20478 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Bulletin Add l an ^O 4�7 8
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CITYOF CUPERTINO-BUILDING DIVISION
Cwtractore Name: Cl Lk.N. APPLICATION / PERMIT S- 3 —ge
BUILIX ELBCTRICALI'LUMBING IC LAICAL CATEGORY CONTROL
Arehltttt/Engineer. - IJc.Na
Q ELECTRICPERMIT FEE BUILDING PERMITINFO
Add.
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Hut lamllcmsedurderpmvblwedChapter9(. APPWANCESRESDEMTAL
B DESCRIPTION
Imenme I5Mbn 7003)of d effdw3o(the Busiroaand Pro/esalonsGde,and try
License b N fu➢bra and d(eIf PANELS
Llanse Cha Lk#
Date Coh1m dor
ARCHITECPS DECLARATION 1-1000AIMPH
p�p�uu re Q7. I understand my plans shall be used as pubbc remrde OVER 1000 ANIFS SQ.FT.FLOOR AREA $/SQ.FT.
&tz� Llaneod Professional SIGNS EIMZ RICAL y 6 0 . o�
fn<< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
i.., 1herebyafBrmth.11.meaemptfromthe Contra roes Ll¢rue lawfethe
z{_ G following re.&S Jon 70315,B.1,,..rd I'rofubns Code:Any city or
O TEMIP.METER OR POLE INST.
K � anyt,onot hlchpn tolapemwt aLowgilteeapmve,demoLLsh,arapto
any.dere taterlolhhoane,abrosed ret tit,lmtfowgin.of to ZOW,��.W�
rC 0 U rile•dgnM euumcnt the he b IlansM pursuant m the pmWbns or the
Ow Ccnlranors License law(Chmpter9(mmmendng wRb Section 7003)d DWT-SVALUATION
OS don3aftheBumnaandPro®bnsCMe)orNnhebessmp hedrom.nd SW MW 0 POOL O
y.' the barb for the illegM eaemptbn. Any violation of Section 70315 by any0
Lai app➢ant forapemdtwbjnesHrappBeanttoadullpensltydvatrtnrcthan OITH.BTSSWTTCFEAFDCURFS 3 Ij
Y ,.. fyeundred dollars($SM.
'R I,aowrer of the property,or my employee with wegnutMbsob
STO
NEW RE?�EN77AL FJFCTR—BEET. Rt TYPECONSIRA'UN'
IO
pens m,wllldotkworkand(hemm�umbnot WendMor offered for
Dsale(5,170K B.hesand Pm(ue loru CodThe Contractors Llot.Law
5$ doe notapplyto an owner d property who builds or lmprowsthereon,and OCCCROIII' RES.Ulv775
who dons wch work hlmseB orthrough his own emple,oyeprovided that much
Impmwmmtma are not Intended oroffered faeale.If,however,the building a TOTAL
Mprowmen ls.a1dw hinomrarofcompletbn,theawner-bummwiB hart
t rden of proving that he did not Wild or Improve for purpose of We.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ApN
Lam ownerof the Property,am ettwlwly osntra:ting with Ilanaed IPFRh11T 15SUANCE
mntracton to mwirun the project(See 7014,Buinessand Prdessbns Code:
The Codractars Lberue Law doe not apply to an owner d property who ALTER-DRAIN 4 VENT-WATER(FA)
builds or leop.theneun,and who contracts (or such pia"wIM a
ogejr�.r(d Banged puewant to the Cuntradorh Lkease Law. BACK FLOW PROTTiT.DEVICE FEE SUMMARY
LJ I am .empt uMet Sec S Is P C for tw reason
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_.
O Owner Dat a RECEBT# '
WORon that Ila SATION DECLARATION FT%TlJRFS PER TRAP SCITOOLTAX Y_ N_
❑1 hereby aelrm the 1 have•artlflau d cmssnt to seB-Inert,a a RECET T#
MOD,L Lb
Worker'Compensatian lnsunna sera artlrled ropy(hereof(Ser- GAS EA.SYS1111-t INC4OLTrLE15
poft, if PARK FEE Y_ N_
Com# GAS EA.SYSTEM-OOVER RECEIPT♦
Y _ BUILDING DIVISION FEES
Certified ropy b hembyth thehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE � yy
❑CenNM ropy 6 filed with the dty IvpecOan dlvidw. V e 3 0
CERTIFICATE OF D(EAII'TION FROM WORKERS GREASE TRAP PAID
ll
COMPENSATIONINSURANCB SEINER-SANTARYSIORM EA L00FT Date RC i t#
Ohhs Ylonneed rad becompleted lithe permit h/m oir hundred dollars -
(9103)orleaJ WATER HEATER w/VENT/MDCTR ENERGYFEE Y N
Iartify that bate performance dthe work for wNchtw Permit isfwed,
I shall not employ any penin in any runner o u to become subject to the WATER S-YSIFM/TREAT NG
.Worlun'Canpewtbn L.w.dCalifomla.Date PAID
O Z NOTMAppliunl NEW RESIDENTIALPIM9.—SOFT. Dale Recei 1#
Z O NOTICE TO APPLICANT.obpetILafterori making(tab Ceinn,preaf Eeemptbn,yw TOTAL:
some,bemos froth to the ply with
Compensation provhbnsoftom Lab or
� N CMeyou r lud.athwghomply with wch provimbns or thio permit shill be
y deemed rewked. _
W — CONSTRUCTION LENDING AGENCY SEISMT FEE
CL IherehyaNrm that there b a mnstmnlon lending agency for the perform, ELECTRIC FEE
7 Z anauftheworkforwhkhthbpemdtbb MLSec.3097,CN.C.) TOTAL,
(,) O Lender.Nanr - PLUMBING FEE
LL I— IeMeriAddresm QTY. MECHANICAL: PERMIT FEE MECHANICAL FEE
O W Lar(BythnlCvemdtwapp➢otbnaMratethAtheaboveinrormnlw
bmmrCt IagreetummplywhhaDdtyaMmuntyordlnanas dstatehw. PF ISSUANCE FEES PAID .
> N relating to bullemg mnstrudim,and hereby sutha rep immudve of this
F Z dy to enter u Pon the abovemenmnsd property fm umpenion pas rpose+ ALTER OR ADDTO MEIN. Date RecCl I#
— (We)agree to save,Wmlw
enlfy an d keep harmless the City of Cu pertmo,
ago lost lhbBities,Pdgmenu,nine and upenses which may In any way amus AIR HANDUNG UNIT(To to,"CFM) SUBTOTAL,
gmnstw clryb e� (the graningdtw pemdt. AIRHANDUNGIINIT(DVEItl0,000CE,D CONSTRUCTION TAX
Signstu (App➢oral/Cont Date SCHAUST HOOD(W/DIA:") CONSTRUCTION TAX PAID:
HAZAR USI.tATER1ALSDISCLOSURE
Will the applicant mfuture building oaupant store or handle havardoum HEATING UNIT(70 IM,000 BM DatC - Rttei t#
material as de➢rud by the Cupertino Mueldpal Code,Chapter 9.1 Z and the
Health and Safety Code Seaiov 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
T� Ye No
111 the appBanta lure building occupant use equipmuu or civ VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkh endt Ma aadous air mnhMrunb a defined by the Bay Area Air
QualHy Management DLUrkt7 BOILER-COMP OHP OR 100,IXD BTU) PAID
Ye No
have read the haa�rdoua materials requirements under Chapter 695 of BOILER-COMP(OVEt 108000 BTU)
the California Health k Safety Code,Sections 2550.5,25533 and 25534. I (;yAY 31 1990
udersta nd that if the building rad a
ding dons have a tenant,that It b my NEW RESIDENTIAL MECH. SQFT,
raporalbBlty to not By the 000 pant of the requiremente which rratn be met
prior to lvuana of a Ccrtiflote of Oaupar y. /a
Owneraauthorf ,agent Date t+ \
TOTAL: ISSUED BY: 4 Wb V U-
OFFICE COPY
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CHECK-ED By
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DATE..
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'_F4pp OVED
IN AC60RDAN E WITH THE CITY Of
UPERTINO CO[ES AND ORDINANCES "!.'SL)
E
SIGNED I V. cc
Tbis set at Pl
ss usl
bi Wt on the ic j at es and it is un
Ifile to.make.a I Y r alterations
pl� nn
same wlthr"U: w:qfn P"miss'On from
4j%bukding OOP, , C iY Of CuPO"LinO-.
pksjampjog.of ;,s pian and speciticz. MAY 2 9 9
NC;l lie I'!dA.j po'hiltOrto be
ksion��1�r
iiicw� LM
p0o%�.. �,! :he, W i n. Of PfOv. INSPECTION DEPARTMERT,
INSF
I any G" FT 0 F
CITY cupERTINQ-
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