20701 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin,Pr res identification FEWWTNO.
Building Addrtes: r
20701
10112 �\2
re amr. one.
� c OSS)Z_ , 9 CITY OF CUPERTINO-BUILDING DIVISION
aaa•"•n•
No, APPLICATION if PERMIT 6
BUrLDINGELECTRICALPLUMBINGMFLHAN)CAL CA] RYCOMAOL•
mnuea/Gglroer. Lk Nn
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmu PFRMITISSUANI� J ❑ ❑
LICENSED kensed ROr pr DECLARATION
Thereby dfkm'hat I KFcdDmikmeeduelhasJ ovlslweof Clapter9(mmmm APPLIANCESRFSIDL BDFSC
Ingwitha,mel Iu.ifull7fXXBotDdf.,t. ottheBuslnasaa dI'mleeilonsCdgand '( L-, \V.
Lieneebin(uBf�m and k,# PANELS �I�iSC
Dimas Gla lk.I
Date, Contractor
ARCHI CI' N 7111-1000ANPS
p�p�uu�C 7 l uderead my plana ehaB be used aspubll records, OVER 10110 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
!s` j Liu:nsed Prdmbnl SIGNS
�G< OWNER-BUILDER DECLARATION SPECIAL
I h /
i.., embyefirm that l am exempt from the Comnnor'a License law for
pppp following mason.(Eealm 7m15,Buelnm and Pmfeebn Code:My dty or TEMIa METER IN
7.
FOE anuntywhkh requW apermNtomnawgiltm,lmprove,demolbh,orrtpilr
�e any•truaure prlortolts lenaaree,ala requheatheapp0ant t«suchp of t e IYX'✓ER DEMI
K file a signed getement that he la 11¢wed punuant to the prodsbn of the
Contractors Lkenae Taw(Chapter 9(..cmg wltn Section 9000)of Divl-
E,3�1 ebn3otthe Ruilnessand Prdmbm Cde)orthat hebexemptthertfmmaM 'ry'flMM1NC IVOL C VALUATION
•]] the basis for the alleged exemption. Any NoWbo of Section 7MI5 b/any
�p5y QO appueant for a permit•ubjecte the applcmda m
t toes eivdl penalty nmothan OVIlEmswnChESFl �\Es l �
C ..� (IvC hundred ddlan(fSWj. SQT7,
ELECIR SIpRl6 TYPE CONSTRUCTION
'$ ❑1,a owner a the properly,or my employm with wagn a flacon ease "Lv`RESIDEMIIAI.
role(&,70K Ba 11dess.nd rf.WeatCde:ebmt4neMee oicenertdw I _
O sale bet a f1µto so owner
flofmbna Code:The Comnnore LImne law
(jS$ don who 4)e apply Cork ownnaproperly who lullsorImprwnthemaRand OCC.GKUUF RES.UNITS
GG Impmve encsuch amrkhlmee Inteor nded
hed ownsfor .If,hoepi,tbeb that such 1
improvementsartmrcithindd or offerrofcompletio.I(, owneror,the building or TOTAL Zv I
Improvement is sold wlthlnone yearafcamplelbn,the awner-builderwW have
t rden of proving that drot build or Improve nee purpose ofsak.). QTY, PLUMBING PERMIT FEE
" hedidI,as owner of the properly,am exc ustw[y mntraNg oval 11¢nsed FLOOD LONE APN
contractee m mmemad the project(Sec 7014,Buenm and m
1'ralon Code: PERMIT ISSUANCE
The Comraaor's License Law dm mat apply to an owner of property who ALTER-DRAIN 4 VENT'-WATER(EA)W Rds or improves thereaR and who comms for such p\ojem with a
celaffctce(.I Ilan�d pursuant to the Contractepal.lanae Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B 4 P C for tw rt
awn Owner Der DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_
WO¢IQ.EAN COMPENSATION DECLARATION F0(NRES PER TRAP SCIRJ(R-TAX Y_ N
❑I hereby af(4m that I nave a mrnMm of consnt to seR-Inur,ora RECEIPT
mnBtexte of Worker'Compenaanaalesurance m a mnekd ropy thenmfRec.
3800,lab CJ GAS FA.SYS7EM-I INCA Ol1TLE75 PARK FEE Y_ N_
Coma GAS PA,SYSTQd-0VER l(FA) RECEIPT a
Y BUILDING DIVISION FEES
Certified copy Is hereby fumIshed.
F—ICerlltled ropy b!Bard with the iity lnapenlon dlvWm. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR-SANTTARYSTORM EA 700FF Date RttCI IN
(Thos sedlon need nes d completed Bthe permit le(«orae hundml dollen
(SI00)mfa) WATER HEATER W/VENT/M ECTR ENERGYFEE Y— —
N
Imwytwt loth perrerrnana of me work brwmahtw permitit iefwed,
libel nes employnIA dman era as to �bjen to the WATER SYSTEM
PAID
W«keno Gl �Dae�. �`o
O Z APpll sD—_D\\/// t NEw RE51DFNTIAL PutB. 9?.Fr. Date Recd tp
Z O NOTICE-WAW$ ANT. ngtw Ccnfl teof Exemptbn,you TOTAL:
Co
ahmsu
ld becomebject to the Worker'Compenaation pmvlsto ofthe Labor
N Ce,you.9f«thwitn comply with sich provbbnsortw pemdt shill be
> deemed rooked. UVILDING FEE 3,
W O CONSTRUCTION LENDING AGENCY EISMIC s
a fherebyafflrm tout Cher Namnlractbnkding age�y for the pMornr ` crar
Z ance of the workfor whkh this perms b kmed(Sec 30977wc.) TOTAL: ELECTRIC FEE nail
00 lendee.Namr PLUMBING FEE
LLI— Lender's Addreas QTY. MECHANICAL PERMIT FEE _MECHANICALFEE
O W I malty that l leve and thbappllatbn and statethatthe above John nutlet
btmr .Iagreetocmnplyw aBdtyandmuntyoNWnmandtlteU. PERMIT ISSUANCE FEES PAID:
} N rtla0rig tobulking mnatrunlm,and herebyeathorlaempresentatMaoftw
F Z dtytoenterupontne abvvcmenlbrmd propertyfor Wpeubn purposes. ALTERORADDTOMBCH. Date Reed IN
— (We)agrn to save,kdm
emkeep fy an d p harmim the City of Ceperlku
againateabolltles,rydgmew,metsadexpenenwhkhnayinsnyweyacxxueAIR HANDMO
LING UNIT CFO 10,000 CFSUBTOTAL:'
ages int said Cary m mnseqa urr of the grant ing a(this permit.
t Alit EEANDLING UNIT(OVER 10,004)CFlf) CONSTRUCITONTAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllom or future buflding omopant stem or handle haxardoue HEITINGUMT(MIOL"ITTU) Date RCCCI IB
material are deflnrd by the Cupenino Municipal Cde,Chapter 9.17,and the
Healthad Safety Code Scabn25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: aC�
rI Yn No
Illthe applimm« tutobuilding ecxupeit use equipment or devim VENTILATION FAN(SINGLE RESIT)) ISSUANCE DATE
whkh endt"Mous W mnnmloam•aa deflned by the Ray Arta Ab
Quality Management Ehxt l 9 BOR.FRODMPOHPOR IOO,OXq BTI!)
Yn ❑No
havereed Nehanrdo,tyC.de,Ssdqulremenieunder Chapter 6.95 of BOILER-COMP(OVERIW,000 BTU)
the mtand to Ftealth bu dfengdoes Sa4bna currently
h 75533 and,that I J U L 0 9 199U
udentadyto lithe WOdingdon not a reently Fovea tenant,that a 13 My NEW RE9DEMITAL MECH. SQ.F7
reaponrouuabnattythe aate of athemgairmem.which musthmot .
prior to issuance da Ccrlilkan of Ocmpancy. �p�,,
.. BBya 1 49gj
owner or autnarisd agent Date
TOTAL: ISSUED BY:
OFFICE COPY
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