19998 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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CITY OP CUPERTINO-DUILDING DIVISION /+ .� A ,
CotndmYName: LI Na APPLICATION / PERMIT
Art Ixt/FsBI^em
BUTLDING—aECfRICAL PLUMBINGME(:IIANICAL CATEGORY CONTROL.-} Lk.
/' /` Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcs: eCj I �- S r I'ERMITISSUANCE 1:1 El [1LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed under previsions of Chapter9(coossione, APPUANCESRESDEMIAL )OB RIPTION
Ingwlth5e n7ON)of Div m3afthe Bumm dProfeWouC and ,_y..n ITS `
Ikense b in full tome and a fed. PANELS 11'—' r1 ` l a.X
Limine Clave [�Lb/ r _Ka Fn =
D,te�[j/_2' Q6 1.omndor xa� anical
ARCxITECI'S DECLARATION xil_I030
�Z IuMerwnd my phru,hall be used as publicmads OVERIODDAMPS SQ.FT.FLOORAREA - $/SQ.FT.
u�O
V Fj Licensed professional SIGNS ELECTRICAL
G OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
I., 7, [hercby affirmthetlamesemptfromthe CoMranor'o License Lawforthe
Z9 fo]Lo ingmaron.0 a .7Q715,BualnmaMR fembru Code:Mydtyor
O G N TEMP.MEITR OR POLE INST.
K� county mrylrvaperMttommlruct,alter,Unpmv<,demoWhormpair
qty anyalrudum prbrm its issuance,also requbathe applicant forsuch permit to POWER DEVICES
g G We a algrud wtereent that he b Ilmrued pursuant to the pmWloru of the
Contrsdori License Low(Chepter9(mmrendng with Sadbn 700%of Divl- SWL341v(ING POOL ELECTRIC
ebn3 office Buslnesand Pmfesloro Code)orthrt he lav therefromaM VALUATION
the held for the alleged enemptlon. Any vidnlan of Ssem els 70313 by any
appltant for,permlt aubjecla the applicant toe civil penalty of not mon than OUTL7:ISSNTICIFSFIXTURES
Dv:undred dollars 050W. NEW RES11YFMIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
k 7< I,as owner of the Property,or my employeeswkh wages as their sok
compensation wflldothewod3 and theecructurc ls rot Intended or offend for
❑ sale t5c'c7!144,Buser and Mrof.W.Code:Th.Conuadars License Law
3fd damnat,pplytoanownrrdpmpertywhobufldsorimpro thermq d OCC.GROUT' NLS UNITS
whodoessuchworkhl Uwthwgh Msownemployees,pro Wedthateuch
Imprvvemcw sem not Intended oroffered fm sale.If,however,thebulWing a TOTAL
wpnvement lssoW within omyearofcompidbsthe owner-0ulldttwW have ,
APN
t rden of proving that he did rot bufld or bnprove for purpose of ole.). QTY, PLUMBING.PERMIT FEE -'
,I,as owner of the property,am bN
esseely mntrading wed Il coed FLODD yDhIE
I'QLWT]4UANCE
enntraoto oemtruthe project(See 7D14,Business and professions Code:
dn d
The Contracio/s IJ the doe sed apply b an ,d property who ALTER-DRAIN&VENT.WATER(EA)
builds or Improve theme,on,and who mntnct, (m such p3ojem with a
gW(adorw Ommdi pursuant to the Cmbader's Llmeae Law. BACK FLAW PROTECT.DEVICE -FEE SUMMARY
U 1 am exempt under Sec B &P C for this, maven
Owner Date —
®
DRAINSFIAORROOF,AREA,NND. SANITARY Y_ N BBC=!
WORKMAN COMPENSATION DECLARATION Fp(IU(pS.PER TRAP SCHOOL TAX Y_ N_
�I h<rc1ry affirm that I have•cediBate d cmsem to self-Insure,ora BEE
/
cedlflab of Workeri Compematlm lrvurarinmamnlflad ropy Nemafl$ee GAS F.A.SYSTEM-1 ING4 OUTLETS PARK FEE Y N
Poll,3a00,Lab CJ
Polley^ 050040779 ' • RECEE'T�
Com��a+ y ddu IIS. Q, G'��''���-0VERt(FA) BUILDING DIVISION FEES
10151 Certified ropy is Mth furnished.
ledMth
py Is hereby the city ImpMbn division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
JJCL�pjT{i CedNed ro
CERTIFICATE OF EYETe PTION FROM WORKERS GRFASETRAP PAID
COMPF.NSATIONINSURANCE SLWER.5ANETARYSDR.MEA.20�T. Date Recd tk
(Ddsaedbn need sea he camplded tithe pemdr ls/more hundred dollen
(f103)mfesJ ENERGY FEE Y_ N
ImrtBythrtbthe performenmofthe wmkforwhich Wspermklsbwed, WATER FffA7IIt W/VFM/p.ECTR '— -
1 shall net empty any pe.In any manner n an to beanme subject to the WATER SVSTFM/TREATTNU
Wmlu, Compensation Laws of California.Date PAID
PP NEW RESIDENTIAL PIMB. SQFI'.
A bont
Z O shoulCETOA,subject
aRerero'Co pe CertfflatedEnemptmn,you Dole Rcecl t#
Coded become subjhat to the women'Gompemmbn provlsbm re the labor - TOTAL:
~ N d,n,Yw yoked. thwhh comply with such provisions orehls pemdt shall be
W 7 deemed rewked. BUILDING FEE
c CONSTRUCTION LENDING AGENCY ECT FEE
1 Ihemby affi.,Nfor atthem lsaerrWructim lending ,Cor.C.) pedomm TOTAL ELECI'RICFEE
0 = anmofthe workfor whbhthiopermXbLwNLSee 3097,CW.CJ PLUMBING FEE Q
02 4ndele Namc -
LL H Lender',Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I ordlfy that l have read this eppBationand nate that the shove informed.
O W
lsco¢a
r .I agreeto complyco
with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
1
} miatbg to building construction,and hereby authectim representatives ofthis
F Z dty to enter upon the atone-mentioned Property fon Melon purposes. ALIFRORADDTOMECEL Date RCC21 1N
_ (We)sgme,to oaxe,Indemnify an d harmless;harmlethe City of Cu pedbn
agawtllabWties,pdgmemC,con,and tape.whieh may In any way amue AIR HANDLING UNIT(17010,000 CM) SUBTOTAL:
asabot ova City In mnaequence art ingot this pemdt. AIR HANDLING UNIT(OVER 1q"CFW CONSTRUCTION TAX
ZS CONSTRUCTION TAX PAID:
grotumdAppBant ont or Date F](1-IAl15TIIOOD(W/DUCT)
HALIRDO SMATERIALS DISCLOSURE
Will the appliam or futum buflding oaupant none ar handle hazard. HEATING UNIT CTO 100,000 BTU) Date RDcci tN
outerbl as deRmd by the Cupertino Municipal Code,Chapter 9.17,and the
Ilea hh and sifety Cade Serum 73532(a)7 HEATING UNIT(OVER IKODD BTU) TOTAL: !7 ' L7
Fl Yes Na
Ilf
ll the applicant S sum building oceupant use cqulpmem or devkrs VENTILATION FAN(SINGLE RESID) ISJ� jJ�):)ATE
which emit hsranlde sir mntsenleants as deRmd by the Bay Area Aur �1�
• llty Managem -0
ent District? BOILFRDMP QHPOR IMAM BTU)
Ye No
shave read theh a,amous materials requinerrcnt,u nder Cha Ater 6.95 of BOILER-COMP(OVIR 100,000 BM JUN 2 6 1990
understand
dthat Ekahh&Safety Code, currentlyave.erttu3 hiuh must it Li rrry NLW RESIDEVTLV.MEai SOFT.
pmut.ev,ua .(.Cyheoat p.f dthemqulmtrcntewhkh mrsthe met ave /s,�M�otW
prior to Lwuance da Cedlflnte of apanry. �yD
6--s=949
mauthorlredagent "` Dte �^- Lt
70TH L: ISSUED BY:,
OFFICE COPY