22950 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
ao33s \1 ,a 22950
ams:
"%s) 4a,4-1O of
a.)va ao. CITY OF CUPERTINO•BUILDINCDIVISION
• ctalaNeme: LIeN. APPLICATION I PERMIT
w '35- S\9 EMDINGh1BCIWC44PLUMMNC.MECHANICAL CATEGORY CONTROL#
A en/Englaeer. Lk.Naa
C-53 On ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreae PERAI'I'I56UANCE ❑
LK:Ehatl CONTRACTORS DECLARATION
IdthS inn7O=tlamBrm3ofthe u.ir andPmfelupter9 APPLIANCESRESIDENTIAL JOB RB N
Ingmeisinfun forma and
Ilmm bin tuB form and d(ect. PANELS
Llornre Cle LInB 3 ---o A\e:-\.S
ate Commcmr
ARCHITECPS DECLARATION
pZ I undendand cry pbmaloUbs used as public remdA OVERIBWAMPBF21 ;E .FIGOR AREA S/SQ.FT.
Llmnwd Professional SENSELBCIRICALER
OWNRR-BUILDER DECLARATION I
Iherebya0emthatlemenmpt(ecan,haCoatnmisLWeselaw(w,ha SPBCIALC�l1R/MISC Nr,]gf
z intL greeon.(SedIm RBD$Buakm and Professions Code:Mycttym
O .1:pQu( TEMP.MEIFRORPOLE INET.
p,' 7 countywhkb tequboaperodibesnenagalev,Impmw,demoWhorrepair
7 anynnrmrreptbrblblmanm,abornrylrolheappBmntfmmdepemdtb
5 file a signed emeM that he b named pumanl b the of be I0ti173R DEVICES
tlal
Connors License Law(Chapter9(commencing With Semon 7MM of Dlvl-
SWIMMI
sion3o4aeBud"e andPMembnCodolortWtbebemmptthemf.,,d NGFOOL ELECTRIC VALUATION
the bests for the alleged examptlae. Any violation of Section 7015 by any OUl7.E1SSWDCFiES177('IURPS
applicant fora pomdt eabjenathe applicant to cMI penalty of not mom than
fi hundred dollar,(SM.�1,as owner properly,or a with NEW RESOEEhIIIALER.ECIR SQ.F1'• STORIES TYPECONSTRUCTION
Y,r my employees wages as their wk
a mmpensaaon,wgldo the work andthe structure In not Wended or offered for
O wk bee 70K Buakmand Pmfembns Cade The Contmmla Llaemei<w
$ dam notapplyman awoer of property who builds or lmprowsthereon,and
whodceaeuchwwkhim lfwthroughbsownemploym;pmddedansueh OC—UROUP RFS(ATIS
Improvmnaataere not bteMed woffered fw We.lC homwer,thehulMbgw TOTAL•
ImprovemetuksoldwkhinonaymrofcempkUmtheownerbullderwW leave
lryp.bu rdenof pmving that he dM net build orlmprove for purpomon.1%L QTY. PLUMBING PERMIT FEE
L L m owner of the property,am exclusively contracting with Beensed FLOOD ZDNE APN
eentmnessb construct lir project(Sm.MK Bualwerand I'mimakns Code: PERMrtffiUANCE
Tha Cert omals Litman LAW dm one apply m,an owner of property who
bell&or Improves themM1 and who mmratla for each pq*m with a ALTER-DRAIN&VENT-WATER(SA)
cqa1(actmW Roamed Forward to theCmmmis License law. RA«�W ,•D FEE SUMMARY
Ll-1 o
am o q t under See B&P C for ab Woman
• Owner pace DRAINS FI.00$ROOP,AREA,GOND. — SANITARY Y_ N_
WORKMANCOMP1NSATIONDFiL RAT10N RFxm7F
❑I hereby in.that I heves a mKifcate of mM b nsself-bwre,or a PBCDIRE&PFRTRAP SCIiOq.TAX Y_ N_
mKBlmbofwarhen'Compenaatlmelewranmesao:Klfled mpylheeedLSxc. RBCFRNF
. MO,lab C3 GAS FA.SYSIFM-1 INCd OVILbTS PARK FEE Y_ N
ISSkyF CAS FA.SYSTFM.OVER 4(EA) RECERPTI
ry RUILDING DIVISION FF.FS
dived copy kharebyth thelrnd. CREASE/INDUSERL WASTE INThRCFrroR PLANCHECKFEE
KNed copy to Ned tuts the city inspection dlWsim.
CERTIFICATE OF EXEMPFION FROM WORKERS' CRFASETRAP PAID
.-
(Thin
NCB SEWFMFSAN(T•ARYSIDRM FA.700FT. Date Rccei t#
(Fblssgbnneedn Bind bfarcaieW dradddlan
(D0)cales WATER HEATERW/VENT/EWM ENERCYFEE Y_ N_
Imrtl atba p fans ed,h br IdtMapermitklmed,
Cemp nos + an bboo m oub)eattothe WATERyYyTEM/TRRA.GM3 PAID
ZO A Ilan a r ngthbCaKBlmtoofEvemmppttInky. NEWRE9DPN'RAI.PIMB. QFC. Date Reoei t#
should pnmthe W bnprowbro tithe tabu TOTAL:
W~ N Codgyeu tlfcat ply such pro northbperm8dullbe
> dmmed cavo BUILDING
CON TR ING GENCY SEISMICFEE
CL
Ibereby me that I le Bagncybrtheperiorov ELECTRIC FEL•
7 Z nmdth rkforw .309/,CN.CJ TOTAL:
V C I<ndela • PLUMBING FEE t,—
LL 1- Iandela mac QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IesKl/ylha ve this ep andtlalelhetthaabavebformauna
bmnen.lag ly witha ckyand muniyordlnanma and tlabbws PERMIT ISSUANCE FEES PAID:
r W Maung to Wl gmMnenbn,and hereby eaacrm repmsnbaroofthk
1- 0 ntybenter upon the abov amntbrud property for Inspection purpoem, ALTERORADDTOMECH.
(We)agme to arm indemnify an d keep harmless the city of Cupertino Date Receipt#
against lbbBUm,pdgmems,tons and expenses which may in nywayaccaue AIR HANDUNC UNIT ITO IQ(DO CFM) SUBTOTAL:
beau ` lee gnat alible pnnRLLY/� AIRHANDuNcuNiTg)VER140acim) CONSTRUCTIONTAX
Signature of Applicant/Cnotmnw Dik4 EKHAUSTHOOD(w/DUrn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building owupam etre or handle hazardous HEATING UNIT CFO 10pDD BTU) Date Recti t#
material ae defined by the Cupertino Municipal Code,Chapter 9.l;and the
Heshhand SalelyCnde Sedlna25M(a)7 HEATING UNIT(OVER FOQOM BTU) TOTAL: at, —
n Ym
Nit
S�JJ
filth.applicard ture building occupant uzecqulpmeb or devices VENTILATION FAN OINCLE RESID) _I W JNff DATE
which emit hazardous ab mrtantuntan defined by the Bay Area Air Y /\ Y
• alRy Management Dimict7 BOIIER-COMPOHPOR IMAM BTU)
Yat QT�'i No
haveread the hommoun matemk requirements underChapiw&95 of BOBER-00MP9OVFIt10,00B)U)
SeNOV `C 8 1991
lhaGBfamb Itesia&SafetyCndq
Section,29505£aU3 end 2RM.1
understand that Ifthebullding done not currently have a tenant,that it bmy NEWR®DENTIALIAKFF. SOJ•T.
responsibility In notify the nmepam d as mgnlremerdewbkb cast be net CITY OF CU.PERI n._
prior to Issuancedtiy the oc odd of the req }��hh
Ownror authorized agent ate IS.UEDBY1.
' 70TAL
OFFICE COPY