21977 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildina Pm et Identification PERMIT NO.
Build mg Address: 21977 1 9 7 7
10-So 1 0• TPa3TALl AVE G
rensN Phone:
DeM �` �T�S .'7953Z It/ CITY OF CUPERTINO-BUILDING DIVISION
conte ,Name: 1 ' Lk.No:
APPLICATION / PERMIT
2�-7 I B=ING-ELECTRICALPLUMBIN'GMFCHANICAL CATEGORY CONTROL Ie�
Aochitect/Fsgfneer. I.feN
ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. 411-
I'FRh917ISSUANCE ❑ ❑ . El
CONTRACTOR'S DECLARATION
I thSc on7Gl ofDhdcn3ofhm er Buslassand of Casions 9( APPLIANCESRE9DFMIAL p ON
Ingwe in in full
of Divlatm3ofthe Budneuand Pro(essloraCod4 and my
license in In lu0leraand riled.. PANELS �' •
Liana Clara LILY
Date Comractor —LIP TO 200ANIPS
ARCHITECTS DECLARATION 1-1 AMP'S da
r4 IuMmmrd my phm,lullbe used as publicrtmda OVER1000AMPS $/SQ.FT.
Ob Licensed Profesebml I SIGNS ELECTRICAL PUT E
OWNER-BUILDER DECLARATION SPECIALCIRCUPT/MI!C /
ZOIhertbya . t}utl 7MI,5, t(mmtheComfr Ir'aLicense sCode.nw(«the
Z folbwby ream.L5ect1on 7m15,BuNnes arW Pmfmbru Codr.Any tlty or ^�
O Hier, TEMP.METER OR POLE INST. nATF
PEI county which rcyuWt aasua t alsoeu4 de the applicant or such
to
e� < anya signed statempriar toent
t Wwrcq,LorequMsuant t the rovisicuu,of Use
SER DEVICES
V 01e•signed Katement that k 6llaneed pursuant to the proWbm of the -
HOw Contractor's License Law(Chapter9(commencing with Section 700D)of Dlvl-
dot 3 of the Businem and Pmfessm bCode)or that he ti VALUATION exempt therefrom and S 'w'ONGIWLEI.ECIWC
the Dais for the alleged exemption. Any vlo allon of Section 7031 by any OUTLETS-SWITCHFSFII(TURFS >.0'
,ppU.tf.r.permR,cab,• the,pplk.ntt.ad ipe.ky fn&.o thin QC� J
fWc hundred defiant;(SSM. NEW RESIDFNHAL ELECTR
�a
F-1 1,as owner of the Property,or my employee with wages an thele wk e•'Q�FFEE
STORIES TYPECONSTRIICTION
mmpensabm,willdo the w«)•and the structure b not Intended or offered for
C O ask i5e,7044,Business and Professions Code:The Comntora License law
don not apply to an owner of property who holies or improves thermn,and OCC.GROUP RFS.IIt•R75
EE whodaes suchwork himclf«through hlsownemplojen,providedthatrtrch
Impmvenenta an not lntmdcd orofferedfm idle.IL havever,the building m TOTAL
Improsem mr "dwdhlnoreyvarofcompletion,theavner-b Werwil w
aaCurdenolpm ngthah dldrw ddorlmpmvefmpurpa,en!„e.). QTY, PLUMBING PERMIT
Lj 1 as owner of the property,am eacWahely contracting with licensed
and
APN
contnton to conswctthe projtt(Sees 7044,Buslnm and Professions Cade: PERMIT ISSUANCE
The Condratari License Law dm not apply to an owner of property who ALTER-DRAIN 6 VENT WATER aW
bu0dro
a or Impvre on
thereon,and who cora us fee such plt
ojes with a
FEE SUMMARY
oltifsecon.) underpursuant to NeCmtnct«iLlceme law. BACK FLOW PROTECT.DEVICE
I am eaamp under Sac B A P C for this reason
rrrq
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT Y
WORKMAN COMPENSATLON DECLARATION }iXIU�SI4R.fRA1' SCHOOLTAX Y_ N_
711 hereby affirm rem that I haw a mdl0cate of eommot to self-Inu , a
RECEIPT Y
certl/loteafworkerse Compmeatim Imuran««a certified copy theaaf Gee GAS EA SYSTEM-1 ING4 OUTLETS PARK FEE Y N
M W,Lab C) RECF�T N
CoY GAS FA.SYSTEM-DYER4(FA)
Co����mpppparay BUILDING DIVISION FEES
I Certlfkd copy is filwthhernity the cityed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
IY�ICertiRed ropy 6111ed with the edY inspection division.
CERTIFICATE OFEIEMPTLON FROM WORKERS GREASE TRAP PAID �-�--•�E
COMPENSATION INSURANCE gEIVFR-SANITARY STORM EA 2001r --Fate Rccef to r)EiSJ
Reds section need not Ix completed Lithe permit bf«one hundred dollars
(ElOOJOf1y EI.eerR ENERGYFEE Y N
I aor le that at N the performance of the work for which thio permit I.Ieded, WATER HFATERw/VENT/
I shall not employ any person In any manner an as to become wh),et to the WATER SYSIEd/IREATING
W«ken'Compematbnlawsof Callfoml,.Date PAID
C1 z Applicant NEW RF9LNDENIAL P —gQFI.. Date Recef t#
Z NOTICE TO APPLICANT:U,after m,ling this CetBkate of TaemptbNY.
should become subject to the Warken'Compensation P==0 of the Labor TOTAL:
CCN Ced4 you must fort hwBh comply with ouch pravfalos,or thio permit shall be BUILDING FEE CA I Ilk
W > deemed revoked. .
CONSTRUCTION LENDING AGENCY S MI FE
CL Lhereby.filhatthertba construction lending agency for the perform ELECTRIC FEE
Z ance of the work(or which thlspermh la bwed(Sec 309/,Ci,G) TOTAL
02 Iender'e Name - PLUMBING FEE
1- L eaten Adders. QTY. MECHANICAL PERMIT FEE
O W I sertifythalI have mad thbapp"donand date thatthe above inlormMion MECHANICAL FEE
4 bmnt
a .I agree to comply whh all cty and county mchri.e.and elate laws PERMIT ISSUANCE FEES PAID:
>. relating to buliding construction,a cal herebyauthoNe repreaenbtive ofthk _
F N ttytoenter upon the ab nnarllored property for Inspection purpose. ALTFRORADDIOMECH.
_ (We),gone to ,W emnlfy an d keep harmless the City of Cupsduto - - Date Receipt#
V aga�tllebBlU ,' dgmeta, red rape which maylna ywsyamue AIR HANDLING UNIT(TO 10,W0 CFM) - .SUBTOTAL:
t agalml C t ng ofthism" rel AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
m ! ppu t/ rot m 5 ate E�a]Ausr H000(w/DueD CONSTRUCTION TAX PAID:
\ HAZARDOUS MATERIALS DISCLOSURE
Cd,the applicant«future building occupant Mom or handle havrdous HEATING UN7T(I0 100,000 BTU) Date Rei:ci t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
HeahhandSafetyCade Sectlm25332p)? HEATING UNIT(OVER 100,000 BTIJ) TOTAL: V��'-
ll •V
En Yo No
�9'illthe ippli.m« tune WOdNga pante equipmen device, VENTILATION FAN(SINGLE RESID) I$$U, EDATE
which emit ha.relm. it meta m)nuMaa,defined by the Bay Arta Nr YO'�,J
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) �{(.SR
4Yn Na MhC 1n1
have read the ham sus materials rcqulrtnenb under Ctupter 6.95 of BOILER{OMP(OVER 100,000BTU)
the California Health k Safety Code,Scctlom 25505,25533 and 75534.1.
understand that lithe building don not currently have a tenant that it in my NEW RESIDFNIIAL MECFL SQF7
responsibility to notify the occupant d the mquirerrenn which most be met
prbrtobsuanaofaCertlfkateofOavpany. _I`
Owner or authorized agent Date
TOTA4 ISSUED BY:�R sPs K'
OFFICE COPY