22361APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
PERMIT NO.
Building Address:
��— .S?7-/G./S%b / �1 �/C-L T^' /i/ �L.7'hiC..Tf ON['
22361, 2 3 6 1
Mr a ante: ane.
-
CITY OF CUPERTTNO"BUILDING DIVISION
APPLICATION If PERMIT
7--4-9/
Con aor'aName Lk. Nee
L
BUR.DIN aDCTRICALPLUMBINC-MECI IANICAL
CATEGORY
CONTROL N
A kect/Engineer: Lie. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
-
Add.
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'SDECLARATION
that Is
Ihereby affirm tD)Ofamgm3cdheBr ovWmneolft..r9 toe ancin
ProlestlansCadeand
IngwithSection7orce
APPLIANCESRESRJENRAL
N JOB N
y'� 60 w_
pdefelm3otNeBuelreaaand
11«nx is In toll a d effect.
PANELS
, IV CC/77�/'�pNJf
LlaweC Li-if
D,te o) e 3hlat��y
`
A n t,.7
CHITE
ARCHITECTS DECLARATION
e "`
I undentaM my pbro shall be.:w o public ra�vdA
OV
OVER 1000 AMTS
. FT. FLOOR AREA
$/SQ. f7.
SGNSELECTRICAL
LI«r MRdewlorul
SPECIAL CQtCIRT/hISC
OWNER- RLDER DECLARATION
T hereby affirm Wtlamexe TILDER DECLARATION
Llernue law fa the
following reuar.(Section 7015, Buesm. and Pmfesbru Cade: Any city or
muntywhkh requbesa pemdt m mmtruct, alter, Improve, demolleh,or repair
..��/•�aa��a
III "
1 1
TEMP. METER OR POLE INST.
anys Mmprbrtolbl ance,aborequir theeppncanlfasuchpemdtto
Ole • signed statement that hc b Ilcem
nsed pursuant to the pvislom of the
POWER DEVICES
^ �/a�
20 �!-'
gWAI.ING IUOI-ELE
Contractors Lkense Law(Cha pter9 (commencing with Section 9DW) of DIA-
sion3 of the Business and PrdembneCN
ode) or al he b ez.V therefrom and
w
VALUATION
the basis for the alleged nernptbn. My violation of Section 7015 by any
applfernt fora permLL subjects the applicant tea civil perky, dna more than
r
_
IR
/Ive�utndred dolWa(¢OD).
u I, a.a the property, or my employees with wages sa their sole
mmperuation, will Bothe Werk, and the structure b not bdendei or Offered for
STORIES
TYPE CONSIItI1CTl0\'
JL
sole (Sec 7040 Buslrrass P
and mfum a
loCode: The Comnors Doman Law
l
doe notapplytosnowmrofprcimnywhobutl"orlmpmveathe I, and
wbodonsuchwonkhim lf«th.ghhbownempinyem,p.Wedthatsuch
OCC.GROIII'
RES UNITSov
imprement are nm Intended proffered for sale. if however, thebuiLding er
Improvemembao Mthl omyearof Idbnter-bas BderwW ve
tl�¢rNenofpmWngthathedid rwtWddheownorlmpmvefapurpoaeofsale.).
Iy _I 4 as owner of the property, am eacluahrecontracting with licensed
contraction to construct the project(Sec. 7011, Business and Proeaflmes Cede
TOTAL:
(ZN. PLUMBING PERMIT FEE-
PERMIT L'SUANCE
FLOOD ZONE
APN .
The Comactm. Lice. Law dm not appy to an owner of property who
Willa or Improves thereon, aced who contracts for such P�o(ects with a
�ytl3fa��ar(J11¢nsed paauant to the contactors Lkerue Law.
LJ I am exempt order See B k P C for this reason
ALTER -DRAM' 4 VENT' -WATER (EA)
FEE SUMMARY'
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, GOND.
SANITARY Y_ N
Y
Owner DateRECEIPT
WORKMAN COMPENSATION DECLARATION
&01&01 hereby affirm that I tuve • certificate of consent to self -Insure, « a
m-nBlate llr Sec"
FDC.NRES. PER TRAP
SCHOOLTAX Y— N_RECEIPT/
GAS EA.SYSIflN"1 R.)C40I1TI.E15
PARK FEE Y N
ofWorken'Comperoatmw ranm a a certified copy thereof(
3800. fab CJ
1'd Y — 6 r
S S7Q.f-0
GAEA. SYVER4(EA)
Cenified copycat filedw s
Certified ropy b flied with the city Impectlon dlvlelm.
BUILUINCDING DIVISION FEES
GREASE/W D=L WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EKEMPTION FROM WORKERS'
PAID
SEWER-SANITARYSTORM FA 2OW1.
COMPENSATIONINSURANCE
(Phissection need not be complded lf the permit b Perone hundreddown
Date Recei tit
WATER HEATER W/VENT/ELDCTR
ENERGYFFE Y N —
($)0)orlam.)
the for pesubtblwN,
Ice nor
employ person
1 sha8 nM amp en any peaan f +ray runner so as m become subject to the
manner tooM1 co
W«ken'Compevsatbn Iowa o/Callfanis. Date
WATER ''Y"1' FM/1RF'MnNG
PAID
ApplicanNOTICEt -
NOTICEould cu APPLICANT:e after sra Co this Certificate of the Labor
ande,you arthwit the pmvhis
Cush
Dale Reoei t#
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
pneatbn
=at
Cade, you crust forthwith �rnpy with such provisbas «this permit shall be
plywit per itg
deemed revoked.
13UILDING FEE_
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that thea b a mmnuctlon lerding agency for the perform.
anero(theworkforwhkhthispemdtbbured LSee3 ,Civ.C.)
ELECTRIC FEEWv
TOTAL
PLUMBING FFE
Lende
IaMer' Ada s
I anifythet I love readthbappllatianaM sutra thrtthe above Inforrmtlm
b mrtect. Iagnee to oomply with ailcttyand county ordWno'•and pate laws
rcyt aprvenpurp000fthb
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE 4D tj
PF]iMR155UANCE
FEES PAID-. I�
�Y' •`
oenterulpon the
o abmctrn,aMhenebyrtyorin
city to)aree to the,Indemnify oned lmpenyfabupe Cit purpura.
• (We) agar to save, Indemnify an d kaen hasWea the City of Cu nlro
ALIPR ORADDTO MECH.
Date Recei t#
SUBTOTAL:
against Babl tlen,'ndgmrntq costs and ezperm which may in anyway ascus
anyway
agaW�e of granting dthio permit.
AIR HANDLING UNIT PTD 10,(X10 CFM)
AIR HANDLING IAER00
Tf (OVIO,CFM)
CONSTRUCTION TAX
Signature,of Applicim944Eirsto Date /
EXHAUST HOOD(W/DUCD
CONSTRUCTION TAX PAID:
H"ARDOUS MATERIALS DISCLOSURE
IffATING UNIT(ID I0,0D0 BTU)
Will the applicant orfuture butiding occupant store or handle hazardous
material as deBMd by the Cupertino Municipal Code, Chapter 9.17, and the
Date RCCeI t#
HEATING UNIT (OVER 108000 BTU)
TOTAL:
rwnh and SifctyCade SeNm 2S532G)r
RYes
ill the appllaIn &to bu llding occupant use equipmont ordevim
whkh endt haardous ali contaminants as defined by the Ray Arca Air
Qualky Management Anct?
Yea
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
BOILER -CAMP QHP OR 10,0(11 BITn
BOILER"COMP(OVER 10000 BTU)
I have read the hors sus materials requirements under Chapter 695 of
the Gnurnia fleakh'4 Safety Code, Sections 2550, 25533 and 25534. 1
NEW RESIDENTIAL M DCH SQFT
undo n,l that If the building dos rent currently have a tenant, that itis my
pommnity, to notify the «cvpam d the requirements swwhich .0 be met
Price
aw/ice
// Z���
ISSUED BY: -
Owntt car such rat o �
70TAL
OFFICE COPY U