23252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION
� �`` L19�+{[yAp APPLICATION I PERMIT �— ��_
BUILDING-ELECTRKALPLUMBINGhfECHAMCM, CATEGORY CONTROL♦ 9
:A eR/Engtneer. tJ
n ELECTRIC PERMqJV PERMFEE BUILDING PERMIT INFO -
nean�
PERMTISSUANCE
LICENSED CONTRACTOR'S DECIAMTION
Ikneby ref( ,hall am licensed undo pru 1zkusof Chapler9(commen APPLIANCES-RES! JOB D N
I�wlth Sento o(DivLdon3 f cMTION
Cade,and
Ibe�bin fu and effect. P Tl�
L C�a Lk./' 1
Ron
ARCHITECTS D ��T PS
x I undentaM my planshag be used u public nemds czwlza, O 000 SQ.Fr.FLOOR ARAREA S/SQ.Ff.
E �j Llansed Prufeebnsl SIGNSE I r-" $I
<<� OWNER-BUILDER DECLARATION WWJALCIRC T/M _ ` ••7 a'� ITU
Zf, ?t Ihereby.fl.the Ien vempt from the Contractor'•LkeneI the
O
foBowing moan.(Section 7015,Bue real Pvfeelou Code:Any dty or
j. TQ.IP.MErFR OR INST.
county which pq Wires apemmeaL&orequiit to conatruct, Btheaprovgdemdbh,ormpar
to
anyatmnureprkr entthe he
msuantt the (orwdisof t e POWER DEICES
5 Ne a signed statement that k b Barued pursuant to the pmvbbv of the f'
OContractoes Uceve Law(Chapler9(mmmenMg with Section 7000)of Divi-
3��ee slon3of,he BudnessandRdrnsbmCode)orthat he b ess ,herefmmaM SWPIMING POOL ELECTING VALUATION
~ ^1 the bub for the alleged ea rnptlon. Any violeion of Section 7015 by any,
appliantfma per mbje4theapplknttoacMipa Ltyof Rmmtkn Sm1<ti6 E1%NR6 —` q�)C
fish rdmd do"%W. NEW RFSIDFN[W,ELFG[R
IL_ff I,u owner of the property,or my employees with wage as their wk '�'FT. STORIES 'TYPE CONSTRUCTION
pewMon,wOldo the wok,and the structure b not bdeded or offered for
5 o sale(Sec.70K Bu,lrcv and Ned.loo Code:The Contractor•LIunnv Law
HRdon ret apply to....,of property who builds or imp..thereon,and RTS
who dmauchwork hlmseBathmugh wownemployees,provided that such
ImpmvemenmamwH tendedorofferedfamle.If,however,the building or
Impmvemendbaddwithinoneyearofenmpldlon,theowner-b Werwillkve
t"rdenofpvving Uehedd not bund orlmprm,e for purpose ofmie.). QTY. PLUMBING PERMIT FfnAT
�l((]]NNFF
I_I L u owner of,he property,am ercwively contracting with licensed mD?.QNE
contrcters to mntruct the project(See.7DK Badness and Professions Cade: PERMIT ISSUANCE /`r/ /
The Contractor's Lloeve Law dm not apply to an owner of property who
builds or Improve the eon,and who contracts for rurh p,jem with • ALTER-DRAMA VENT-WATER MA) 1
CyDlr+dor(•)Maned purwaot to the Contractor•Llarue Law. FEE SUMMARY
1_J I am essmpt under Sec B A P C for this soon BACK FLOW PROTECT.DEVICE OUTSIDE FEES
ORAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_
Owner Date - RECEIVE
WORK MAN COMP INSATION DECLARATION FD(TURFS-PER.IRP SCHOOL TAX Y_ N
❑I hereby affirm that I have• l rt me of aouent to o"the m,a a RE=
3NOlAeafWorkers Comperuadanlw'anmaaanifkd ropy thereof 6ec. GAS,FA.SYSTEM-1 INCA OUT= PARK FIE Y N
ivic Lb C.I —
I'dky# DING DIV
GAS EA,SYSTEM-0VPR 4(EA)
Com any BUILDING DIVISION WE
CrtNedmpy4fUed ththec d. GREASE/INDUSIU,WASTE INTERCEPTOR PLANCI'IECK FEE a1
�pCerllDed ropy l•(Iled wlthtk city lvpMbn dlvlsim�. 2{ 1�� /
CERTDTUTE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE f '^
(Thin
senlormed not be completed lfthe permit Is for one hundred dollar• MWE'SANTrARY-STORM EA.20OFT. Date RL'Le t
($100)rr1m) WATER HEATER W/VETT/OR.CIR ENERGY FEE Y
1 certify that In the performance,of the work forwNrh thispemdt b bsuea,
I,hail not employ any person In any manner so as to become subject to the WATER SYSTEM/111FA.DNG ` , -n t g
Worker'Compensation laws of California.Date PAID L \ a
PP SQ Date Remi t#
ZQ NOTICETO APPLICANT:If,after making thin Certlficeeof Eaemptbn you 1`rEWRIIDFN77AL I'LMB' 'FL
should become rubi d to the Workers Compeesatlon provision•o the Labor TOTAL
0 Code,you.9fwthwith comply with such pmvbbvorthb permit shallbe
LU > dermad revoked. .1.
CONSTRUCTION LENDING AGENCY SEISMIC O. o IhrmbyafnmttktthembamvtmRbnkwing.gemymrtkpermm. Tor,klw ELECTRIC FEE
Z once of the work for which thio permit b bored(Sec 3041,Clv.C)
(,) O kdera Name PLUMBING FEE
IL — Lender,Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W l certify thel have red twappllatbnand yste that the above information
b.,reel.Iagre to comply with.B�y and countyordivnm and state law, PERMIT ISSUANCE FEES PAID:
YN relating to building mnatructle ,and hereby authortre repreaeruelvnaftAb
F U) ety,to enter upon the above-mentioned Property for Wpectbn purpore. ALTERORADDTOMECH. Da[C Recei [p
_ (We)agree to eve,bdemelly an d keep harmless the City of Cu pert Ego P
•g,Int UbWtln,N d w,coRsaMeapene-swhich nuylnanywayactexu AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
N of he gran,Ing of I pe
MR ruNlxlNc unnr(OVER 10,000 CRA) CONSTRUCTION TAX
sig u ppn rat/Co nor c7 Da, DCHAUST HOOD(WI DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MATERULS DISCLOSURE
WWthc applkant or Tutor building arvpant stone or hadle h...rdous HEATING UNIT CIO I O,(UO BTU) Date Recei [Il
ental as dAned by the Cupertino MuNRpal Code,Chapter 9.17-and the
F aithad Safety Cade Smim 25532(x)7 HCATNGUNRT(OVERl00,lXDBM TO 1
Ye �]No
Ic
nithe appBau.ercuamnding mvpndby thWpmeot.Air m VFNDIA7lON FAN!SINGLE RESID) ISSUANCE DATE
whbheMa krement airrrmWn„ude0rcd by the Bay Area Air
Qua Wy Management Disblct7 BOILER-NMP OIi!'DR l00,UD BTU)
n Y. - ❑No
�I have and the havrdous meerlab rtquUcmenb u oder Cba pier 6.95 of BOILER NMP(OVER 100,000 BTU) P A ' p
the Ctifomb Health A Safety Code,Sections 75505,rS33 and 25511. I
urAerslard that lithe building don not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQFr
responsm0fty to notify the orropant of the requirements which oust be met BD -1 a
prfarto Lmrameerfa Clnfim
lteofoaMAR 1
vparcy. 1992 G�
Owner or authortmd agent Dale ISSl1E� n I .11 1�
TO all
OFFICE COPY