22898APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ea Identlflratlm i;;(�` ORM
Building Add
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELkZTRICAI PLUMBING -MECHANICAL
cmtnaN,me: tx.No
s
CATEGORY
CONTROL #
A Xect/ neer. w I
UVfv_
QTY ELECPRICPERMIT FEE
BUILDING PERMIT -INFO
Add. ..
PISRMIT ISBUANCE
❑ ❑
LICENSED CONTRACTOR'S DECLARA ON
!hereby d(um thatlamlkmaedunderprovbloruof pter9 (msruom<
ingwlth Sectbn7000)ofDMdm3oftbe BudremandP esdotu Code,and
Al'PI.IANC6RESIDENTfAL
,
JO DESORB7lON
liocnsr bin lull fora and dfea.-
LkenmCbm Lk.g
PANELS
/��- •�
K
Date Contranor
UP TO 2DOAHM
fU
—
PS
ARCHITECTS DECLARATION
I underdae rey pbm elul) be used as public r ord>
OVER 10D0 AMPS
SQ. Ff. FLOOR AREA
$/SQ. Ff.
SIGNS ELECTRICAL
Lkenaed Professional
OWNER -BUILDER RDECLARATION
BUILDER DECAMTION
I herebya(firmtI .emptPrem the ars Llerm I�w (m tie
following reason. (Section 70315. Badness, and Profmbru Code: My city or
countywhichrequl apemdttomrc maJter,lmprove,demolbkorm-palr
anykmdumprbrtolbbeuame,mb requrestheappha tfmauchpe to
Ole a attired statement that he b homed pursuant to the pmvisbv d the
D I
gyp'' E�
I I.`� R
tl� l
SPECIAL CIRCNT/M6C
m,{p METER OR POLE AST.
POWER DEVICES
SWMMNIC POOL ELECTRIC
Contractor. Lkeme law eC pter 9(mmmencing with Section 7000) of Div
dbn3oflhe Buatnmand Pro(smbm Cee)orthathebevemptthemh mad
�J VALU TION
the basb for the dinged es<mplbn. Any vidatbn of Section 70115 by any
appbant fora permit subjects the applicant to a civil penalty d nn more than
OIITLE75SW17CHFSFDcrt1RESDATI
�r
_
NEW RESIDENTIAL ELECTR 9QJ7.
fiollars 0IM.
I, u owner the Property, or
v6,.oundredrofthepro employee with wage a 1Mtr door
STORIES
TYPECONSTRUCDON
hrrTye
l
mmpeeu 70K tntadM oroffered for
doe 7014, Basdouthewwl,andtheetsude. Tis he
Prdembm Cate: The Contractor. h Gees Law
,
to an ow er
does wh.d tapplyto,khw Udth. hM..w.ty who il pl.y m,p.Ld a on, andh.t.rh
whodoesuch dthding
Mende
OCC. GROfTIa
RES. UNITS
orwghhbownemplgee,er,the
am net or
impmvemenbarendlntendneye.rferedfmdan,fibe oweveb the building aoe
lmprwerrcnt bsold wnhlnarcycarafcamplNbn,thewvner-W ilderwW have
TOTAL
en of proving that he did not build or imm
prove for purpe ofd,le.).
Lb1, as owner of the Property, am eschuNdy contracting with liumard
contractor to mnalrua the pmjcd(See 70K Business and Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE �
FIL)OD ZONE
APN
The Cc dnaor', Lkerm Lw doe out apply to an owner of property who
Wild. r improve thereon, and who mnham far such p ojrm wuh a
-WIracWr(d fiemed pursuant to the Contractor. Liner. Law.BACK
LJ I ,m ...rept under Sec B k P C for this n eon
��g-DRAIN k VFM - WATTR (EA) -
FEE SUMMARY
FLOW pROTFLi. DEVICE
�
DRAINS FLOOR, ROOF, AREA, CONT). �/'
SANITARY Y— N
RECmT 0
Owner Date
WOR"AN COMPQSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -Insure, ora
ceninab of Workm'Compercaum Imuran¢ora ertiflm ropy thereo(LSec.
3800, �b C)
FLYIlIRES I'FR .IR,Vs
SC)i00L TAK Y N— '
tea g
RECGASFA.SYSTFM-1
INC4OUTLE1S •fin
PARK FFR Y N
Bey 4
RECF81'
GAS EA. SYSTTMOVER4(EA)
C. ny
BUILDING DIVISION FEES
rtified copy b heed wthmis eftyed.
Certified ropy b (0ei with the dty ivpeabn divhdm.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAIL
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(Thlaeectlon need nal be complet.d u permit pedt bw
(ore hundred doldollarsa
PAID
Date Rccef t#
SEWER-SANITARYSIORM EA i00FT
(5100)ce lm.)
mer
I certuyt)nt in the pedounce of thewk for which ,a pemdts tare
id
ATTR HEATER w/vlxr/ET.FcrR
ENERGYFEE Y N —
T shag not employ any prom In any ro nner.o a to become subpct to the
Waken Compensation l.. . d C, Womb. Date
PAID
WATER SYSTTM/TRFA'IINO
Appll.90TICd
Dale RLroei t#
NEW RESIDENTIAL PLMB. SOFT. '
TO
shoulNOTICEoomn s'L)mt to eWorker ns'Cornaking a Ceres procate of Enemption, you
Code, oum us subjectto theworkers'Compenwisk s orthisprethe Lobar
Cee, You mrd forthwith mnply with suds peoNsbv orthb Perera shall be
deemed revoked.
TOTAL:
BUILDING FEE
S I MIC FEE
CONSTRUCTION LENDING AGENCY
IherebyaNrm that thcnbamruwMm oreing agency for the pedomn-
ensu of the work for permit this pert b Issued(Sec 3097, CW. C.)
TOT
ELECTRIC FEE
LendeNa
Lender Ada
Ioedlfythatlluveree<hb appllatlonaMmtethrtthe abwelnfarmrtlm
bconea.lagreetocomplyw h,BdtyaMmuntyordhunmandelatelaws
QTY. I MECHANICAL PERMIT FEE
I PER]hITFT.SUANCE --7-
PLUMBING FEE' ��
MECHANICAL FEE �"
FEES PAID:
relaungto WOdNgcorutrualmacts herebyautharb repee,entallvnofthb
atytoenterupon the abovrmentbrcd property for lmpedbn purpose..
(We) agree to live, iMde fy an d kr.p herr . the City.of CupMlw
ALTIRORADDTOMECH
Date Rece1 t#
SUBTOTAL:
against liabilities, hndgneeis, cat, d upeeue which mayor anyw,yacaae
agairW W+CI In en the graeabgdt . n.
d _^ ��/
AIRHANDUNG UNrr(IOIO,OIOCFM)
AIR HANDUNc uNIT tovFR to,000cFTno
CONSTRUCTION TAX
s�ge�t arA /cont W 7 4i,ie��'—
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
(_HAZARDOUSKrATTRIALSDISCLOSUR
HEATING UNIT (TO 100,ODO BTU)
Will the epplkcmt or future WBding« pant store or luele, harardous
material as defined by the Gnpertion Mudapal Cad,, Chapter 9.3 Z and the
Date Recei 1#
HEATING .UNIT (OVER lOg00o BTln
TOTAL
H.ahhand Safety Code Smtion75S3l()t
E Yn I''I No
Ty ill the appilaM m`� Nn Wilding a pant use equlpmed m devlm
which emit haaardous air contaminants as defined by the Bay Area Alr
VENTILATION PAN(SINGLE RESID)
-
I U ATE
��
BOBFR NMP QHPOR 100,000 BM
4 Quality Management DlsvW 7
Y uajrQ No
havareadth.b oiltmWr,a ioelnmenb5533anM1apter6.95of
the I ft fvc b]theh kSafety Cada Sebeement755)7and75536.1
OCT 24 1991
BOII.ERCOMP(OVCR10o,000BI1n
NEW RESIDENTIAL MECH. SQFr. -
undmtandtlutifthe WXdingdo mwt ntlyhaveatenantthafitbmy
Pr°°eob� �«iythe wnoot;:ey ir`medawhkhmstthemet
CITY OF CUPERTINO
Owner on autFaatud agent Date
IOTA
ISSUED BY
OFFICE COPY