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20478 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY # Buiming Frn'ed Idendfwtlw PF WT W. Bulletin Add l an ^O 4�7 8 me: G I CITYOF CUPERTINO-BUILDING DIVISION Cwtractore Name: Cl Lk.N. APPLICATION / PERMIT S- 3 —ge BUILIX ELBCTRICALI'LUMBING IC LAICAL CATEGORY CONTROL Arehltttt/Engineer. - IJc.Na Q ELECTRICPERMIT FEE BUILDING PERMITINFO Add. PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm Hut lamllcmsedurderpmvblwedChapter9(. APPWANCESRESDEMTAL B DESCRIPTION Imenme I5Mbn 7003)of d effdw3o(the Busiroaand Pro/esalonsGde,and try License b N fu➢bra and d(eIf PANELS Llanse Cha Lk# Date Coh1m dor ARCHITECPS DECLARATION 1-1000AIMPH p�p�uu re Q7. I understand my plans shall be used as pubbc remrde OVER 1000 ANIFS SQ.FT.FLOOR AREA $/SQ.FT. &tz� Llaneod Professional SIGNS EIMZ RICAL y 6 0 . o� fn<< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC i.., 1herebyafBrmth.11.meaemptfromthe Contra roes Ll¢rue lawfethe z{_ G following re.&S Jon 70315,B.1,,..rd I'rofubns Code:Any city or O TEMIP.METER OR POLE INST. K � anyt,onot hlchpn tolapemwt aLowgilteeapmve,demoLLsh,arapto any.dere taterlolhhoane,abrosed ret tit,lmtfowgin.of to ZOW,��.W� rC 0 U rile•dgnM euumcnt the he b IlansM pursuant m the pmWbns or the Ow Ccnlranors License law(Chmpter9(mmmendng wRb Section 7003)d DWT-SVALUATION OS don3aftheBumnaandPro®bnsCMe)orNnhebessmp hedrom.nd SW MW 0 POOL O y.' the barb for the illegM eaemptbn. Any violation of Section 70315 by any0 Lai app➢ant forapemdtwbjnesHrappBeanttoadullpensltydvatrtnrcthan OITH.BTSSWTTCFEAFDCURFS 3 Ij Y ,.. fyeundred dollars($SM. 'R I,aowrer of the property,or my employee with wegnutMbsob STO NEW RE?�EN77AL FJFCTR—BEET. Rt TYPECONSIRA'UN' IO pens m,wllldotkworkand(hemm�umbnot WendMor offered for Dsale(5,170K B.hesand Pm(ue loru CodThe Contractors Llot.Law 5$ doe notapplyto an owner d property who builds or lmprowsthereon,and OCCCROIII' RES.Ulv775 who dons wch work hlmseB orthrough his own emple,oyeprovided that much Impmwmmtma are not Intended oroffered faeale.If,however,the building a TOTAL Mprowmen ls.a1dw hinomrarofcompletbn,theawner-bummwiB hart t rden of proving that he did not Wild or Improve for purpose of We.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ApN Lam ownerof the Property,am ettwlwly osntra:ting with Ilanaed IPFRh11T 15SUANCE mntracton to mwirun the project(See 7014,Buinessand Prdessbns Code: The Codractars Lberue Law doe not apply to an owner d property who ALTER-DRAIN 4 VENT-WATER(FA) builds or leop.theneun,and who contracts (or such pia"wIM a ogejr�.r(d Banged puewant to the Cuntradorh Lkease Law. BACK FLOW PROTTiT.DEVICE FEE SUMMARY LJ I am .empt uMet Sec S Is P C for tw reason DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_. O Owner Dat a RECEBT# ' WORon that Ila SATION DECLARATION FT%TlJRFS PER TRAP SCITOOLTAX Y_ N_ ❑1 hereby aelrm the 1 have•artlflau d cmssnt to seB-Inert,a a RECET T# MOD,L Lb Worker'Compensatian lnsunna sera artlrled ropy(hereof(Ser- GAS EA.SYS1111-t INC4OLTrLE15 poft, if PARK FEE Y_ N_ Com# GAS EA.SYSTEM-OOVER RECEIPT♦ Y _ BUILDING DIVISION FEES Certified ropy b hembyth thehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE � yy ❑CenNM ropy 6 filed with the dty IvpecOan dlvidw. V e 3 0 CERTIFICATE OF D(EAII'TION FROM WORKERS GREASE TRAP PAID ll COMPENSATIONINSURANCB SEINER-SANTARYSIORM EA L00FT Date RC i t# Ohhs Ylonneed rad becompleted lithe permit h/m oir hundred dollars - (9103)orleaJ WATER HEATER w/VENT/MDCTR ENERGYFEE Y N Iartify that bate performance dthe work for wNchtw Permit isfwed, I shall not employ any penin in any runner o u to become subject to the WATER S-YSIFM/TREAT NG .Worlun'Canpewtbn L.w.dCalifomla.Date PAID O Z NOTMAppliunl NEW RESIDENTIALPIM9.—SOFT. Dale Recei 1# Z O NOTICE TO APPLICANT.obpetILafterori making(tab Ceinn,preaf Eeemptbn,yw TOTAL: some,bemos froth to the ply with Compensation provhbnsoftom Lab or � N CMeyou r lud.athwghomply with wch provimbns or thio permit shill be y deemed rewked. _ W — CONSTRUCTION LENDING AGENCY SEISMT FEE CL IherehyaNrm that there b a mnstmnlon lending agency for the perform, ELECTRIC FEE 7 Z anauftheworkforwhkhthbpemdtbb MLSec.3097,CN.C.) TOTAL, (,) O Lender.Nanr - PLUMBING FEE LL I— IeMeriAddresm QTY. MECHANICAL: PERMIT FEE MECHANICAL FEE O W Lar(BythnlCvemdtwapp➢otbnaMratethAtheaboveinrormnlw bmmrCt IagreetummplywhhaDdtyaMmuntyordlnanas dstatehw. PF ISSUANCE FEES PAID . > N relating to bullemg mnstrudim,and hereby sutha rep immudve of this F Z dy to enter u Pon the abovemenmnsd property fm umpenion pas rpose+ ALTER OR ADDTO MEIN. Date RecCl I# — (We)agree to save,Wmlw enlfy an d keep harmless the City of Cu pertmo, ago lost lhbBities,Pdgmenu,nine and upenses which may In any way amus AIR HANDUNG UNIT(To to,"CFM) SUBTOTAL, gmnstw clryb e� (the graningdtw pemdt. AIRHANDUNGIINIT(DVEItl0,000CE,D CONSTRUCTION TAX Signstu (App➢oral/Cont Date SCHAUST HOOD(W/DIA:") CONSTRUCTION TAX PAID: HAZAR USI.tATER1ALSDISCLOSURE Will the applicant mfuture building oaupant store or handle havardoum HEATING UNIT(70 IM,000 BM DatC - Rttei t# material as de➢rud by the Cupertino Mueldpal Code,Chapter 9.1 Z and the Health and Safety Code Seaiov 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: T� Ye No 111 the appBanta lure building occupant use equipmuu or civ VENTILATION FAN(SINGLE RESID) ISSUANCE DATE whkh endt Ma aadous air mnhMrunb a defined by the Bay Area Air QualHy Management DLUrkt7 BOILER-COMP OHP OR 100,IXD BTU) PAID Ye No have read the haa�rdoua materials requirements under Chapter 695 of BOILER-COMP(OVEt 108000 BTU) the California Health k Safety Code,Sections 2550.5,25533 and 25534. I (;yAY 31 1990 udersta nd that if the building rad a ding dons have a tenant,that It b my NEW RESIDENTIAL MECH. SQFT, raporalbBlty to not By the 000 pant of the requiremente which rratn be met prior to lvuana of a Ccrtiflote of Oaupar y. /a Owneraauthorf ,agent Date t+ \ TOTAL: ISSUED BY: 4 Wb V U- OFFICE COPY _7 F F) -T 4 7 - [ _1 -PLOT CHECK-ED By DA L L G 3SPT. DATE.. d '_F4pp OVED IN AC60RDAN E WITH THE CITY Of UPERTINO CO[ES AND ORDINANCES "!.'SL) E SIGNED I V. cc Tbis set at Pl ss usl bi Wt on the ic j at es and it is un Ifile to.make.a I Y r alterations pl� nn same wlthr"U: w:qfn P"miss'On from 4j%bukding OOP, , C iY Of CuPO"LinO-. pksjampjog.of ;,s pian and speciticz. MAY 2 9 9 NC;l lie I'!dA.j po'hiltOrto be ksion��1�r iiicw� LM p0o%�.. �,! :he, W i n. Of PfOv. INSPECTION DEPARTMERT, INSF I any G" FT 0 F CITY cupERTINQ- -7 j— F: 7 7 I�D I