22229 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuIldinX PmjIdeml(kation //'' , 1 ;{�^a� ,l PEILWTNO.
Building Adds 6 Ut uxo G- �Ju t`' j 22229
e mc:
C 4QQ � ��6 4 r CITY OF CUPERTTNO-BUILDING DIVISION
r� Centracter'.N.nas Lk.No: APPLICATION / PERMIT l7 O L
BUILDINGdBC'IRICA4PLIIMBINGMECHAMUL CA=RY CONTROL I
Amhftect/Engircer. Lac Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ Imo- ❑
LIC ENS EDCONTR under SDECLARATION /I/AVN
I hereby affirm that lam lkmsedunderpessand dCsionsC(commenc AI'PI]ANCESRFSIDENIIAL ;OB�JE9CR➢'TION
inarnati mlon infou7 teeardlvffoet. Ne Buaravand ProfnelomCode,and tjryrgef-
Lice..b. /or¢and d(cat. PANELS '
Lkxnac Cha Lk.g
Date Cordncwr
ARCHITECT'S DECLARATION 701-
7. I urderatard my planashag be used n public record. OVER IODO AMPS 5Q.Fr.FLOOR AREA S/SQ Fr.
LI¢med Prefembrol - SIGNS ELECTRICAL L E D ' N
uuuu01 OWNER-BUILDER DECLARATION SPECIALCIRCDIT/MLSC
Zt,�G owin raaen. Uuton 7031mp usir he Ca oletor'ell erateode;Law fee the p U T E R
following re.aon.(,Seam70xem Bwbm and Pmfeabro Code:My city or /r
O I:a TEP METER OR IDLE AST.
F� anytym khrequirmapemdt tomnaeud,ate capmve,dem.u&pe rtpalr
anyamaure pfemtothat he i.abomry4erount to
provisions
of to IVIVFR DEVICES
r4 5
fill.agnea aaenaeeLa that he b Ilonnedr9(commencing
pumnnwt the pm,70M) f the [((( s
sumCon3ftheLct.ndPC eaeer9 CammendngwHh Sempt 70M)of Divi- SWIMMING POOL FT FCT?dC ATION
01 aen3dithe Buanea and Pro/eabm Code)orthst halo exempt thertfromand
Sit.•]] the baab for the.ILgN exemptfm. Any Wolatbn of Sedbn ABI5 by any
a ppll¢ntforaperm bjeUtheapplkanttootl 1penaltydn¢monthan 011'ILETSSWI7CHFSFLCI"ORES
Qve area doilans 05M.
�n a owrcr d the property,or my employes wish wagm u thetr sole NTiW RF57DENTIAL ELFLTR SQFi. STORIES TYPE CONSTRUCTION
pewtlm,wW clothe work,and Newuaure b not intended or ofeml for
oh(See.7a4,Bnabm,awrmreammc�ae:rneeomrador.u¢melnw
Pjs$ on not apply to an owner of propertywho builds orimprove.thereon,and OCC.GROl1P RES.UNITS
C: a domwchworkhimaelf mm
thugh Meownemployees,provMM that such
bnprovemenb art not Ntended oroffered fmaale.If,hmerver,the building m TOTAL:
bnprovernemlaeoldwlthinomrarofcm,pletb thewmerbuMerwthave
th,horditm.fprovingtharthedid notbuudorlmprovefmpurpoaeofaale.). Qry. PLUMBING PERMIT FEE
I,as owner of the property,am ewhuively contracting with llcesd
nFLOOD"LANE APN
contractma to emutruct the project(See 7034,Businma and Profeedom Code: PERMIT ISSUANCE
The Cordadori License Law don net apply to an owner of property who ALTER-DRAINk VENT-WATER(RA)
builds or Improves thenen, and who contracts for wen ea ppjwith a FEE SUMMARY
�or(aBrensed wm
punnt to the Ctractoe.Lie.Law. BACK FLAW PROTECT.DEVICE
LJI am exMec
empt uer SB 6 P C for this rtuon
Avner Dae DRAINS AR FTOROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION ��a
•
71 hereby.frim,that I have a terBtkate of conaent to aeB-insure,m a FOOURES PFR TRAP SCHOOL TAX Y_ N_
W RECTIPT Y
rarBBatoof orkrrs'C pewtlmlrounn¢a•¢rtRled ropy thertof Ger.
380Q L.b CJ GAS F.A.SYSTFI.I-I IN'C.40iJ'ILEIS PARK FEE Y N
PeBry I GAS EA.S1'STlT1-0VER 4(FA) RE(:=#
Cu ny BUILDING DIVISION FEES
�Cvmfied copy b heed withmbhed. GREASE/INDUSIRL WASE INTERCEPTOR PLANCHECK FEE
❑Ccrtlfled ropy b filed with the mY Iropectbn division.
CERTIFICATE OF TY MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEW FR-SAt.TTARY-STORM EA.21N+[ Date Revel tk
(Ildeeextbnneed not he ccmryleted Bthe pemdt bfarorc hundreddolhn ENERGY FEE Y N
RlOO)m le.) WATER T-ffATER W/VENT/EIFL'IR
I ceutRythat lythe perbrmn¢dthe wmkfmwWch WapermBis Wued,
I"U not employ any person In any manner a as to become vbjed to the WATCR SYS[EM/TREIIING
Wwken'Compematbn laws of Ch
mWmn .Date PAID
ZZ Applicant - ��.. Date Reaei tff
0 NOTICE TO APPL)CANT:If,after making lMa Certifkete a(Ezemptbn, NhVV RF9DENirAL I'I.MB.
ahead become wb)tet to the Workers'Compemabn P=11 oftheLbor TOTAL:
Q y Code,you must forthwith comply with such provbbro or this permit aballBUILDING FEEh
LUG deemed revoked. -
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I henby.flim,'bar
whichthere h•mmtmam bnding agency for the perform
7Z .nceot the work for which tpermitpcdt bsa
lN&c.c.307/.civ.C.) TOTAL: ELECTRIC FEE
V O Lender.N. PLUMBING FEE l
LL F Lender.Add rme QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerttfythetl have read thhappllatbn and antethat theabove BdormaBm
a bmrncf.lagrte to comply with allcttyand county oNLanm and state laws PERMIT ISSUANCE FEES PAIL ..
>_ N relating to bullding comtructlm,and herby authorise reprenenadve of this
IZ dty to enter upon the Grove-rrcntlomd property for 4dbP—
Pone"ppose. ALTTRORADDIOMECH -
V _ (We).gree to ave,indemrify an d keep harmles the City of CupertUio Date Recei ek
agaWtllablBHn,NdgmeMe,costaand expenam whkh coatis anywayacvue MR HANDLINGtJNrr(M 10,000 CFM) SUBTOTAL:
age d ley to mnaryuence of the gas d tMs R.
AIRIfANDLINCUNrr(OVERIBOXCFM) CONSTRUCTION TAX
groPpliant/Contactor Date I EXHAUSrHOODM'/Dix:D CONSTRUCTION TAX PAID:
HAZA R DOUSM uLS DI SCIASURE
Will eappBcardmf Wmbuddingo pantstomor Ma Icha Motu HEATING UNIT(TO 100,0D)BTU) - Date Rt'cel ell
material as defined by the Cupertino Murddpal Code,Chapter 9.12 and the
health andSafety Coder Sectlm 75532()7 HEATING UNIT(OVER 10B000 BTU) TOTAL: T1—UU
❑ Yn rLL��--��,�No
WBlmit appllam¢r cren building as occupant by the Bayamdevfrm VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE -
Quichemithnvrdmaairriet? rants as defined by the Bay Area Nr
Quality Marogemera IXMrletr - BOILER-COMP DIiPDR1W,IXq BTU)
-04
4 Yn a�Eb ���
have read,lash sus matedah requlrenrnLa under Cluptcr 6.95 of BOTI.FR-NMP(OVpt IOO,ODD BTU) ea
thecl1U.hIieaBh ASafety Code,Section25505,75533and75534.I Ij/
undmtand that lithe building don not currently have a tenant,that It bn7 NEW RESIDENTIAL MEIN. SQ.FTv
rmortonr uanc ndcertihe oavpntdUbe requlnmene whkh Bwst be met
ptbrtobwy to d.y he occupafOa pa nets
e
Owner or authodud agent Date 755I1ED BY:
TOTAL:
OFFICE COPY