22389 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Pram Ident1flcelon �j,p PE TNO. /
Building Add re : 7 r \ 2 2 3 8 9
e a ( I Fhorm: 1 A
DA
a( CITY OF CUPERTINO-BUILDING DIVISION
Contraacva Name: LIB No, APPLICATION I PERMIT -7- 2- 91
BUnIMNGFLECTRLCALPLUMBINGMFCHANCAL GTFCARY CONTROL.
AtohRm/Englver. Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE* ❑ El � ❑
LICENSED CONTRACTORSTI
DECLARAON
Ihereby affimn that l am hmmed under provisions ofO pter9(olmmenc APPLIAN ES-RESIDENITAL t JOB D6CRD'ITON
ingwlth Sevt1on70W)of DlvWm3dthe Businessand RofealoruCoele,and myI rl
l i¢na lalnfuB ddfect. PANELS P�
Lbenyef�Lk.a
Date Cantndo ra�G
ARCHITECPS DECLARATION 1-1 AMPS
K OVER 1000 AMPS F7.FLOOR AREA
pkv O'Z ]uMeratand my plan ahaBbe used mpubllcre�da ./`✓�T. S/S�.FT.
of Lf¢nxd Profeubvl s - SIGNS ELECTRICAL
«< {WWiyy OWNER-BUILDER DECLARATION SPECIALCIRCU1T/10I9C \ I v
IherebywifirentheI.,.emptfromtheContreor'sLlmose, awforthe
pO following re..(Sm1m70315,Bvema.nd Pmfe+.bv Code:Anydtyor
TFMIa.METER OR POLE INS!.
KE anygm=ntyldtretol aper m"lsorequdtheaprn tfmsuch,er to
,q anyrtnurnrreater -tth u he b aamued pumant to the rovisi .& te .•. ..
(11e a signed Yatement the he b Ibenud purwant to the provbbv of the �W�D�� 4 9 OQOO
Qµ Com ado's Lkeve Law(Chapter 9(mmmenMgwBhSedion7=)ofDivl-
�OS eon3 tithe Buainms and Pvf.IuraCode)orthat he b exempt therehomand �MLL`�C POOL ELECTRIC VALUATION
Q 9 the Web for the alleged e.emptbn. Any violation of SeGbn 70315 by my
apphantfora pent mbjeNthe.ppBc ttoad Hpevltydna morethan OUTLETSSWTTC:
Ove hundred dolleat%500!_
'9..'
r-1 1.u owner of the property,or my.employ.with wages.,their sole NEWRF�ENTIAL EI.ECIR ��• Sf0 TYPE CON'SL D(=lN
mmpwatlm,willdothe work,and Neewdure b rot Intended or offered for
ie(s
o vec7014,BWromaaed!Pm(eaeo ,Cade:TheCommdoreLdameLaw TER
doenrtapplytoanownerefpropenywho bulWaorimpro¢athemon,and - C. ROUP RES UNITS
C whodoseurh work hlm,elforthrvrgh hbown employes,pnovded that such
Impmvemaw art rot Intended oroffered for ab.IL however,thebul)dIngor DANE
Improvement bald within oneyearofeomple(lon,the ownerwilderwi0 have
t rden of proving the he db not wild or tmpmve for purpose orale.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,en evcluev0y trading with Ilmnaed FLOOD ZONE APN
cormeton to mvtrua the project(Sm 70K Bush es and PrdeWov Code: PERMIT ISSUANCE
The Contndori LI¢ve Law don not apply to an owner of property who ALTER-DRAIN 4a VlM-WATER EA)
Wilda,or Im umms theme.,and who¢mnm f¢ouch pLojMa with a
c
gl1¢vciam
(a)Bna di purwaot to the Cmtndori Lleense�. FEE SUMMARY
L_)I am vaempt under See. B k P C for this reaaon BACK FLOW PROTECT.DEVICE
DRAINS FLaoR ROOF,AREA,RIND. SANITARY Y N
® Owner Date RFLE N
WORK MN DLA
AN COMPENSATIOECRATION FDCTURES PER TRAP SQTOOL TAK Y_ N_
nV 1 hereby affirm the I have a¢rttlioh of consent to self-Insure,a a RECE[PT N
oa�g¢teo(Worlvn'Canpmvttanlvunnm ara¢nBfed copy thereof L"rec. GAS F.A.SYSI'EM-t INC4 OUTLETS PARKFFE Y N
3800,habC.)
Pd rya
m •-1'—• ��� GAS E1.sYSI4M-OVER4(FA) xLCEII'1'1'
Co BUILDING DI Vi510N FEES
CertNe�rbpy b hereby fuMah�.
Cmnined oopybruee wdth the dry wpmtlm.alddm. exEABE/mvusrRl WASTE tNrtRCErrox PLANCHBCK FEE
CERTIRCATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE
r
( SEWFR-SANITARY-MRM FA 3AET. Date Recei til
ITbaeabnnecd na bc¢nplpldediftBtha permit bfmorchunarc0 dollen ENERGY FEE Y N
(5111 o a lea.) WATER HEATER W/VENT/FIECTR
I¢notify employ
o the person
In any m work so as to btela eertNj c botee,he —
I,hail not empty any person In any wnvn a as to become subject to the WATER SYSIPM/'IREATINC
W¢ken'Compenutbn haws of Gllfonb. Date WATER
O Z NOTICInt NEW R1MDFNTIAL PLMB. SQFr. Date Recei ted
Z2 Nould beomrxfl.iCANthe ager res.dm C.en er Ceton eate proof Ezcm�pb Lebo
should bemme aubfM to the Woken'Compematlm provbbv oflha Labor
- TOTAL
CC T Code,you nowt f¢thwith comply with ach provbbv or this perenit stall be
LU
LU > dow
deemed reked. 1
CONSTRUCTION LENDING AGENCY S ISMIC FEE 1
1 herebyafxrm that there b a covtvdlm lending agency for the perfomn-
Z an¢of the wohfor which this permB b lamted(Sec 3097,CN.C.) TOTAL ELECTRIC FEE
U O . Lender.Name PLUMBING FEE
LL ~ Lender.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1omfythat l have read thhappllatbnaM patethatthe above Infomntlon -
bmmd.IagreetocmnplywithelcityandmuntyordmanmsandMate lawa PERMIT ISSUANCE FEF$PAID: 14.1
} N relall�towlWing rovtvnlon,and herebyauthu tmmpm,mtehesofthIs h
f.. Z city to enter upon the abovcmmidonel property for Luproum purp.. ALIERORADDTOMECH. Date Revel til ' 1
V - (We)agree to.ave,ideemd fy an d le mp haredm the City of Cu pen4ro - P
against WbWtles,I,dgmemn,",and spenxe white may in anywayamue AIR]1ANDLING lIMr RO 10,000 CFM) SUBTOTAL
.gelrataai ty n t e f thagrmtmgdthlspcm NR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX
��
Sgr!'or ApplTcaTi�Cm tat-Auer Hoop(W/DUCT) CONSTRUCTION TAX PAID:
R MATER ALS DSK SURE
Will the.Ppllvnt or future wlldlea ar pent ream or handle havnlmu ' HEATING UNITOO 100,000 BTU) Date Recei ted
material as defined by the Cupertino Mur,d al Code,Chaper9.Il.and the
Heahh and Safety CadrSalm 25531 W 7 HEATING UNIT(OVER IDD,000 BTU) TOTAL:
RYe
all the.Pphcam fulurebuilding.pant use egWpment ondevka� VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkhemRhavtdov. -mnumWmaa.defnecbythe B,y Area Air
• Quality h(avgemmnt Dbt 7 BOILER-OOMP OHP OR IOUM BTU)
4Ys No
have read tha bavl wledab requlremenb underChapler 6.95 of BOIIXRCOMP(OVER 100,000 BTU)
the CalBan flat Ifthk Safety Cods of 7550.5,75533 and 25531.]
usporeldthat BthewildIngdos notthatwhinhen,t It mer NEW RF9DENTTAL MEl7i. SQF7.
priori m'to notify the ocapantdtherequirtmewwhkh mrrtW met
priori ce A Ce (Ib fOmnpancy.
Owner or authood agenttI We . r ISSIIEDB ' (L1/Jrl/� ✓4•W�`N
TOTAL:
OFFICE COPY