20484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proeat tdentlf1wim PERMIT W.
Building Address: 20484o
rens alae: one
TANDF-M ConnF,Lnnes wr-Zjy_3ZgS CFIYOFCUPERTINO-BUILDING DIVISION ��'�
C �1
. ontana'sName: LleNa APPLICATION /PERMIT TO
BIAIDINGE].ELTIUCAL-PLLTMBINC-MECHANICAL CATEGORY CONTROL al9
/
ArchRect/F giver. Lie Na
F►NCLIGN�ROMINL
Qry ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.Yron •S L CR' PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I berebyaflirm that l am lkm,d under provblona of Chapter 9(commeru, APPI3ANC[SRESIDENi7AL JOB DESLRPHON
iogwith Section 70001 DIWdm3o1fthe Bual.and ProfesdmsCude,and my
Ilan.la In full force it effect. PANELS
Llmve Clas Lle.I I.�LEy�t Y•Id QTF—L-
Date Contnctor LM IQ 2QQAM[PS
ARCHITECTS DECLARATION 701-TWO
re I understand my plans sha8 beueed as public records. OVER I=AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
00U
Llarixd Pei®bol SIGNS FEDC'IRI
6 OWNER-BUILDER DECLARATION SPECIALCIRCUJT/
Thereby of renthat lam ezemp from the ContraCari Llarae law for the
following mason.(5ect1on 70315,Bueiner and Professions Code Any tlty or
POMINW
Fav' wantywhc requ4 apemdttowr md,Oter,lmpr ,demolbkor"r TEMP.M R
44 ,py anyatructure priato ib issuance,also requlreathe applicant for such permit to POWER DEMI
6' D foe a signed statement that he b IIttvM pursuant to the pre t loss of the
Contr ori Uceve w(Chapter9(mvurcndngwhh Sec n70W)of Div{-
OSWIMVALUATION
4 S ff' sbn3ofthe Welneseand larofembns Cde)orthet hebeze thertGomard MING
the Web for the alleged eaemptloo. Any vldadon of Scatbn 7m1s by any '
�•4 appBcent fora pemdt subjects thsapp0canttoa tivll penalty a ors mortlWn ZOJ.oOd
pp eve dred dollars OM.
R �I,mas owner of the property,or eny employees with wages as their sole RESID STORIES TYPE CONSIkIXl'ION
compensation,wBldothe week,and the structure is not Wended or offered(or
sok 5cc7f111,Business and Professions Codr.The CoMneors U. Lw
Moo ret apply to an owner of property who builds or improve thereon,and
�S^ who doe such work himself athrough his own employee,prvvdd that_6 C. RES.UNITS
sart not Intended oroffered la mit.If,however,the Wilding or T TAI.:
Lnprovement lasold wdhin avyearofcompietbn,tW eswner-bullderwW Wave
t m of proving that he did not Wed or Improve lee purpose a ems). Qry.MLUMIBINGPERMT FEE FLOODZONE APN
P,as owner of the property,am exel alvely contracting with limned PERMITL6UANCE
tra roto consamet the project(Sm 7041,Buainemand ProfmlonsCade:
The Contractors License law dm rot apply to so owner of property who ALTER-DRAIN 4 VENT-WATER(FA)
bu0ds or Improve Neuron, and who cornara for meh p(ojem with• FEE SUMMARY
b reasonreasonC ff, wW freewill pursuant to the Contractors l.kew law. BAER FLOW PRO'rEC'I'.DEVICE
U 1
am ezempt order Sec B 4 P C for ehse
Q.1T11QE FEES
Avner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• NI
WORIAN COMPFNSATIONDECIARATION RK,=r
F11 hereby affirm that 1 have•anigate,of consent to sell-Iwrc,or a Fi%]1JRF PER TRAP SCHCOLTAX Y N_
rertfilwe of Worken'Cumpevatlom leauana ora certlfkd rupythereof(Sec. RECETT 1
3800,1.6C-) GAS EA.SY9IFM.1 TMCt OUTLETS PARK FEE Y_ N_
R XHPf a
policy a GAS FA.SYM-EM-OVER I(FA)
um ny BUILDING DIVISION FEES
CC:19F ropy bhertbyfumbhed. GREASE/WDUSML WASTE IN'TERCFPIOR PLANCHECK FEE
❑CenNd copy b filed with the tlty Ivpoulon dW W on.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAIa PAID
COMPENSATIONINSURANCE SEWER-SANITARY-MRM EA.]INTI'. Date R. 471
UhbsMbn need eat be completedtie SU bfaonshundred dollars
($10))or lean.) WATER HEATER W/VFNT/ELEcrR ENERGY FEE Y
I unify that ih the perforrvna of tha wok forwMch fhb permit b Wud,
I s W llnM employ any person In any runner sou to become subJed to the
WATERSYSIIM/TRFA'LNC
Workers Compeneatbn Iawea Gllfanla.Date PAID
O Z Appgont NEW RESUDF1T1AL PLMB._SQ.FT. Date ecei tN
Z � NOTICE TO AITLICAIJT:If,after mklry thh CeM1liute of Fxemptbry you
should bamme abject to ins Warken'Compensation pmvlalnnsothe Labur - T TAL:
CC N Cde,ymmuatfodhw hmmplywilhsuchprovbbmorthbpermkeha114 BUILDING FEE em
deemed rt kad.
W >
d CONSTRUCTION LENDING AGENCY SEISMIC FEE ado
I hereby afRrm that there 6 a mvtmctim Ending agerry!or the perform ELC•CTRIC FEE
= O so,woftheworkbrwhkhthispermRlsb See 30Y/,CIv.CJ TOTAL: -
() _ Ierderi Nano PLUMBLNGFEE
LL ~ Lender,AddQTY. MECHANICAL PERMIT FEE MECHANICALFEE
OWIs lanifythatl Wvz rcadlhieapp0atlonarrd atatethHtheabovelnformatlm�
(1 cornet.]agree to comply with all city AM county omllnancos and state laws PERMIT ISSUANCE FEES PiM
} relatingtobulldingconstroctlon,and hereby author represenative ofthb I
Ztlty to enter upon the sWue-mentbrcd property for WpeRbn purpose. ALTER OR AI3DT0 MFCFL Date
— (bud agree,to asst,IemMfy,n d keep barred.the City of Cuimpenr 1 471
against WbWtln,j,dgrrcNa,cosaand ezpe.whkh may in anywayamue AIR HANDLING UNIT(TO 10.=CFM) SUBTO L:
agaivtsaidC eros the his pernR.
AIR HANDLING uNIT(OVER to,tnocFM) CONSTRUCTION TAX
14 0
nature AppOa rot EXHAUJST HOOD(W/DUCD CONSTRUCTION TAX AID:
RDOUS MATERIALS DISCLOSU
W0ltheapp0 morfuturebu0dln6oavpantstoreor Wrdkhaurdous T[EATINGUNH7rOt00,000BTU) Date Reee t71
mA,rul as defined by the CupeM1lro MuMdpal Code,Chaper 9.47,and the
HeallhitM Safety Ccd on75S37(A)7 HEATING UNIT 100,000 BTU) TOT 3.1
❑Yes Nm
03111 the applicant fu building a aupant use equipment or devise VIN'IILATION FAN 6INGLE RFSID) 1$$UAQj(�DATE
whicheMthar M., irmnta MraMaa,deRndbythe Bay Area Air u
Quality Management t 7 DO=-COMPQHP0RtD0,0DDBTUn
4n
Y.
Wvereadtheh 0u,rvtealarcquirtmenbunderCWpter6.95of BOI1ER{OMP(OVER tN,000BM AUG 31990
the California Health SafetyCode,Sections 75505,75S33and 75534. I F'
undmtadthatifthe buildingdoro note oily It eatenantthathbmy NTIVR1NDFNTLALM¢CH. SU.IT.
msporoBrRitytona theoccvpaM meets which nu at be met ((ff la
prior to lwua drtifka ,OWI rirfl).y,
rel
n eau Be TOTAL: ISSUEDBY:
OFFICE COPY