21902APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm'M Identlfleatim -
Buuding Addna.:
7 0 ALLL Gr e
PERMIT NO.
"I a� n O n
21902
G I Vy G
r• j�(„� �PH ),k 11hme.
CITY OF CUPERTINO-BUILDINGDIVISIONGy
APPLICATION I PERMIT
BUILDINGET.EXHtICALPLUMBINGMFLHANICAL
ca,mad«•°N•^,e. (/�•p L. No:
`�" u
CATEGORY
CONTROLI[
D vfs
Arehkec/Fsgircer. Lir No:
5 rZA lit DS
QTY ELECTRIC PERMIT
BUILDING PERMIT INFO
�
Addreuq"(J3N S� nth N RNC
❑ El ❑
PEELMITISSUANCE
LICENSED CONTRACTORS DECLARATION
I hereby affbm that l am licensed under provWau of Chapter9(conunenc
Ingwlth-gam n9W0)of Dlvblm3ofthe Buel andlhofeae Code,and
APPLIANCESRFSIDENTUL n
p0 ON
Renee is In full f«m and effect
Limner tit 2
titA
PANELS
\' /�`
Date�� Comraa[or
I iy_r
MIS
' UlT�- ��NL. rB V'
i01-
DECIARATR)N
I undersand my phmahallbe used as publlctecceda
OVERIWOAMPS
SQ. FI'. FLOOR AREA
S/SQ. Fr.
SIGNS
Licensed Professional
CIRCUIT/MISE
OWNER-IUILDER DECLARATION
I hereby affirm that !am exempt I. the Cornrador'a Lksrae I-
Wkl ,ins madm. ES oo 7131 S, Buelnm and Profmlona Code: My d or
oatntywhk requb apermktommlrucl,alter, rove,demolbh,or r
TIMP'METEROR 1
anysru¢ure prlortola baanc6 also requmnthc appBanHor such pe to
file a signed alamb
teent that he Ik erued Pursuant to the provisions, of the
POW ER DEVICES
STVP.4MING ELC
OIITLETSSMTC
Contractor's License IAw (Chapter 9 (romnendng with SeUlon 7000) of Dlvl-
aon3oftheOusinmeandl'Nenbro Code)orthat heiserempt lhcrtfmmerd
the bub for the alleged exemption. Any violation of Section 7m15 by any
.ppeont fora Ne tmb)a theappl anttuad 1pnahy fnm mortthan
)
VALUATION �v
NEW R® SQ
fiv hundred d r oft (S.riOPf.
as owner of tic Property, or empbyeea wRh wages u them dole
STORIES
TYPE CONSTRUCTION
e a tion, wW Bothe he dart not nt Wed or offered for
cote
and tura,
ES and Pr C h
tale (Sec 704/, BuaNev and Prdru.bro Cade The CoMndofd Llmroe IAw
dos not apply to an owner of property who builds or Improves thereon, and
who doessuchworkhlmase orthwgh Meow, emplgees, prwldedthatach
OCC.GROIlI'
RES. [1NCI5
improvemew are not Intended oroffered instate. If, however, thebuildmg o-
fmptovemeM bsold wkhNoneyearolcomplsbrktlrowner-0ulld<rwW have
7
aa¢t rdenofpmving HuthedOmbufidorlmproveforpurpodeof vie.).
LJ L as own« of the property, son e.lusively contracting with Banned
mntrscbn to ooro tithe projim(See 7044, Busin,s and Pra(nsoro Code:
QTY. L N RMI FEE
PERMIT C
FLOOD ZONE
APN
The Corkrador's Lkxrse Law does out apply to an owner d property who
build, or improve thereon, and who contracts for a3i plo)eda with a
�➢j+�or(q lloeneed puraant to( eCmtraet&. Llarise Law.
U I ins cnempt order Sec B & P C for thio re.n
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAIN& FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RFCQPT /
Owner Dae
WORKMAN COMPENSATION DECLARATION
F-11 hereby affirm that I have a mnif eau, of content to self -tore, o- a
artifioate of Workero'ComperaaHmlwrance or a certified copy thereof (Sec.
380(LLb C.)
Y
RE4I'F.R.RtAI'
SD{OOL TAX Y_ N_
-RECFFlPT Y
GAS FA. SYSTEMI ING4 OUTLETS
PARK FEE Y_ N
RFLF]IT I
GAS EA. SYSTEM -OVER 4 (FA)
Go
Co ny
BUILDING DIVISION FEES
rCenlfled ropy b hereby furnished.
Cened copy b filed with the city Inspection division. ,
F� Ri
Y'C CERTIFICATE OF IXEMI'TION FROM WORKERS
GREASE/INDUSCRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
CREASETRAP
COMPENSATION INSURANCE
CTM.sectionneednotbecompldedffthepen bforonehundreddollam
Date Recef [#
SEWER-SANTCARY-STORM EA. 370"1'
WATER IffATER W/VENT/ELECTR
ENERGY FEE Y N
Cf1IDJ) ftfy that
loenot thatoy he apermRbbo
any of work for
intobecohich
1 °lou not empky any Laws f any manner eo u b become abject to the
any person I he
W«ken'CompensaHon !Awa of California. Date
Applloant
NOTICE TO APPLICANT: If, after nuking this Conffiate of Exemption, you
should become •ub}ct to the Worken'Compematbn provbbm of the Labe,
WATER SYSIFAI/TRFAnivO �
��((��
PAID ,���.[.I_ t�
Date Recti t# 1ST' cc
NEWRESIDENTIALPLMB. SOFT.
TOTAL:
Cade, yore voted fonhwbh comply with ach provbbna ordhb permit shall be
deemed revoked,
CONSTRUCTION LENDING AGENCY
a (� 1
BUILDING FEEt
5EISM IC FEE . Sb
Ihereby.fRrm thattherebacomtrucHmterding•ger forth per(ortry
a of the work for which this permit lr L�ed(See 3097, W.C.)
TOTAL
ELECTRIC FEE
Lerdert Name
Lender'. Add
] o-nifythat l have readthbapplintionard tlaetha theabwe ln(omutlm
is cor . !agree to crenpty withal] ctyaM county ordinances and state laws
relating to buikfro
ing rotmWon, and honr ereby authreprete°tathe of this
Qct. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
EEINII'T ISSUANCE
FEES PAIj}�
3 -1v! -JY Y7
dty to enter upon the abev rncntbred property for bupedbn Eau Tomas.
(We) agree to save, IndemN Ey an d keep harMets the City of Cu penlno costs
agebat habWtba, Pdgments, ab expeves which may In anyway...
age W[ dCByldcontequerce of the gassing of Wa pmdt.
�
11
ALTERORADDTOMECEL
_b�q
Date Recel t#
A(ft LEA [JMf CIO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (DYERIO,WOCFh1)
CONSTRUC77DN TAX
Sigrutumof AppOa mtractor Date
EXHAUST HOOD(W/DU(:T)
CONSTRUCTION TAX PAID:
H DOUSMATMIALSDISCLOSURE
HEATING UNIT (TO 100,000 FEET)
Will the app0nnt or fuwre buildingomtpnt tlarear haMle h.rdous
rnatertel at defined by the Cupertino Murddpl Cade, Chapter 9.17, and the
IieYe Sefety Code,Snllom2S537(a)7
Wtheapplias orMnTuuturo Wildingoecupantumequipment mdev4m
Date Rceol t#
BATING UNIT (OVER 1X,000 BTIZ
TOTAL: �JS
VENTILATION FAN(SINGLE RESIO)
ISSUANCE DATE
which emit havrdous am mntarnrurn° an defined by the Bay Arca Air
alNy Managcmerd Dlatrkt7
fte
MOILER{OMP QHPOR 100,000 BTU
Yn ❑F� No
BOILER-NNP(OVER 1W,000 BTU
have read the havwou° nateriab requirerrcnb under Chapter495 of
ted CABf.0 Health &SafetyCod, Sectloro 75505, 75533and 75534. i
R� / PYA
71,9
NEW RESIDENTIAL MECH. SQ.FT.
uMerstand that lithe building dm wt currently have a tenant, that it b my
r '#/ 1
respon°Iblllty to notify the oaupnt ofthe reqM
ubennee which must be met
C
prior to isuame of a Certificate of Oc upancy.
map
L6IlED BY�C�/ �
Owner or authorimd agent Date
TOTAL:
OFFICE COPY