21735 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin project ldemlikeion Or �� PE3tbDT NO.
Building Add� U re�Z: —1 - 21735
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Name Crtc�uq,'( GrOJ S n5.- orae. CITY OF CUPERTINO-BUILDING DIVISION '1 _ Z _ G \
Cmtntgr'e Name: LIB Net APPLICATION if PERMIT
BUILDING-n ECTRICAI4PLUMBING-MECHAMCAL CATEGORY CONTROLM
Arch /1Inglnnr. . Glc N¢
�F BUILDING PERMIT INFO
Q ELECTRIC PERMIT FEE
Address PQib9"f ISSUANCE
LICENSED EO CONTRACTOR'S DECLARATION
I henry affirmthe lam Bcrosed underprovblon.of0upkr9(mmrrsmc MIsLI JOB DFS
In ere.t Setbn 9lIW)ol d efegn3otmeBuCrcssandlarvlewmuCode,andmy 1!!! 114411L
RIPTI
II¢nm b In fv8 f d effect P
Lben.Class�Lie.. ��OOQ t
Dale Contractor an KA
J Vel/ W
ARCHITECT'S DECLARATION 90-1
�Wqou0QQ7 ]uMerelaM my plane shall be used u public rMOrdL OVER1IXp AMPS SQ.FT.FLOOR AREA $/SQ.FT.
< Licensed Professional SIGNS 4 5
�<< OWNER-EUI DER DECLARATION SPECIAL CERCUIT/MI9C
to„ I hembyafflrm that l am exempt from the Cmdractot.License law for the
67 following re..(Seerim7MI5,BuCn®and PmfessloaCodr.Anycityor TTNHa,SER OR IOLEINST.
m
oatntywhich require.•permit tomestruct,alter,improve,deoWh,orrepair
�[ anyeructurt prlortolbw
larre,also requle
rmcen
eappllt toe such pemut to
K 5 file a signed gatemen that k It,Bcrosed pursuantPOWER to the provisions of the WDEVICES
1- Contractor's Lfc,.lawfCWpmr9(mmmendngwith Section 7000)of DM-
E,�� sioo3 ofthe Buslnem and Professions Ced0orthe he b emnept therefmmed SWIMMING IDOL Fd.ECTRIC VALUATION
the bib for the alleged ee,mption. Any violebon edSection 70715 by any
p applicant fora permiteubjets the applicant to a Wil peruoy,of not room than OITTLETSSWEICHESFIXTURFS ` C�4 rj 41]
five ndmddoll.WEs0).
as vomer of the pmperty,or my employee whh wag..theb sob NEW RESIDENTIAL FT R2111 SQFT. STORIES TYPECONSTRUCTION
mnpeeseion,wnl do the w¢k,and the em=m b not Intended or offered for
Osalr&t.70t4,Bueoeaeei Pmfmbnscede:Thec mouctoe.U¢veiaw
don rot apply to an owrcr of property wh.W ild.or improv.therms,and
S.. OCC.GROUP RES UNITS
who Mmse dedcrcugh hlaors e.lIhc qp ,the uhatuch
Impmvem m are riot Intendedo rof o forsale.14however, Mer WWgve TOTAL
Impmvemem bsdd wohIn orcyvrofcomplellorn,the own,bullderwW have
t"mien of proving the he,did not bund or improve for purpose of soak.). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with 11¢rued FLOOD ZONE APN
mntracton to mvtrut the project(See 9OµBuaInessant Pmfealo.Code: PFRMITISSUANCE
The ContnctoY.License Law don nes apply to an own,of property who
Funds or Improve thereen,and who contracts fur such pScjens with a ALTER-DRAIN VFM-WATER(W
�Ifact¢(s)b¢nxd puraoanitothecontractor'.Li¢nae law. BACK Flow PROTECT.DEVICE FEE SUMMARY
LJ I sen exempt under Sec B 4 P C for this renin
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
RECEIPT.
WORIO.TAN GAMPENSATION DECLARATION N
PFR TR" SCHOOLTAX Y_ _
❑I hereby affirm that I have a¢rtlficee of consent to seR-IwrtFIXn1W5
,or RFLF N
uomf.m.fWorkeri Compensation lnauran¢¢.¢hBledt mpythereof(Ser. GAS E.A.SYSI.FM-1 INc4 OUIZES PARR FEE Y N
3B W,Iab c)
RECEE]PT
Pesky. GAS FA.SYSTEM-OVER 4 MAI Co���rrrn aaanv l .,.sit K.I PSI. BUILDING DIVISION FEES
wertlfled copy b herebyfutheeft. GREASE/INDUSIRL WASTE INTIXCF11OR PLANCHECKFEE
Certified ropy,b filed with the tlty Inspection didsion.
CERTIFICATE OF IXFMPTION FROM WORKERS CRE'S''s'E TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM FA aIQ,.f. Date Rtt i t# 1 5.S O
(11d.sedio.ntedn¢beconpleed ifthe permit bfor..hundrtddollue ENERGY FEE Y N
($101))or tro.) WAT'ER]-WATER W/VENT/ELEC7'R
I certify the In the performance of the work(or which role percent le bored,
I shall not employ any person he any,manner n as to become subject to the WATER SYSTEM/1REATING
Wmkun'Compen.elnn Law.ofOWomla.Date PAID
Q = Appllom NEWRF�ENTIAI.PLMB. 9Q.Ff. __Date Recti t#
Z NOTICETOAIaPLICANT:R,aft,nukiryted.C,HflvteofEzempnbn,yw
should become em),et to the Workers'Corrpensanlmm
s pvbbv ofthe Labor TOTAL:
N Code,you forthwohm plywithsuchpmv Wmorthbpermitehallbe OUILDING FEE
l2. bO
W `� deemed revoked.
CON them Is a ONLENDING AGENCY SEISMIC FTE 13.brj
CL eofthe linerthat orl,f.twhhert bamvtvctlon lending agemyfor the pegorrry TOTAL ELECTRIC FEE 3.t-2,
0 Z Le'", erre for whkhthb pe b belted(sK 3(/97,civ.C) -
LL O Ieed,:Addr ��`T"n PLUMBING FEE "13.13
LL I<naer.waare„ QI'Y. MECHANICAL PERMIT FEE MECHANICAL FEE 3 .l
O W 1¢Clfymatl love readthb applivtlonard Cate that the above Infornution
S Mating to
unylmreprmanaCstelaw. PERMIT ISSUANCE FEE All).
N city to gtobuilding pontheconstruction,abmw-crentim hereby eultrortyfeelI rtpreanpurpoi of this
F Z city to theabove-membrcd keeperty(orw to Cr purpose.. ALTER ORADD'IOMFSH.
(eat)agree m save,ledements an d.per which the coy of Cupen cal D to ReO t#
V agawnhabWtl.,)udgmew,cents IM ezpene which may to any way amue AIR IiANDllNC UNIT CN 10,000 CFM) SUBTOTAL:
against said Cry In mnsecI m.of the granting of this permk. aao3Z5:D I
AIR HANDLINGHANDLINGIt
NG carr(OVER lo, cFM) CONSTRUCTION TAX
C CONSTRUCTIONTAX PAID-
HAZARDOUS
of ApplHAZA DO Date EXHAUST HOOD(W/DIK'I7
HA9A RDOUS MAT RIALSoccopa DIt.,or RE
Will me applicant or future building omvpant Ston or hnrdk havrdous HEATING UNIT 100,000 BTU) Date ReCel t#
rruterial as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I leeeth.M Sanely Code Smticr 95533(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 1 5 5 L.
RY. No
nithe appllnnt« .,ebuildinguccvpantu .Nipment cedevices VENTILATION FAN(SINGLE IHSD) ISSUANCE DATE
which emit"Hous ale mnbmlnants as defircd by the Bay Area Air
Quehty hfanagereent District? BOELER-COMP(311F.OR 1000N BTU)
Yn F❑'o No
have read the hav7wsmaterials requlrtmenb under Chapter 6.95 of BOILER-COMP(OVfR 100,000 BTU) pIPW�pMf
the Calltorets Health h Safety Code,Sections 75505,7:533 and 75530. I ,
understand that irthebullding do,s trot currently have a tenant,than It is my NEW RESIDENTIAL MECH SQ. FEB 241991
responsibility to notify the occupant of the requirements which most be met
price to i mane,of a`C,ertifiate of Ocmpanry.
C- .� . iJa �asv
Ownergr aim agent Date P ern/ A� . Vl�
ISSUETOTAL: 'eV '
OFFICE COPY