22522 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pm ed ldentlflutlm - PERMIT NO.
@ullding Add.: 22522
ren•IT= e
akOH W&QK)CIQ. _ CITY OF CUPERTINO-BUILDING DIVISION
Cmtrsdor'•Name: Lle.N. APPLICATION if PERMIT 'o
BUILDI aECTRICALPLUM MW MECHANICAL CATEGORY CONTROL 0
rcbeeu/Engireer. Lic.Ne,
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
LICENSED
ICtED CONTRACTOR'S DECLARATION PFRECTISUANCE
IMeloya he l underprwbiomofCburommmAPPLIANCES-RESIDENTIAL APPLIANCES-RESIDENTIAL 1❑Dj
�vjYr'amyrI-C-nGaJ¢)_
mSb.700D).(Mv .3.ftheBYnndPro® ..C.deud "r `�6„Ilre,,hInsoil form and feet. PL
License Clay e.#
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�
ICF��I C
Dan. Contndor ' UP TO 2DOAMM
ARCHITECTS DECLARATION 10-OOU AMI5
p�p�uu p Q]�Q. ]uMerYard my phmehailb urdupubilc rerwda OVERI000AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
Fi I' Limned Prodmtonal SIGNSELk117McAL
<<GStuF�nna
G
OWNER-BUILDER DECLARATION
SPECIALCWCNT/MISC t
7, Thereby affirm m than l aeafrom the frothe Comd
raorb License law for the
following moon.GG.dlm 7W15,Busln®ark Profeselom Code:Mytlty or TEMP.MEORPOLETN
�� rountywhicbrequbmapemdttowm ctalter.Upm ,de oWhormpalr ETi ST.
(�1
r anyatmc mpdortoltet aagaborequlrutheapphuntfaeurhper to POWER DEVICES
0
Ate a algned statement he b
tateent than Ilmmb
ed purauant to the provhm of the
u. Conrado/s Ureme 3Law(Chepter9(moureneingwith Sedion7000)ofDlvl-
0 abn3ofthe Bus con dP mfe Code)orthHhebeumplthe fr...M SWII'MNG POOL ELECTRIC VALUATION
�n the bash for Ne alleged eaerrWtbu My ddatbn of Senbn 70315 by any
<'e appH.ntfor.permit subjecle the applant to a ehdl penelty door morctlun OUTL�SWITCIIESFLXTURES
a q undrcdd In%5W.
u owmr o!the property,or rry empbyen g NEW RESIDEKHAL ELFCIR SQ}T. STOWES
Y7�n Ve w4hwa nutffered for TYPE CONSERLCTION
G pec.7DKh.ere,theworrmssions rudnum e:Th ml Wended oroffemdfor
q r,('Sec.7014,Buelnev and Prdubv Code:The Comndors License law
doss notapply to an owner of property who build.or lmprwn thereon,and OCC GROUP RFSUNTT5
33.• who donaNworkhlrreetforthmugh hiaown employm,prwWed thatuch
1'opmvements am wt Intended oroflered fatale.If,however,the W illing of TOTAL:
Improverrcm hold within oneyurofcompiNon,the ownerbuilderwel have
Lt�rdeo of pmAng than he did not Wed or improve for purpose of ser.). Qn'. PLUMBING PERMIT FEE
Lj 1,as owner of the property,am e.cbuhxly nontrading whh n
limed I `L
FLOOD?ONE APN
otedradae to mm rud the project(Sec 70K B .l
unem.d Profesm ebCade: PERMIT ISSUANCE (Ila
The Comrsdota License Lw dm net appty to an owner of property who i
builds or Improves dirmeR and who mmnm for such ptoXds with a ALIFR-0RAIN k VENT-WATER(EA)
galrxor(J Banned punuanl to the Contraders Lkense Law. BAOC PLOW PIm7ECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for thk mon
Owner Dale DRAINS FLOOIt,ROOF,AAEA,GOND. SANITARY Y N=
AFCE[PI e
WOR KMAN COMPENSATION DECLARATION FIXNRFS.IrER TRAP `�' SCIi00L TAX Y_ N
❑I hereby affirm that I have a certificate d cauent to artFinum,m a RECEIPT s
amelatedWmken'Cnenpemard.Imuran¢ora artlfled ropy lhemof(sec. GAS EA.SYSTEM-1 WC40UTLEIS PARK FEE Y Npwicy _
3800,Lab C.) _
Co F GAS EA.SYSTTM-0VER4(FA) DING DIY
I—
BUILDING DIVISION IBION FEES
Certified ropy is heeebytumlehed. GREASE/WDUSTRL WASTE IM'EFCEPIOR PLANCHECIC FEE
CemiBed mpybflled with the city lupMbn dfvlelm.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEVER-SANITARY-SIORhIEA 700E-I Date Recd t#
(Thi.aedbn need not be complded lithe permk h(aore hundred dollars
(f1W)mlefa) WATER 1-II:ATIx w/vFxr/ELEerrz ENERGY FEE Y_ N_
I artilythan bthe pedone nceoflhewerk/orwhich tbl.pemJt Is hued,
I slap not employ any person In any manner u as to become ubjeet to the WATERSYSIFA:/TREATIIJG PAID
workers Campemanlon Lwed Glltomb.Date
O Z Appilant NEWRFSDENTIALPLMB. ST. Date Rece1 t#
Z O NT3DCET0 APPLICAM:R,after making thb Cemelate of Enamptbn,you
should become subjeet to the Workers Compenaatbn prwlalom ofthe tabor TOTAL:
CC N Code.ywn mforthw hmnplywlthuapmvbbmorthhpemal eilae
W > darned revoked.
BUILDING
W
p CONSTRICTION LENDING AGENCY SEISMIC FEE
I herebyaHlrtn that there is a mmtuett.leMing agency for the rfomm
7 Z ance olthe work forwhleh thio permk ubee 304)
es hed ,CH.C.) TOTAL `LQ ELECTRIC FEE(,) O fancier'.Name PLUMBING FEE
LL H Lander'.Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iameythatl love read thb appBaHonaM Yate than lhe.bawe Nlormutim
a bmrree.I:greeto complywlth alldtyaM muntyord Wnmand.tate laws PFRMITLSSUANCE FEE$PAID:
} N neiatingto Wlldingmrutmetim,and hereby authodra repnyvntativea olthh
f- z aytoersterupontheabovcmentbmdpropertyforbnpedbnpurpo , ALTER OR ADDTO MECH. Date Remi t#
— (We)agree to aaw,Indemdfy and keep harmless the City of Cupmlno p
agalrm llabWtin,}ldgrnema,mgsaM eapemn whkh rtuybmy way accrue AIR HANDLING UNIT CFO In,"CFM) SUBTOTAL:
ag.l Id City Ino
of the gr.ming dthh permit. AIRHANDLINC UNTf(OVER IQQ)I)CFM) CONSTRUCTION TAX
- -q
gummof Appereu mtmctm Date EKHA1bTFI0ODfW/DUCT) CONSTRUCTION TAX PAID:
HA DOUS MATERIALS DISCLOSURE
Will the apPllant or future Wilding oceupant Blom or bundle hanrdom HEATING UNIT(TO 100,000 RTL)
mDate Rttei t#
aterial as defined! the Cupertino Mu Ndpe Code,Chapter 9.17,and the
I k.hh and Safety Code Sedim 755I7(a)r HEATING UNTT(OVER 100,000 BTU) TOTAL:
w�es Na
the applant or future Wilding oaupant use equlpmant mdevbea VENTILATION FAN(SINGLE REED) ISSUANCE DATE
hkh,roil haardwa ab rentamhunts..defined by the Bay Area AU
Qnaiey Management Dinrl.i BOIL RAMP DI-B'OR 100,0(10 BTU)
4 w �W
Wdomdt Health
mode,S reunimmenb5533 and 2S534. I of BOILER-COMP(OVER IN,000 BTU)
PAW
IleerWoidt health bSafety Cade,Sadlom,5505,watand,that it
urdaYandytohat nobsf the the ing ocedoes of the mg lyhm.which)that ltbmy NEW RESIDENTIAL MECH. SQ.}T.mapo ��^ ♦QQ�
prior iseu notify Lpgf of the irsmemewhkh muY be roti
prim bsuana eCert��..�eg fOr panty.
�Vl� t�.vl 8 �¢9ax�.
Owneraauthod gnat Date ISSUED BY:
TOTAL
OFFICE COPY
CITY OF CUPERTINO
INSPECTION DIVISION -
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S.,I:t Perri Addiett
PERMITU: 0U'at
DATEDESIRED: Pett/Fad
INSDESCRIPT: ITERMITE REPAIR ci,:
A,.P. F1 Note:
ADDNO: 10535
STREET: IFOOTHILL OLVD-S.
La#. 0INSPHOLD:
CONTRACTOR:
Datec-k,t 827/1991
DdeDane: 820/1991 +1
F. I�Ifo L
5
UAP.5
AM
110:24
0:24 AM
4
u Eie Ed< Yww Usart Fgrnid flecixds Inds y(ridow ydp
F ,'�... InpW Pnni Nu•ber.�, '
u" 'Sebcl Perri Addws:'. F
PERMITti: ® UA.
DATEDESIRED: 10/1/1941 Paee/Fak
INSDESCRIPT ISHEAR NAll1NG Cade:
MPm �] Nate:
ADDNO: 10535
STREET: IFOOTHILL BLVD.S.
Ldtl. O INSPHOLD:
CONTRACTOR:
DateCaEed: 10/I/1991
DdeOa : 10/1/1991
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ectw: CC —
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.............
PERMIT#: Unks:
DATEDESIRED: PaWFi
INSDESCRIPT: JINSULATION C.&
A,-P- F1 Nal ,
ADDNO: Fl 06W--]
STREET: IFOOTHILL BLVD.,S.
LDt#: O INSPHOLD:
CONTRACTOR:
DeaCe%d, 8/29/1991
D*eD.: W29/1991