24226 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm en IJentifkaian 7
Add. PIX.V9TN24226
, 4 2 2 6
Building Add
o ]Jail D
etro n .// r
(_Oi1 L) f7T G. 4t CITY OF CUPERTINO-BUILDING DIVISION
e C hand Na N APPLICATION /PERMIT
BIIILDINGELEICTRICALPLIJMBING-MEC. MCAL CATFLORY CONTROL a
A ed/ glrce.
QTY ELECT-RIC PERMIT FEE
BUILDING PERMIT INFO
Ad `/V o p NS PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRALTO S DECIARATIOttFFjjjj
Ikrtby affirm that l un licensed under prervWon,of Chaptel�'A AIWIIANCESRESLDENTIAL JOB N
Ing HthSeciion700Wd DMNan3ofthe Badrsaand feulonsCede,and 3�1
Ikense Gln full rgQqra ana erten. ^^ PANELS // ,,` -`�
Lkxmr C-_ We. f-�' av/ V rr VSE{_
Dat] CoGJerdad
ARCHITE CLAVA 701-10DDAMI5
Iurdentand my platy shall be used aa public r&6rda OVER 1000 AM[5 SQ.FT.FLOOR AREA f/SQ.FT.
[2rvil ty�j Lkenaed Prd®lorul SIGNSELBCITUCAL
/6- OWNER-BUILDER DECLARATION SPECIAL CIRCUIT MISC
7 I h1mbyaffi.that I.exempt from the CorHndoes Licrow Law fee the /
o ppQp followingre..(5edion70315,Bualner,M Profesaba Ced,:Mycityor
5 munywM&requU aper tomwme,Oter,lmpmve,demol6h,orrepalr TEMP.ME TA OR POLEINST.
$$$R aydmdum price to its bsuano,also requlreatheappllant for such permit to
O5 ilk a signed statement that he b Ilansed pursuant to the prwisbru of the POWER DEVICES
Y. Contractor's Uterus Law(Chapmr9(mmmenciog with Sedion 7000)or Divi-
3�G slon3 ofthe Businessand Prdeasbro Cude)orthat he 6 ere therefromare SWBrQUNC I'OOI,ELECTRIC VALUATION
Sn 5 the bub for the alleged exemption. Any edatien or Section 70315 by any
applicant for a pemdt sub*M he applicant to a del penalty of not mom,lun D[T1LElSSWHCFIFSF'DCTUR6
$ ffhundred do"($5=. NEWRESIDENTLALFT TR
vnI,uawrcrotthepmpertyormyemployemwflhwagnastMeh le SQ'7' STORIES TYPECONSIRUCTION
comperuatlan,"Ido the work,and thestmnure isnot hu ended or offered for
Odleo`ec-7011,Bualnm rcdpmpelny Code:ilborintpa th¢mel d
F�$ d .d.Pply ,kht 1f rth.gh sob Wl pl ym,p idhdth t.nh
^ whodaneuchwark himself orthrwgM1 hisownemploym,prwdedtiutsuch OCCGROIIP RES ANDS
Impmvemevb am not I tmdedoroffered far sulci l(however,thebuilding or TOTAL
Impmvemembwldwithlnor yearofc Idbn,theowner-bullderw ve
1fRkaNendpmving the kdid nut build improve tet purpose of sea). QTY. PLUMBING PERMIT FEE
u L a owner of the property,am exclusively mntractlng with Ikxnaed FLOOD ZONE APN
mntnctm to mvtruet the projed ISM 7011,Business and Professions Codr. PERMIT ISSUANCE .
The Contradoem License law does net apply to an owner d property who ALTER-DRAB)4 VENT-WA]772(FA)
builds or Imprmv thereon, and who mrdram for meh pTjeds with
cgnu+tor(UBernad pursuant to the Contndorb License Law. BACK FLOWI'RQIFLT.DEVICE FEE SUMMARY
LJ I am exempt under Se B h P C for this mason
Owner Date DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y_ NIf_
• WOR gNAN COM 111VTION DECLARATION
F-11m RE{FIPT
1 hereby affirthat I have a fiam of consent to self-Insure,¢• M%7VRF5'PER TRAP n ^ S(ZHOOL TAX Y N
3 Tab C CSY abC Workers Cwnpewtion lruuran¢oraaMifkd ropy thereof(Sec. RECE1PTI
3800; GAS FA. -1 IND PARR FEE N
R1xF]PI'
��If
r GASEA. tl BUILDING DIVISION FT.rs
ce red.—Py Is hereby ru GREASE/INDUSTRLtt2t6it PLANCHECK FEE
"Itmdropy is filed with the city Imb
pecin dlv6lun. -
CERTIFICATEOFIXEMPI'ION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE 1 R-
SANTTARY-STORMEA 700FT ec
Date Rd tX Seo
lrtiry fis
Ohbaedbn need nes be compided lfthe permb bf¢orc hundred doBan
(f1fB fyth¢ t loth¢perforwn¢o(thew¢klorwhlch tMa pemdtb I WATER FffA74R W/VFNT/F].TiTR ENERGYFEE Y N
I ehaB cid employ any penin In y erunner n m to become subjecito the WATTR SYSIU//TREATING
W¢kers'C¢nperuatbtn of I . Dare PAID
O Z Appllant NEW RESIDENTIAL PLMB. SQLFT. Date Recei tk
Z O NOTICE TO APPLIC 'T: , fIr sing this Certillate of Exemption,you
N shauldbemmewbk-dtotn or m'Compensa provbioruofthe Labor w -a� r1 /-- TOTAL:
cc — Cade,yournurtfarthwhcmplywthachprw6baarthls Perron kut he /��/ /T�C BD
ILDING FEE
deed revoked.
LU emo CONSTRUCTION LENDING AGENCY l/E SEISMIC FEE
I hereby affiron that there b•romtmdlen lending agency for the pedarm ELECTRIC FEE
7 = as of the work for whkh this mdt timed bee 3091, Iv.C.) TOTAL
U O lander"Nares PLUMBING FEE
F Lender's Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W Iumlfytharlluv ad h ap I tbnaM sutetharthc above lnformallm
bvo d.]agree to comply ttha dtyard county ordWnmand etatelawT PFRIM ISSUANCE FEES PAID-.
1 releing to building mnstmction,aM hereby authorise representatives of this
F fA city to enter upon the abase-mentbrled pprspeny for bupedion purposes. ALITRORADDTOMECK
(We),gom to save,bdemrdfy as a keep harmlea the City of Cupertino Date Reeei til
V
against liabilities,pdgeren6,osssand experun whkh may In anywayadmue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
agaWtsaid City In consequence o/the granting of this permlL PIR HANDLING UNIT!OVER 10,000 CFM) CONSTRUCTION TAX
Slgneure of Appbant/Contracmr Date E(HAUSTHOOD(W/DLCO CONSTRUCTION TAX PAID:
HA 7ARDOUS MATERIALS DISCLOSURE
Will the a ppBa nt or future buRdinas pto
antsreorluMishu cus HFATINGUMT(TOI0(L000BTU) Date Rccci IM
nuterblasdefleed bythe pertlro Nf pe Cod,Chapter9.l2andthe
Healthced Safety 7553]((.)7 HEATING UNIT(OVER 100,0(0 BTU) TOTAL:
WIIIthe.pplloM a um building o pant use equlpmeiu or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which eMt Fuard air rNrants as deRned by the Bay Arta Air
Qu IltyN.arugemest t 7 BDIIER-OOMP(3HPOR100,000BTU) P A I Q
Y. o
Thavereadthehe,a a usmerlahrNubemenbunderChapter G95of BOILER{nMP(OVER 100,000 BM '
the Califom6 Health fety Code,Seetion 75505,75533 and 75531. I OCT 7 1992
understandn reut
that ifthe building dot currently have a tenant.Hit b my NEW RESIDENTIAL MECH. SQ.F7
resporub0lty to note a avpam of the requirements which roust he met -
prior6euar�ce da Certiflateo
CITY Ur Guru
Qv tharissdl ente Date TOTAL ISSUED BY:
/ —
OFFICE COPY