FROM WORKERS' GAFASEIRM PAID
CONPENSATLONWStIRANCE SEWER-SANITARY-STORM EA.2MFF Da[C RClTI I#
(Iorion need nes be campldedIf rte pemtlt bf¢orc hundred doBan
(SIM)or I1esaJ WATER I{EATER W/VENT/ELFCTR ENERGYFEE ' Y N
Iunify that bthe Person 1. of the work for whichthis Permit is
I sale not employ any person In any nunner at as to become subject to the WATER SYSTEM/TREATING O nmu�i omperoatlon law,af e.lumnb Date PAID
Z O NOTICE TO APPLICANT.If,after making this Certlflote,of Exemption,you NEW RESlDENDA1IaLI.IB. SQ.FT. Date Reeef t#
should became subject to the Workers'Comperu oIcxa provisions of the Labor TOTAL:
CC N Cade,you Trust forthwith comply with sued prodiluroor this Permit ab li be
> deemed revoked. BUILDING FEE
LU CONSTRUCTION LEN'DIN'G AGENCY
0 - SEISMIC FEE
ll Iherebyafft thatthereb.mrmtructionkedlagagencyfartheperfurca TOTAL ELECTRIC FEE
Z an¢WtheworkforwhkhthispermBbb (Sec30T/,CW.C.)
(� O Lenders Name - - PLUMBING FEE
LL H Iewer.Addroaa QTY. MECHANICAL PERMIT FEE MECHAMCAL PEE p
O W n
IcrAyythi havercadthla.ppe tbmve
nard stateth.teabalnformatlon k-�
1 Lemront.I agnetocamplywhh all dtyand countyordbunamm
d pate Laws PERMIT ISSUANCE I. ,C0 FEES PAID:
N relating to buildingmrwructlon,a nd hereby authorize representathres of this
Z ceytoemterupon sae-mentis rty for Wpectbn purpoem. ALTERORADDTOMECFL Date, Recei t#
— (We)egrcet bdemnity d phamd the City of CupartW
against llab0lt ,p mew, .nd person mayloanyw.y.caue AIR HANDLING UNIT(TO 10,000 GEM) SUBTOTAL:
a rotsai aft gnntin his permk.
3/90 AIR HANDLING UNIT(OVER IQCMCFM) CONSTRUCTION TAX
NgaaffiIroof Appb, tractor pan, EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WBl theappllontorfuture building cxmupant More or handle hazardous HEATING UNIT(TO]OIpW BTT) Date Recei t#
material as defined by the Cupertino Murddpal Coda Chapter 9.IZ and the
Elealth and Safety Cm ion)991ipI? HEATING UNIT(OVER 100,0008'CU) TOTAL: L
Ye N
o
o111 the appli¢ or fu re a dingoovpantuseeVlpmerdordevkes VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air cmitaM V nls as de8¢d by the Bay Area Nr
Qualny Management gistrtat BORFA-NMP PFII'OR 100,Of)BTU)
�� No PAID
s
4 Ye
Tuve read theF esus nuI rla11 irenrna un der Chapter6.95 of W=-COMP(OVER IM'"Sm r
the Califmnb HaA,65afety Cade, reE.509,255d3+nd 25534. 1 - JU� 31 1990
uidosUMthat l(th Ngd not rrentlyhave tenant rust it b my NEW RmDFNfIAL MECH. SQ.FT
rapo.lb Ifty ton a nt of a squire wMrh nest be met
prior to of rH of W ar
n authorlud agent Date IS5UFDBY:"`�L
' TOTAL Q(.�
OFFICE COPY