21114 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY DT
Building ProIdamilkaaem O ppRMITI�.
Building Addams:
0 3 o acro e To � D rz�v 21114
am: Franc
fM-PA Gve jp CITY OF CUPERTINO-BUILDING DIVISION
MN' _ APPLICATION I PERMIT 1
r ph Jim BUTUN GELECTRR:AL PLUMBIW-MECHANICAL CATEGORY CON'fi0D1..
Arthleeplfngi�eer. K_ C ,!.-b p p Lm Na BUILDING PERMIT INFO
X010 ELECTRIC PERMIT FEE
. AddmK, PERICTISBUANCE �� � �f
LICENSEDCONTR madaprCTOWS vWmsoDECIARATION Y
IhmbyaEmlhallmBcmaadhegust wWonso/Wpler9(lkandr APPLIANCES-RESIDENTIAL )OB ev
Iran lths5edbbn7mW�Dlvidm3e(tha Buslnm�Pre(esslensCnde,and PANES
Damm . CoN'attor99 s FID w Lr
ARCHITECTS DECLARATION .I AMPS
Oyu aWWWOtZ I understand my pWu@hall be used a public rtmda OVFRIODDAMPS SQ.FT.FLDDRARFA B/9Q.FT.
Se Llaaed Professional SCNSELRCIRICAL ^I 3qa
<«< OWNER-BUILDER DECLARATION a{• 1
Ihembyafgrmlhatl@mmemptfromlbeCa ra esLk nm IAwfwthe SPE)CIALCIRCUIT/MI9C
blloavbg mum.Wectlae7011S,Business and Pmf®IwnCady.Anydty orL.t6$ .
FE muntywhkhmqulmaperff&W Mme4alw,bnpm demolkh,arr"Wr TEMP.MMMORPOLEDW. '
a� aDYsw mPciwblbbmmK aborequimikeappBontfwwchpemdtto POWER
g s (lie a signed Yahmnt that he b gamed Forum b the pmvbbm of the me
f Contractor'sLkeme Law(Chapter 9(mmmmdngwith SedbnAOWofgvl-
E, sbn3oflh.Budnessarrd PtafmlunCsde)wlhatheism.ptthemfro .ad SWIMMING POOL ELECTRIC VALUATION
lbYI the basis for thus alleged exemption. Any violation of Section 711115 by a OUTLRISSNSTCHES-FIXTURES /'� ,�T / ca
p$f $ appliantfor a penntl subjects the applicant to a dull pealtyofnet more than 1918.1
W 18. ` b4--
E fiv,2-hundmddnibn CESmJ. V VVVV J L
ye L a owner of the property,way empbyeawith wagauthabaob NEWRESDENT7AL EI}]C[R_SQ.Fr S70EES TYPEOUNSTRIICDON
C rompensslhn,wllldoth work,andlheawdumbnot Intended croRemd for
� 3 sale Wee 70K Budassand Prdasslu.Cdr.The ContmctaALlmuefaw
a�R data ntapplybm ownerof propertywh bulMacclan rmmalweamt,and OCC.CROIIP RFS.UMB
a whodmmehworkhLn LfwNwgh Waownemplay pr idedtbatmmh
Improvements are not intended woffered fwsale.IL however,thebulldbg or TOTAL•
Improvem issdd Mlbinowymrofcompb Wo the wneMulWerwlghaw:
tlr9 rdenofpmWdid rom
ngthat he did build mhnMve fw purpcfale.L QTY. PLUMBING PERMIT FEE
LJ L as comer of the property,am exclusively contracting with amusedFLOOD ZONE APN
oanlRam -mwmat lits project Wee 7EµBusbm and Pmfml..Cade•. PERMIT$UANCErz.CD
The Cenindor7r Loewe Law does ad apply to an owner o(properly who
budds w Improse theeaL and who dmbaN for such pl jscb with a ALTEWDRAINk VENT-WATERMA)
calB7actwWlmnted pummtblhe Coamsdora Llmwe Law- BACK FLOW PROTECT.DEVICEFEE SUMMARY
LJ I am eaempt under Sec. B k P C for this remit
ffiff
DRAINS-ROM ROOF,AREA,COND. SANITARY Y— N—
OUTSIDE FE
•. Owner ITwe RE CEPr 9
WORKMAN COMPENSATION DECLARATION FDOlIRE4PER7RAY SCIi00L TAX Y— N—
QI hereby aaba that I have a xniBute of cmums to sell-Tuan,w a RBCEBT P
ordlflIAbC WwkentME.-wMlonlmuranwwa QRlRed copythemfWea GAS.EA.SYSIYM-1INCA OUTLETS PARK Fite Y— N—
Polic3tlm,labCJ
re
Com GASEA.SYS7EM-0VER4(EA) DING DIV
Com try BUILDING DIVISION FEES
CMIfiedW copy bhambyfumedtyI CREASE/INDUSTRL WASTE WTtRCE'TOR PLANCHECK FEE
CMIIIed ropy b(14d with the cS)'Inspection dNWm.
CERTIFICATE OF EXEMPTION FROM WORKER ' GREASE TRAP PAID
—
LISEWER-SANITARY-STORM FA LNFT. Date Recei ted .
RM@sadbnneed net hoampleled lithe parents bfwoahundmddoBam
CRm)wlmJ WATER i¢ATFAW/VPNT/EFLTR ENERGY FEE Y N
Icandlylhat M the perhavatemofthewerk forwhkh thbpemdt blamed, —
I shall not employ any poser,in any manner an as to become subject to the WATER SYS EIA/TREATING
O WorkersicanCampewb
atn laws of Callfwmb.Dab PAID n
13
ZQ NOTICETO APPLICANT.IL after making this Certlllmb of Exemption,you NEW RFSIDIN77AL PIAIB._ BOF[, ate J- RCL<'1 ted
sbmldbecomesubjectblha Wo,k.WCongensstlanp.lot Rofthe LbwTOTAL'
F m Cndeyou matforthwith mmplywlth aurh provbba orlhb permit hall be
� > deemed revolted. CC
Wp CONSTRUCTION LENDING AGENCY SEI
CL IhambyaEmthat them be mmeudim leadlegagemrKyylorthe perfom>• : L1EC6RCi1EE
Z arm of Ne workfwwhkb Y
h this permit med(Fee.3Clv.CJ TOTAL
U Joe
O Landers Name PLUMBING FEE 1
LL H Land.e.Addmm QTY. MECHANICAL PERMIT FEE MEC L FEE
O W ImdifylhdlhavamdthleapplkalmandeaWthlthechevebfo jw
S Lsmnert.lagmtommplywithall and ammyoedhunmeddablawa PERMIT ISSUANCE CO FEES PA
} N Mating tobullding construction,an hembyautholiampmenbllvaofthis
1" Z city to enter upon lhabovanentluned property for bupealmpurpowa, ALTER OR ADD TOhiBCH. Dant ROcei tit
(We)
agree b WemN sr,d keep burMess the of a rtitss
V against Wt dgmntk nand e. may ways AIRHANDLINGUNI7(TOID,maCFM) OTAL:
-gal bcon ofI nii •his pemdt
0 3/ AIRTIANDLING UNIT COVER IUMCFM) CONSTRUCTION TAX
reofAp /Cmlrc EGIAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
XHAZARDOUS MATERIALS DISCIDSUR
Wgltheappeunl wCuban Im ingompant atom orhandbharaedous HEAT'1NGUMT(10I00,110DB'IU)
materials.defined by it.Cupertlw Municipal Code,Chapter 9.12,and the Dant �t Rmvi t8 ukZ
Health and Safety Cd Scala 75S32W7 HEATTNGUNIT(OVERImpm BTU) Qf-c TOTAL:
Yr, No
WIIltheappOoMw turcbulklLngampantumequlpment wdmim VENTILATDNFANWINGLERESID) ISSUANCE DATE
whkh emithaardet atroabntlmntaudeaad by the Bay Area Ab
r• alityMawgemniDblrN. BOB.FhCDMPOttyORIOD,DDOBTID PA1�7,,
j I Yes No
voedal baa mumb7lSeeloh rcnwn 25Man 2551LI of BORFRCOMP(OVER lmpm eTUl
roe Gltandt Hefth4Si(etyCde,Secibidntly.b 29533 ad75hatIt NOV z 71990
understandhat if the does paMoflcomnRyhavealhich lhalilbmy NEW RESIDENTIAL MFAi. SQFf.
mpamWONybndlfytheaaupant of the mryleemenlawhkh ma(Be�pt City a CertlfloateofOctupaay. • / _ City Of MIP-0
Ownerwauthodadagent Data
(yeah
TOTAL. 4 ISSUED BY: V UC/FY�JF+T"�^'N.
OFFICE COPY