21677 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buluing Project Idemlflotlm PLRMI'TNO.
BRBdbg.�ddrvs' — 21677
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CITY OFCUPERTINO-BUILDING DIVISION
IJ� �� ^O
batloreN me: No. APPLICATION it PERMIT
cozy / BUIIAING-F3.ECTRKAI.PLUMBINGMF NKAL GTFL'ORY CONTROL Y
A ked Frglreer. Lk.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adder
PFRMTISSUANCE ❑ ❑ ❑ ❑
LICENSED that I a CONTRACTORS DECLARATION
I thSry effirion? l ofl)i km3oft MB r andaoffeWp r9(mmmm APIeUANCESRESIDENIIAL J DESCRIPTION
Ingwlth Seaton 7000)0/qv Won3oftW Buelrresand ProfmlmaCde,and
Horses bin f d](((pppgeee and effen. PANELS
LbeveClea Lk.,
Drteu ' CoMrador �j��A[`cva_ —UP TO 200AHM
ARCHITECTS DECLARATION MI-1000 AMPS
iX Iurderatad my Plana e.11 be uad as public teauda. OVER100AMPS SQ.FLFLOORARFA VSQ.FT.
kod4 Lfmved Professional SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION 91ECIALCIRCUIT/MLSC
IhembyaM.tltlamevempt(rmntheCMratlor.Lla Uwforthe
following re eon.(Seeimr 7015,Bu.inu and Professions Codr.Any dry or
F TEMP.METER OR POLE INSr.
5 montywhkh mryb.apemd1,5,Bu rod,and Prmpmons Cod Wh,y city
anyaw=mprlmtolbl amal requ4 theappBontfmmchpem to POWER DEVICES
G file a vigned mtement that he Ie Bmnaed pursuant to the pmv is v of the
Contndore Umnae Taw(Chapter 9(mmmendng with Scotto.700)of DIvF
.bn3ofthe Suvin dPoofmlomCode)orthrthebe mpttherehomand SwE11Mt rc6L EfZ1DUC VALUATION
•.t the beep for the alleged e.emptbn. Any Wdabn of SeGbn 7015 bj any
to<x appB.nt fora pe
rM b*e theapplleanttoaddlpenaltydndmo.than 7
flv hundrd ddbrs CsW. 611
.- 1,as owwr of the property,or my empioyen with wages u their vole NEW SQ'FT' SIORIN5 TYPE CONSIRUCTION
C7a mmpenWlon,willdo the work and the.trueure brio inerdrd or offend for
❑ ule&r.70N,Bue m,ss and Pmfmlo s Code:The Cor6ndoes Lim.Law
j, 5$ don rotapply to an owner of property who build.or improv.themgand
c. whodonwchworkhimeefforthrwgh hl.ownemployees,provided thatsuch OCC GROIIP RES DNrIB
ImpmvemeNa arerot Intended orofferd forsale.lf,however,theWlNing m TOTAL
Improvement baold whhmoneytarafrompletbn,the ovner�flderwW have
t rdenofpmdnglhat he did not Wildorlmprove forpurpweofub3. AGAS-F.A.
INGPER IT FEE
G u Omer of the property,am euhutvety mntrading with Renard FLOOD ZONE APN
mnMOma to mrutme the proJed(Sec.7046,Buelnm and Profmloro Code: PW E
The CantnGori Limve Law does not apply to an owner of property whobryupil�d.a nor Improves Nem.,and who mwaes for.uch pSo" witLJ e.)npnmoanttomeConor 'sLknveLaw. D FEE SUMMARY
LJ 1 e -oder Ser. B 6 P C for thla rtawn F, GOND. SANITARY Y— NOwner Date RECEIPT 0
WORKMAN COMPENSATIONDECLARATION SOltJ TAXYN❑I hersby a(fbm that I haw a anlf{ob of omrnt to uB-marta a RECEIPTIINCt OlIDF15 PARR FEE Y N \
380, �b CJ
If
Cpm# 6 GAS EA. -OVER6(FA) DINRBCG DIVISION
Y _ BUILDING DI VISION FEES
CeeBied mpy here with
the od. GREASE/INDUSTRL WASTE INTERCEPTOR 13LANCHECK FEE
C7P_crtlfled mpyb(Iled with the city lvpeSlon division.`7o CERTIFICATE OF IXFh1PTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSIORM EA l(IOFr Date Re i t#
(91
(gbsee,) need notWcompleted tithe pepermitbfaorc hundred dellen
00)orlem.) WAI`ER DATERW/VRNT/ELECTR ENERGYFEE Y N
I anB thato the peef iaof forwhIdi tobthbpemdtisbased, —
i mlv not employ any pnwa In any manner at n to become abject to the WATER SYSTIN/TRFA,ENG
Workers Compenutbn I&sv.of Glffornb. Date_ PAID
Z NOpllomt
110E PD AI'Ie1,ICANf:IL after reeking thfe Certlflnte of Eremptbn,you NEWRMDFNIIALPUAB. `.QF7. Date Recti t#
.hmld become mbFct to the Workers'Compevrtlon provbbv of the Labor TOTAL:
CC
Lu 0 Cde,you. fonhwkhmmplywlthwchprovl.bvorthbpemdt olbe ,M
> deemed revoked. V
W 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebya(flrm that then feamretrudlon loMbg agency for the peAomr
7 Z .a.ftheworkbrwh hth6permnbbrt,ed(ser.wn,Cw.C.) ttyrAL: ELECTRIC FEE
U O lemeeiwme PLUMBINGrEE
LL I- Lender.Add rm QT-y I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ianl(ythrtlhave mad thbappliatbnaod rote thrtthe aboveinfomxtlm
bmrod.Iagreetocomplywithelayand m-ntyordwna,andstatelaw. PFRhffT ISSUANCE FEES PAI D:
} N mlrting to Wilding mvmaction,•od herebyauthorlu rcprmnbthro of thb
f- = dty to enter upon the above. eruoned property for Wpetllon purpmea. ALTER OR ADD TO MECFI. Date Recd t#
(We)agree to uve,bdemM/y an it keep harm2m the C.,of CupenW
g'irst Babifftkb,�'dgnsenb,metaandnpenaeswhldrmeylnanywayamue AIR HANDING UNIT(TO 10,000 CFM) SUBTOTAL:
.galrut fry N ens of the gra Mbg of thb permit
�sAIR HANDU NG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SI ofA U.nt/Contractor Date EXHAusr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
Will the applort or future Wilding oavpert.toamhandle hawed., HFATTNG UNIT(TO 100,00 BTU)
material adefdew Chapter 91Z and the
Date Red t#
fleaHhed rcC ,
ENIm 255T7G)7 HEATING UNIT(OVER 100,000 BTI!) L:
Rill111 theappllaMa tuo Wlldingoccvpanluu equipment ad.-ulm VEN7ILA770N FAN(51[vC1.E RF51D) ISSUERMCMATE
which emit hawed..x r oantamJ.rt,ae ddloed by ted Bay Arca Al, '1
Qu Ihy Afavg.ru Distrid7 BOILER-0DMP OLIPOR 10,0(10 BTU) !!l rl 1�Q�
Y. I�No " b II.Rk
Ii.vi, dthch.w�aasnuterial.r qubemenbunder Chapter6.95of BOTIMICOMP(OVER IO,000 BTU)
tedChf.m HealthkSafetyCde,Seth..25505,5533and25534. 1 46 a
undcrstard tWtifthc WOdingdo.rot mmentty have atevnL tlutltbmy NEW RESIDENTIAL MECH. SQPf
rapov(bWt analfyt omrpam of Uerequlrtmeme whkh mu.t be met
reaPO obs rte a(a oteo(Occthe req ��,,{{////,,..
Gw a gent TOTAL
Dote ISSI/F.D
OFFICE COPY