21015 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identifkafiae PFRMITNO.
Building AClresa: 21015
ner.
CITY OF CUPERTINO,BUILDING DIVISION q G n
tnttor'e Name: 6 .Ne, APPLICATION /PERMIT
BUILDING-ELECIWCALPLU ING.MECHANaCAL CATEGORY CONTROL.
ArchIUM/F ginnr. Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu PERMITISSUANCE ��_0() ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm n70that)amlkmsed under h.Busi anti of Cxt4ons ode,anw APPLIANCES-RESIDENTIAL JOB RATION
irgwit1h,er.h Sedlon I..anDlefeimt3otNeBualrcsaand ProfeadoruCade,and
my
Ilanac b In ml!orae and d(ed. PANELS
Diu Class Lfc. 5K t- LrI 1 C
Date Comndor
ARCHITECPS DECLARATION 1-1000 aM
O z I urderarard my plam anal be used as public records OVER IMAMPS SQ.FT.FLOOR AREA $/9Q.FT.
CC0
o U Lberued Pmfembnal SIGNS Ef.ECIRICAI,
�< OWNER-BUILDER DECLARATION 9'FLIAL CIRCUTI/MISC
Z Ihereby affirm that I—.-.Pt from the Cortranor'a Lure Law for the
O� following reaeon.(Sectio MLS,BualneaaardProt®lo"Cede.Anydtyor 7FAP.ME W ORPOLEINS.
�y muntywhkhrryuW apermitto mrutrud,Wter,lmpmvq demoWh,orrepdr
y any atrudureprforto that he I,Bee sed pureheapploet no each peof tto POWER DEVICES
the a e1gnM natemeN flat he b IfoevM pursuant to ens proalbr�o! the
F,30J ebn3 ofthe Butlna dPmfembmCod)olhrthhelaeumptnth�f mad SWR.4h9NC POOL FTI EJ:CTRI VALUATION
u •7] the Heb for the alleged exemption. Any violation of S Ion 9m15 by any I //��//�s��
tj5 Q'� applicant fora permit subFds the applicant to a dWl penalty dnot more than ournXTE-SWITCED'SFIXNRES rIJ.J
C, flee hundred dalars(S". r
�n
F]1,as owner d the property,or my employees with wage m their aok NEW RF9DENTLM.ELECTR STORIES TYPECONSTRUCUON
t cnmpewtlm,will do the work,and the Structure h not Intended or offered for I
Y 0 vk(Se,7DK Busiwsand Pmfeitoro Code The Conind.e.Lberur Law Z 1FAME
don not apply in an owner of property who builds or lmpmvea thereon,and OCC GROUP RES IA7T5
RR who dam sueh Work hirnel«through his own employee,pmvWed that.6
IomprovemeMa are not Intended or offered fee sale.If,however,the build ling« TOTAL
Lnprovemem b Bold within one yea rof completion,the owner-0ullderwW have
t rden of proving that he dW rot Wild or Improve for purpoee of oak.). QTY. PLUMBING PERMIT FEE
LJ L n owner of the property,am ex hrefvely mntrading with lamed A)NE APN
mntrad e,to comtrud the project(See 7074,Buelwaand Peofmloro Code: PERMIT L'SU F.
The CaMndm.Liee.Law don nes apply to an owner d property who
bu Oda or Improves eonm
thereon, and who rmam for ouch p(o) with a ALTER-DRAINk VEM-WATER(EA)
cqalT+d«(a)lleeneed prrmam to the Contractor'sLic,me Law. BACK FLOW PRO"TBC?DEVICE FEE SUMMARY
LJ I am ewopt under Sec w
B 6 P C for this rean011T%inu; ES
Owner Date ORAINS�KROOK AREA,GOND. SANITARY Y_ N_
RTSEp'f.
WORInthat COMPENSATION f .t TION ITX.NRES PER TRAP / SCI100L TAX Y_ N_
MI hereby ffmorkem C 1 have• l r cone of cros,nt to apyffic rt,« . RECEIPT
«rtWateof Worken'Compevatlonlrounn««a mtBkd eopythe vt�tt.
3800,Lb C) GAS EA.SYSTEM-1 QJU OUTLETS PARKIg Y_ N_
Policy I GAS EA.SYSTEM-OVER 4(EA) RECEIPT Y
Co ny BUILDING DIVISION FEES
I I Cenined ropy b hereby filed
the ed. GREASE/INDUSRiL WASTE INTFRCFPIOR PLANCHECK FEE
Ccrtlled ropy b filed with the dry Iropedbn dlvlelm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCEmdtNCE SEWER-SAMTARYSTORM EA 30RrT Date Recei t#
(Tial,e<dbn needs HcompletedltM perrtdt bf«oro hundred dollen
(f10%m1y that
WATER HEATER w/vTM'/ELECTR ENE
RGYFEE Y N
ImrtBy that tithe «arthe wo wMeh this permit b Issued, —
Ishaln ymann n to the WATER SYSTEM/,BEATING
O work, neat woof Womb. PAID
Z Z NO er ngt bted Exemptlon,you NEWRmDFNIALPLMB. SQ,FT. Date Recei t#
should bnmme sub)eett the worker:Cmr condor provbbro of[be labor TOTAL
~ N Code,yuumrrtfoth comply with ch pmvbbro or thin permit Aall be - vO
Q > deemed revoked. FEE
CONSTRUCTION LENDING AGENCY
W O SEISMIC FEE 1
d Ihembyaffl
fthewrr(thatthareb pc rot dlonkedingagentyf.C.) perform ELECTRIC FEE V
7 Z an«of the work for whkh fhb pertdtbLsared LSee 3097,C1v.C.I � TOTAL:
U O lender',Name PLUMBING FEE
LL F UrderSAddtns QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
O W I«nlfy that l have read thb applkatbnard state that the above itu mutton
binnedlagrectoc plywuhaBdtyardmuntyordivnma dabtelawe PERMIT ISSUANCE FEES PAID:
fl MMATERIALSDISCLOSURE
mtrudim,and hereby authorlss reproentatWes of this
U) 'ere tbned property for impoctbn purposes. ALTERORADDTOMECH. —Date Recel t#
— , emnly an d p harodene the City of CupertW
cost. whkhrraylnanywayacerue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL: _ D
n na of the tingdthb
49
O AIR HANDLING UNIT(OVER IO,"CFM) CONSTRUCTION TAX
t/Cant,wor r Date EX )5THOOD(W/DUC) CONSTRUCTION TAX PAID:
ARDOUS MATERIALS DISCLOSURE
Wlilthe applant«future buildingoaupant store or handle haranlmu HEATING UNTT(TO 10O,ODD BTU) Date RttCf t#
material as defined by the Cupertino Munidpal Cede,Chapter 9.13,and the p.
HeohhaM Safely Inde Sedlon 35533(+)7 HEATIN'GUNIT(OVERIM,0WBTUA TOTAL: $� D
I-1
Y. [�No
Illtheappll M« wu Wilding.pant.ee plp.mM devkn VENTILATION FAN(SINGLE REM) ISSUANCE DATE
whkh eMt harardoua air mnbm W Ma as deffned by the Bay Area Air
Ouality Marugement District? BOB.ER.COMP QHP OR 100,OOD BTU) PAID
IhaveYm a.Q� Cha
read then mrt e,Sb Iuulremenbundeand255 .I of BOILER-CONP(OVER 100,000 BTU) SEP 11 1990
the CaliforniatHealth hSafety Code,Sedbro3550.5,ve a tandt,that 1
urWersbMthatl calf bulldingdon Atm regnfivmnt,whah rntuatLamy NEW R6IDFNIIALMEa. SQF7
�aporulbllNy to ndlty th<oavpant d the rnqulrcmema whkh mal H rrrt /a���TIV ,�u{
prf«tounuaroedaCertifiateofOY
dvpanq. T In"unfi(M
Owns or authorteed agent Date ISSUED BY:�� \A. O
TOTAL:
OFFICE COPY
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