21976 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMATNO.
Building Address:Z0,23I '.(•V`ESZ " DRQ VE CUPERDA10 CACI 21976
OwnersNares: - one:
Mg �&y'mm pgASpp CITY OF CUPERTINO-BUILDING DIVISION
Contractor',N.;
y �j/� '{s--y Lie.N.: APPLICATION I PERMIT M APC 4 a 199/
CALIFLYE/IIIA A41/o ni r�LQ�5f 5��� BUR.DING-ELECTMCAI PLUMBING-MECHANICAL CATEGORY I
En nCONjq r e�
J
Architect/ eer: Lie.No: SC
`6 a BUILDING PERMIT INFO
yr QTY ELECTRIC PERMIT PEE
Aaarea:aja9C2 CL /7E,C D. w PERMITISSUANCE �CY�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(communc, APPLIANCESRESIDENTIAL JOB DESCRE'CION
Ingwlth Seft! 7000)of Division 3 ofthe Business and PrefeulonsCods,and my
It..Is m fall fo deffea. PANELS P4T'10 SC2EB�Na
LimnwCiaa_,�a° Lk.N YAYy!_ ro CL.(JSl.�ICIf.
Date Contractor
ARCHITECT'S DECLARATION /JRI'S 207-IOODAMPS
^all ZO erste d Iy pl I.I.0 be used a public record. OVER 1000 AMPS SQ.FT FLOOR AREA g/SQ.FT.
1&d� Limned/Professional II SIGNS ELECTRICAL /SD
6 OWNER-B LDER DECLARATION
SPPLIALCBfCI➢T/MISE
t., Ihereby
mascoaffirm that lamezempHroossa ContractorsLkenm law fmthe
ZO..@ f ntyn reason.(Sedlon7ml$Buslnea and Profeulon Cmlbh, tl or
OZI..µ9 g y city TEMP.METER ORIOLE INST.
F,� � muntywhich requires.perMltomntruct,alter,bnpmve,demolbh,or repair
�a .a
any stmentre prior to its Wuance,&be requires the appUmot for such permit to POWER DEVICESIs
file a signed statement that he is licensed pursuant to the provision of the
C.Mrseurb License 1.w(Chapter9(mmmendngwith Section 7gD)ofDivi.
N�O slon3of the Buelneuand PmfeabnCode)orthat hebexemptthere(mmend S'WRsfM1NC POOL ELECTRIC VALUATION
Q a the basis for the alleged exemption. Any Violation of Section 700IS by any OUTLEISSWITCHESPIX TURES
�a" O apphc iforaperiNtaobis theappllcanuoadWlpevityanam mthan /8O
(7 five hundred dollars($SM. STORIES TYPECONSTRUCTIQN
work, NEW RRSIDENTIAL ELECTI( Pa7I0 SUdFEN
Z ❑Las owner of the property,or my employee with wages r offered
sok
Ocont n,70Kflon,Bairdwill do ,andhe and im structure The C rtnud ed or off Law
sale(Sec apply to anowandPMealan Code:The Contractors Wcenn law - EyeL C$ddC!
r3$ don notsucht apply weanowner ofp roughoperty who bulmporimprwvidedes that
OCC.GROUP RES.UMTS
who dceeauchwork himself or through Nwwnemploye.pnrvldod that sorb
Improvements are not intended oroffered for sale.](however,whebullding or TOTAL: L LP
improvement issold withinoneyearofcompletlogtheuwner-buRderwill have
(ItiLkorelenofproving that he did notbuOdorimproveforperpouofsak3. QTY, PLUMBING PERMIT FEE
-FLOODZONE APN
{an owner tr the property,am exclusively Business
ess anding with Is maddCode: PERMIT ISSUANCE
roe Contratoronlmtlthewdo (Sec apply
BusNenand of pro on Cade:
The Contractor's Lase Law don cad apply e t f owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improve thereon, and who contracts for se L p(ojecv with. FEE SUMMARY
m,Iltra am a empt pursuant to the ContnROYs License Law. BACK FLOWPROTECT.DEVICE
LII am exempt under Sec. B&P C for this.mawn
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner - Date RECEIPT p
� WORKMAN COMPENSATION DECLARATION FIXTURES PER 71tAIa SCI{00),TAX Y N
laI'hereby.(firm that I have a adlBcale of coneem to self
-Imre,ora RECEIPT M
ce,,I_eofWorken'Compensatlonlnurinca er._.if,.d copylhereof(Sec. GAS FA.SYSTEM-I INCAOUILEIS PARK FIE Y_ N
3811 Lab C.)�" �rOQ'��s'ey RFfIR'TN
Pollrya s�.a a��J J l'f CAS EA.SYSTEM-OVER 4 IRA)
Gm nv_ f['!a/�ie � CQys((_( d>/O BUILDING PTDIVISION FEES
Com
copy t.9 hereby fumiahed. GRRASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
rKertlfled copy is filed with the city lrspedion division.
VV 11 CERTIFICATE OF EXEMPTION FROM WORKERS' CRFASETRAP PAID
- COMPENSATION INSURANCED
SEWER-SANITARY-STORM IiA.71NIH"f. a 111 Lte Re V I
(TFlasedio°cased na be compl&ed if the permdt U foron hundmd dollars
0100)°`less') WATER IEEATLJR W/VENT/ELECTR ENE R E Y N
I oertifythat In the performance of the work forwhlch this permit Is Issued,
I shall not employ any person In any manner n a t b 71,Ubfsct to the 1
Workere'Compensat�gn Lawsofj'ilifo� Date° L WATER SYSTPAI/TRPA77NC PAID
T)
Z Applicant G/�Y��.. NEW RESIDENTIAL PLMB._SQ.FT. 00
ReCei N
Z o NOTICE TO APPLICANT.If,after mlIlffng this G cafe of Exemption,you
Hshould become subject to the Workern''Compensation provisions of the Labor TOTAL:
fD Code,you moat forthwith comply with such provision orthb perrNbhall be
Wj deemed revoked. LD NG 'E s
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrenthat there Is a construction lending agency for the perform- ELECTRIC FEE
D O anre of the work for which this permit l9 issued(Sm.3097,Civ.Q TOTAL:
,L) I,ender'.Name PLUMBING FEE If
F Lendels Address QTY. MECHANICAL PERMIT FEE
O W Icortlfythatl have read thlsapplicallon and statethat the above Information MECHANICAL FEE
Incmect.I dgme to complywilh all city and county ordinances and state laws PERMIT ISSUANCE EF PAID:
} 0. relating to building construction,and hereby aothorlae representatives oflhts
F N city to enter upon the above-mentkad property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harmless the City of Coped Ino .ADateRece
l
O against liabilities,jtdgments,cortsand expense which may in anywayacems AIR HANDLING UNIT(TO 10,000 CFM) '
against said City In consequemm.ft gr ting of this Permit. AIR FONDLING UNIT(OVER 10,000 CFM) !CONSTRUCTIONSigamre of�Puranuc°ntractr Date M(HAUST HOOD(W/DUCT) ID:
HAZARDOUS MATE89 SDISCLOSURE
Will the applicant orfutu re building occupant store or hand In haeardcux HEATING UMT(TO 100,000 IT=
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Ilealt Yzannd Safety Code
e Setlio
on n2S537(a)7 HEATING UNIT(OVER 700,000 BTU) TOT L: I SS Ca
ill the applicant of(uWm building occupant use equipment or devices VFNIILATION PAN(SINGLE RFSID) ISPr/I�TTA
which emit hanrdous air cenaminnb a.defined by the Bay Arca Air a�r�
Quality Management D�btr +.7 BOILER-COMPDFR'OR100,0001ITU)
4 Ye pgNa ASR 1991
have read the havr5. rtutedala requlremcnts underChapter6.95of BOILER-COMP(OVFR 100,(100 BTU)
the Callfomla Health&Safdy Code,Section 25505,75533 and 75536. 1
understand that lithe building doe not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFT.
reapoaibRitywrosifytheoccupanlofther quircmems which must be end at CUW"
PH.,to issuance of Cedlfrete ofOcc°p ry.
Owner or authodud agent Date TOTAL: ISSUED BY:
OFFICE COPY