22094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
PERMIT NO.
Building From"Idemi(ir Lion 2 0 9 4
Building Address: Rai
1/7 760- 41Nlde -2,j; ' --7?03 I
V e same: .'hone: APPUTA uUN S�nNw.A�JA.c
C/oT•••nnn��\ ( - a r!✓e, CITY OF CUPERTINO-BUILDING DIVISION
o7aName:Y ( Lir.No: APPLICATION I PERMIT v l
G(�ls^ .emir /^'/��IbJ[ OW'gy - }SeZJ.�L) BUILDINGELECTRICALPLIIMBINGMEC}IAMCAL CATEGORY CO �LM
ArchitWEngineer. �T `� Lle-No:
t •� . " : . " BUILDING RRMIT'INFO ,•
/ ,x �� QTy t � ELECTRIC PERMIT;� � �PHE I"�'' �-" -" '"
Address:/i/S.S /- 12P/` ,trd .8d Sec PERMITISSUANCE _ - -- ❑ ❑ � 4,l ❑
LICENSED CONTRACTOR'SDECLARATION rfJ USA '—Y
I hereby afilrmthat l am(keoved utWer provlsloesof Chapter 9(u...1 APPLIANCES-RESIDENTIAL • JOB DFSCRUInON
IngwUhSection 7W0)of Dlvislon3ofthe Buslnevand ProfevionsCode,and my , ' `[\T!'n I•�`�
Ilunse Is In full farce and affect. PANOS
Lkcave Claas� Llc g '
Dale Contractor -+low-ARCHITECPS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT. ;
W'L luffiersnrA my plan nhaB be used as pabllc recordw I
O
� Liunsed Professional SIGNS ELECTRICAL
<�_
OWNER-BUILDER DECLARATION $PFOIALCB2CNT/MLSC
I-, X I henebyafnrm that lam exempt from the Contractors Lkense Law(or thel --
ZQ-� followingreatutC i..7031S,Businessand Professions Code:Anyntyo,l TEMP.MFrER OR POLE INST.
OGt-. county which requires a permit to construct,alter,Improve,demollah,or repair -- - -
q�`•Ug.'aa anystmnurc prior to it,Issuance,also requmenthe applicant for.uch permit to POWER DEVICES
p << floe a signed statement that he fa licensed pursuant to the proviniom of the
Owu outndors License Law(Chapter 9(commencing with Section 700))of Divi- SWIMMING POOL ELECTRIC
30�<' n3ofthe 0usiness and Professlam Codc)orthn hebeumpt thercfroma•a VALUATION
W` �^•c the basis for the alleged exemption: Any violation of Section 7031.5 by any OUTLETS-SWITCHESHX'I'IJRES
¢� appBontfora pert tsubj ectsthcappikanttoacivilpemltyof n°tmetuthan
g five hundred do11an(5500). NEW RESIDENTIAL ELECIR SQPr. Rif" ^'�� TYPE CONSTRUCT1OPr
RI,as owner of the property,or my employees with wages as their Bole y
rompeneatlon,wflldothe work and ihestrvcn+retsnot intended or o(femd(or
f l p gain(Sec.7044,Business and Pmfeesdous Code:The Contirence.License V
5$ does not apply to an owner of property who builds or lmpmvn thereon,and �� I�OCCCG RES.UNITS
whodonsuchworkhimself orthrough Msownemployees,provldedtbat web
imprournents aro not Intended oroffered forwit.If,however,thebullding Or TOTAL:
impuverentbsold within oneyearofcomplellomtheowner-bullderwBl:, . �)
to ,denai proving that he did not build or improve for purpose of We.). IQTY, PLUMBINGPERMIT. ,FEE I FLOOD ZONE APN
L as owner of the property,am exclusively contracting with 11 it PERMITISSUANCE (^l
rontracton to ronslru t the pmlect(Sec.70K 8uelnex and lkofessiem Code �•!
The Continence.License Law does nu apply to an owner of property w .. 1
Wilds or Improve thereon,and who contracts for each pi°Iect.with a ALTER-DRAIN VENT-WATER(EA) .,
c as Itsnlcensed pursuant to the Contracor:License Law. BACK FLOW PROTECT.DEVICE"FEE SUMMARY',
LJ 1 am exempt under Ser. B k P C for thU xvon PU°S`Q FI'ns
DRAINS-FLOOR,ROOF,AREA,CONTI. SANITARY Y N
Owner Date RECEIPT g
* WORKMAN COMPENSATION DEMRATION 5CF[OOLTAX Y N_ 1
i MI hereby affirm that I have a certificate of consent to self-insure,or a FD(TD/ PER TRAP RECEPT 8 I
a emblote of Worken'Compemation lmurance ora certified copythenof(Seal GAS EA.$Y$'I'FMd WC.I OUTLETS PARK M, Y N
1800,L.b C.) I -R!MEIt0 -
Policy0 I GAS PA.SYSITM-0VER4(EA) BUIL ING DI VI SION FEES I
Cam v
,ioCeNReaupyfahcubyfiamisbed. I CREASE/INDUSTRL WASTE INTERCEPTOR PLANCI IEC FEE
OCreffled copy ts filed with the city inspection division:
CERTIFICATE OF ID(EMFFION FROM WORKERS' I GREASE 7RN' PAID'
COMPENSATION INSURANCE $EyVpR-SANITARY-STORMEA 200117. Date Receipt#
(This section need not W completed If the permit is for one re
hundd d.Ilan
($190)orlesa0 WATLR IiEATFTt W/VENT/ELFO7R Z� ENERGY FEE Y_ N_
I unify that In the performance of the work for which thb perNt b Loved,
I shall not employ any person in any manner so as to became subject to the I WATER SYSTEM/TREA77N0 PAID
Workeri Compensation Lawro of Gllfamla.Date
O Z Appllcan[ NEW RESIDENTIAL PIMB._SQFT. Date Receipt#
Z O NOTICE TO APPLiCANT:If,after making this CemVieste Of Exemption,you
should become subject to the Wureeri Compensation provlslom of the Labor TOTAL: 1
F N Code, u=at fort hwith comply with such revislom orthb nNt shall6el
� _ . Y° p4, P x I BUILDING FEE
deemed revoked. SEISMI _FEE
'LLI — CONSTRUCTION LENDING AGENCY
a0 thereby affirm that them b a comtrunion leadingagency forthe perform- TOTAL:
q WICLECI ICFEE ''yy
7 Z anceof the work for which this permit fe fewest(-Sec.3097,Clv.Q - PLUMBING FEE
(� O Iz.Oder'.Name
LL t- Lender'sAddre^• IQTY. MECHANICAL PERMIT' FEE MECHANICAL FEE
O W Icertl/ythat l have readthb application and statethat theaberve Information FEES PAID:
is count.l.greeto complywuh.B enyand county Ondmarictaindstate law.I PERMIT ISSUANCE
} 1 relating tobuilding construction,and hereby authorlu mpresentathse,ofthlb
N city to enter upon theah.,mentioned property for Inspection purposes. ALTE6ORADD7OMKFL
? Indemnify cad keg humlev the City Of Cu bra Date Receipt# 1
(We)agree e,use, ns a P H Part AIR HANDLING UNIT(TO 10,000 CFM)
O aga1mt11ablWlu,Ndgmcnm,rost.and expense.which may in.nywayacoruc SUBTOTAL:
(.ga m`"ssaId(C/i}''n mmequence of the granting of thb permit AIR HANDLING UMT(OVER lO,WOCFM) CONSTRUCTIONTAX '
3°tg'.ntLrc°f App>ItCO,;.,n� ?n D,«7-- EXttnu$THOOD(w/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the ipplicaut or future bulldinguoupant store.,handle hazardous HEATING UNIT(701 KOW BTU) Date Receipt#
mrterlal as defined by the Cupertino Municipal Code,Chapter 9.12 and the t4,
I JuBh and Safety Code r�SSection 25531(.)7 F4FATING UNIT(OVER l00,lXD 8'M TOTAL: ( _l�W
�YO LJ NO VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
Will the applicant or future building occupant me equlprnent or devkcs
which emit hazrrdous air mnYkMwnb as dented by the Bay Area Air BOILER-COMP OLE,OR 100,000 BTU)
0 Quallly Management DlsMnt
n❑Yes ❑t No
`FFave read the bazallous materials requirements under Chapter 6.95 of BOILflILCOMP(OVIRIW,000BTU)
the California health&Safety Code,Sectiom25505,75533 and 25536. I I _ I�pQ V�,
undentandthaI tithe building does not umently have a tenant,that it a my NEW RESIDENTIAL MECH. SQ.IT APR
napomfbllity,to notify the occupant of the requirements which must be met ✓fiA
prior to issuance of a Certificate ofOcevpancy.
Owner or authonud agent Date TOTAL: ISSUED BY
OFFICE COPY'