20596 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building P=en Itemllkrtlana a PEILMIT 20596
Building Address: l r`a ' 1 l.,
�eiI 2S _21c
ro . `fti1V1 �r-epJ �e APPIICATioN,�H.M]11AL DATE
CITY OF CUPERTINO,BUILDING DIVISION
e acto a rc: Lk.(��m APPLICATION /PERMIT
`e I�� Y� • BUILDING-dECIRICALPLUMBINGMEC:IIANICAL CATEGORY CONTROLY
t /Englaaar.
N
r Lfc o:
2 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
nae 9r PFRMITNSUANCE ❑ ❑ -1 _
CF.NSED CONTRACTOR'S DECLARATION LAQ
l MMbyaHlrmth tla me duMerpr Wmiaof Chapler9(mmmen APPLIANCESRE9DEMlAL pBD RMION
Ing Section 7W0)or DlvtheBudre»and Profesdaro Code,and
Lllice
ne anseH in.II I.=and effect, �(7 Z PANELS
Gate Contractor _i QMa OUrr--���I
O ARCHITECT E A O 791-1 PS
q�q�uu m0 2 I urderataed rty plaro W,be used u publle recxa s, OVER 1030 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fi0 LI¢nsed Profemiarul SIGNSELECTRICAL
fns OWNER-BUILDER DECLARATION 9'ECIALCIRCUIT/MISS
ZF, IhetebyafRrm that l am exempt from the Cormatem'a Licenae law for the
follvwing rtaon.6MIan 7m15,Rostra®and Pmledoro Code:My city or
O 9 TEMP.METER OR POLE INST.
K� wntywhkh requires a permit tomeamet,alter,Improve,drenLlak or repair
y any.avei, pdortalWhat he
I$Mnwd pursuettothe t furwcordsof to ROWER DEVICES
K Co a Ngned.hte t,Lx,I M la 19(con wrcing to the Secdo 7000) of the
Cenli afore Lkeroe Buixiness and Proapter9(mmmenctng ei, xvirpt 70001of .rad SWCdA9NG POOL ELECTRIC VALUATION
BOJ thebaotthethe0lge dexempabroCodc)orNal hel+e¢mptthertfmm and I
Sn•]] 1M u.for the alleged oemptl ap My Wdatl orS my o nm by any ��SSW1TCHs
�A app,rant/ora permX subjectntheapplhnttoardWl perohy of net moretlun i` � .
4` Eve hundred della.IT M.
.. nI,as owns of ted pmperty,or my employees w,h wage a.theirsole NEV.'RESIDENTIAL „v J i� TYI'G CONSIRl7CT10N
7 comperoation,wBldothewarkand Ne.tmmm6wt Werdedoroffeted for 1
p de(Sec 7 p)y to s. and p.p,,ty Code:The Comraaora hi. I�w
dmnota pplytosn owner d property whob ernpl imprwvided eon,and DATE C.GROIJPI RES MTIS
who doeewch workhlmeelf or nded toughhi.fixnemp,hux,, er,thedthetwch f
improverrcwuoW wittendedea,.fretpletlo,the vevu,ihebultlJ har TO
t"relmem isspro i wthat he did not
or hapim a for pu dlae a salove
t ,aen of pu of t e pro did not bund erl=pmve for with Lona). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
�I,as owner of the property, Se exelveshvelyB.,l ese n d Pro with,mmsed
mntnctmato construct the project(Sec 7044,Busher sed l'rofmbro Code PERMIT 66UANCE
The Coninctore L oe.IAw does not apply to an owner of property who AL'IFR DRAW 4 VENT'-WATER(EA)
belida or Improve thereon, and who contracts for such pluje to w•Rh a
ellf cm(a)Banad wnuant to the Contractors License Lw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_f I am exempt under Sec B A P C for this rea.onOUTSIDF FEES
S Owner Date DRAINS FLOOR,ROOF,ARCA,GOND. SANITARY Y_ N_
�) WORgNAN Ir
COMPENSATION DECLARATION RECm'N
�/'R hereby affirm that I have a artl(fute of consent to ael4Wurt,rc a IV(TURES PER TRAP SQiODI.TAX Y_ N_
At,
oafiWor4sn'Comperuatimlrwnnae m•¢rt,ied ropy thereof(See. RET"I]I'T s
7'dlcy Ib C/"(13 o r r o t o 9 0 o y GAS FA.SYSIFAI1 A'C40[JFLEIS PARK FEE Y_ N_
Co GAS E.A.SYS OVER4(EA) RECDI'1's
iCyBUILDING DI VIS ION FEES
utMM ropy to hereby tum Wed.
rtNed ropy It hereby
the elity,retained.
I ospection dlvWm. GREASE/INDIISIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATEOFDfHMPTlON FROM WORKERS' GREMiE:TRAP PAID
COMPFNSATIONINSURANCE SEIVFRSANUARYSIORM EA_I(I�T Date Recel tN
(Thlaaectbn need not be completed U the pemdt V for arc hundred doRua
�OOJ mIe`) WATERHFATERW/VOYT/ELDCTR ENERGY FEE Y N
lartery that Int heperfo bin of thework torwnich thl.pemdtla booed,
1 ah , person in net ompley any peany manner at u to bamrre object toted
WorWATER SYSTEM/TREATING
tlen'Compewtbnlwwa of California.Date PAID
O Z NOTICE NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
Z Q NOTICETOe,subCAtothe .e .' ngthbCtionp eofore=ppet1oon you
ahmedbemme forth to led Wor4en'Comp rimem provbbpermit 11lLabor TOTAL:
N Cedgywreatat voked.rthwhhomply withwch provlsbro ortMa permit shallbe - BUILDING
LU ] deenM revoked.
CONSTRUCrIa LENDINGAGMCY SEISMIC FEE
d Ihercby.lflrm thattherel.amrotrudiwn Md gagemyfortMpertortn ELECTRIC FEE
Z aree of thew for which ted.pemdt b loved Eec.3097,CW.C) TOTAL
02 I< PLUMBING FEE
ndee.Name
IL h Mnderi Addie® QTY. MECHANICAL PERMIT' IEE• MECHANICAL FEE
O W Imdltythrtlluve rtadthbsppllatbnard atatethrtthe.bore WformaHon
ismmext.Iagr wcomplyw aUdty.M.m tyodin .n dntelaws PERMIT IhbT3ANCE FEES PAID
} C
Z relating to building mrotrualcm,and hereby authorb representative of this
F cdy to eeteruwn the aboa•a rren(brcd property for inspecvbn purpose+ ALTERORADDTOMECH.
_ (We)agree b ,Ind ort p hamdca cityI Ce dlm Date Recel to
agaWtllabii1t mewgemn.nwh, aan peylnanyway�m AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
I y noes .nermh
AIR HANDLING UNrr(OVER loa(3o crM) CONSTRUCTION TAX
Sig of Applira.17Contrienor Date EKHA41517 HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant oe future buliding ocm F et Morn or handle havMws HEATING UNIT GO 100,000 BTU) Date Recel tic
material ae defined by the Cupertino Municipal Corte,Chapter 9.I7,and the
Ile❑anh and Safety Code,&ctiow 25537x,)7 HEATING UNIT(OVER 100,000 BTIp TOTAL:
W Yv
Ill the spp,ant« tum bulldNg omupant use cyulpment or torero. VENTILATION FAN(SINGLE Rcern) ISSUANCE DATE
whW eMtlaemwaalr VM»ratsa.defined bytM Bay Arta Air PAP
T�j r� L�
Q❑u1LLy Ma»gemeni 7 BORFR{OMI'OEB'ORI00,0(D BILI) 1� �1�
`® Ihavereaameha�nuterlatsruplrcmenhunder Chapter G95of BOILER-COMP(OVER 7N,000BTU) JUL 311990
the Ca llfomW bra 8
Health k Safety Code,Sect 505,25533 and 75534.I
uMentaM it ebu,dingd currently haveatenant,that it isney NEW RESIDENTIAL MECHE 5Q.FT.
reswmbWty n the rat the let. whiehenekbemet n 1P(1
prior to nm aCcrli/ a Pa"`)'' Girl PI art^ rf•
Own aauth cm Date ISSUED BY3C�V fw `—
TOTAL: 7729
OFFICE COPY