22445 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMIT NO.
BaZ2dgod ca(s, op 22445
h FpYZU AA YLOJ T �" CITY OF CUPERTINQBUILDING DIVISION
yGy tractarsN.me: Lk.Na. APPLICATION / PERMIT. — L
hj Y S ZZ03 1 BUILDING-ELEC7RICALPLUMBING-MECHANICAL CATEGORY CONTRO Ie if
AwbReet/Eiglneer. LI,No, 1
'3C/
'QZ
S' Q ELECTRIC PERMIT FLE BUILDING PERMIT INFO
Address' 1 I(� PFRhRTISSUANCE - X,
LICENSED CONTRAROr pr DECLARATION
Thereby affirm that Di leensed vW dPmf apler9(®mdnc AI'RlANCESRESIDENTIALing�tJOBD N
lice..F Section force ofd vlslon3oftheBwlrenndPm/enlouCade,rad -
licenxbin(ull force and d(M, p PANES
License Clan Lk.a RLI 8y POOL
ARCHITECTS DECLARATION201-IOUQ AMPS
O aJ.
uwiundmtand n
ray pla .IuB be used npublic records,. OVER ICAO AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
z Licensed Professional - SIGNSELECTRICAL
�«<< OWNER-BUILDER DECLAMTION SPEGIALCIRCUI.F/MISE P
,E, 3 IheinbyafBrm tlutlamexempt frtxnthe CeMATIO License l�wfathe
6M folbM
wleg wason.(SIon 7MIS,Business, nd aProfession.Code:My rityor TTMRMETERORPOLEINST.
F� cvuntywM&requl aper tommtmMaltn,Improve,derm h,ormpalr
anyaromnmpdorm .ibmtaborequbntheappuantfnac permltto
POWER DEVI .
µ file a egned eatement t k b banxd pursuant b the pro m of the
Contractor'.Line.Law(Chapter 9(commeneng with Seelon 7000)
OJ sbn3ofthe Bus,bessnd Frofmbm Code)ortFut esmptttiemf is 1 NG L CI7II VALUATION
the bassi.for the alleged uemptlon. My vldalbn of SeGbn 70315 by any I req eq,` xY'l
apph.ntfor.perm bj,c theappllcanttoadvllpe.hydnat.oG ,�l1 lJ✓V C.��
C. tl6.dmd dollars($5=.
v -
I,uownerofthe property, R alIAL STORIES TYFECONSTRLCTION
p party,or he employees with wags u there wk
7 I .1=Tian,Buswilldothe w1 Pw(d thmCod n The Co nterded o.r1 o—ffered(
❑ vk 0kc.7011,Bualness and Prof®loos Cade The Codnctoe.^ rise
��
p'js$ doa rotapplybnawrierdproparty who Wlld.orimp.t and OCC.GROIIY RFS UNITS
whodw.u&h Ahlmaelfmthmghld.ownemaplay prwldedthatmch
Improvements,am not Intended oroffered ferule.If,however,the building or TOTAL.
' Improvement lased within oneyearofcrmipletbn,the wvnerbuili have
t rden of proving that he did on,build or improve for purpose of sak.). Q7Y. PLUMBING PERMIT FEE ROOD IDNE -AEN
t L n owner of the property,am esbstvely contracting wtLh llnnaed
aontracton eon to construe the projectEE,,7014,Bulnmand Prdessbm Code: P + ISSUANCE "')
The Cortrao".Lloe.Law dout apply to an owner of property who c
Wills or Imprwea thereon and who coraram fm such p1)ects with a ALTER-DRAIN lr VENT-WATER
rypVfctor(s)Ilnneed pununt to the Contractors Lire.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt underSec B k P C for this rtuon
e Owner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
Ei
y WORKMAN COMPIENSATION DECLARATION RECEIVE
jr ❑l hereby affirm that I have a certificate of coruent to self-Insure,or a FDCTURE$PER TRAP SCHOOL 17 % Y N_
{ ceAi0ote of Worked Compensation lmn
urmerr a certified copy tbewafbS INC
.41, ^ �RECEIPT a
If 3E00.ub C") f GAFA. I OUTLETS {t07 PARK= Y N_
Peiryl �o S7
GASFA.SYSTEN1-OVER4(EA) RECEIPT
Compny j �S BUILDING DIVISION FEES
/IIY'�'ellCertlRed mpybhercby urNehad. GREASOINDUSIRL WASTE INTERCEPTOR Pr7—Da
ECK FEE
CenNed copy b(Ike with the HY Ivpe Hon dIWYon.
III CERTIFICATE OF IXEN!"ION FROM WORKERS' GRFASEIRAP Pt6�1 Cn�4�6 r,,y�a �'
COMPENSATION INSURANCE gEVER gAM'TARY STORM FA]DOST te Rcecl t# 7tU(ThbxHonreed ns,beeomnpleted Hthe permit lafwone hundred down
(SIM)or less.) —
+ Icertlfy that tithe perfomnaafthe work forwhlch this pemW b bored, WATER HEATER W/VENT/E.ECTR RCY FEE Y N
1 s,FuB not employ any peraon b any manner m u to become sub)en to the WATER SYSTEM/TREATING
�) Waken'Compensi laws,.!C.Ifomla.Date PA D
r' 0 Arplicant
2 ZO NOI'1'I,IC
AANT:If,aher maldry this CertHlaNEW RESIDENTIAL PLMB. SOFT.
te or Exemption, Dale Reoei t#
should become sub}d to the Worker'Compensation pm rialoru of the LaborTOTAL
r CC y Cad,you must forthwith complywlth such proWbv permit this pedl l be �� E.
DING FEE
W C deemed invoked. -
CONSTRUCTION LENDING AGENCY IG
CL Thereby.Hikfor w heinb.comtroHonlerding097,C for the pedorm�
� FEE L
_ ,ns,of the work far wMahmbpermsbb>ved(ser.3u97,crv.c.) TOTAL: � CFEE
'I U O larder'.
N.
- PLUM GFEE a
LLF Lewler.Addrn, QIy. MECHANICAL PERMIT FEE MECHANI LFEE
O W Icertlfythati have inad thio.ppllotbnand eats thrtthc above lnforrrvtlon
I bmrree.Iagrcetocomplyw haBchyaM=ntyordinamm.d Katelaw. PERMITS ANCE ev FEES PAI . .
} 1 relating to building cox
in met-Woo,and hewby..N.we reprenn tatNofthla
1._ Z arty to enter upon the abovcmentlbned property for 4upectien purposes. ALTERORADDTOMI{H. Date Rttci I#
_ (We)agree to save,indemnify n d keep harmless the City of OnpertW
against liabilities,ydgmenb,aoe.and experun which may In anyway amue NR HANDLING UNIT"CFO]Q0o0 CFM) SUBTOTAL:
against said City In consequence of the grating d this Permit-
C AIR HANDLING UNIT(OVER 10,000 CFM) CON CIION TAX
j s tyre of App ant/Contraem Date EXHAUST HOOD(W/DUCD CONST CFION TAX PAID:
HAZARDOUS MATERIALS Of SCIAS URE
Will the applto M or future lou tiding oavpaot store or hard In hazardous HEATING UNIT(70 100,000 BTU) Date Rttei 1#
material u defined by the Ce pertmo Mu Nepal Cade,Chapter 9.1Z and the
Ekahhand Ssfey Code Scelon 255n(a)1 FEAiING UNTT(OVERTW,000 BTU) TOTAL j
n
Yea I�No _ -
Bltheapplicantemit ha.oduu in buBding acv fired by the Bay Area
Air s, VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
whkA emit hanment airritt? M.a.defined by the Bay Arca Air
• Quality Management DWrINI BOILER-COMP DEEP OR lOO,IXD BTIn
4Ya nn No
havereadthe h s ousmaterials requirements under Chapter h95of BOILER-COMP(OVER 100,000JIM
the Glifornbllealth R.Safcty Code,Sm mZ5505,25533and255M. I -
understandthatlithe building dm not currently have atenanL that It It my NEW RESIDENTIAL MECH. SQ.FT
responsibility to really the eavpant of the requirements which must be met AUGs 0 1991�
a
prlorto imuanada Cemlileateo!occupancy. f1 z Y4
.
rornNori:ed agent !Ate TOTAL: Q ISSIIE ��2'�`
OFFICE COPY