22212 (2) APPLICANT TO FILL IN INFORMATION WITHIN REU LINES - USE BALL POINT PEN ONLY
Rvildln I'mect Identification I ��+ PERMI1 No.
Building Address: BV`LID = C s rTl/�� ) 22212
( o7co A3• DFS �� 2r� QWC>, il+--
ne: APPLICA TON SUBML I LALA
I�4- �, 5 CITY OF CUPERTINO-BUILDING DIVISION 31�
Contraja�w�a.s�NJ)ame Lie.NO APPLICATION / PERMIT 1
i•• Archie /1'�B BUILDING ELECTRICAL-PLUMBIv-MECHANICAL
CATEGORY CONII20 �
Lfc.Ni kkaa
97Y1 i ELECTRIC PERMIT t7 r FCC-' BUILD
INGPERMITIINFO "+
4 5 .ti
Address: P ISSUANCE (IV
111
LICENSED CONTRACTOR'S DECLARATION X/�f
I hereby affirm khat l am licensed under provisions of Chapter 9(commenc. APPLIANCES-RESIDENTIAL JOB DFSCRUMON `
ingwfth Seddon 700B)of Divisions ofthe Buslnessand Professions Code,and my J
license b In full fame and died. PANELS sl t r t � CO
Item Class Llc.p l ' �'1�
D,Se Contractor
ARCHITECPS DECLARA ON 201-1000AMi'S _
q0% I understand my plana shall be u.sedas publi record OVEFtl"AMPS SQ.FT.FLOOR AREA E/EQ.FT.
pOp L (�
<�(k Licensed Professional SIGNS ELECTRICAL 011-7
,y-{
Q to OWNER-BUILDER DEC ION
I'n SPECIAL CIRCUIT/MISE
Ihercby affirm thatlam exempt(romihe Co odor's License law for the
following reason.(Seddon 70)1.5,Buslness and I feBsions Code:Any etty or '
TI'MP.METER OR POLElb�aa
Yp� ceya"cluchrequlw it.t..peritmcorutrua,alter, pmversf...tvh,ormit to
anyswduru pdorto its lssvancg also requlrea th pplicant forauch permit to POWER DEVICES
pO o U file a signed statement that he b Ilcenaed pursua to the provisions of the
(d n Contractorb LiceaeLaw(Chapter9(commencing Seddon 7000)ol Divl- SWIMMING L C VALUATION
O aeons of the Business and Prolussloa Code)orthat he m tiherefrore a fid •�
L`Sn^t the basis for the alleged exemption. Any violation of Ion 7011.5 by any OUTLETSSWI ICS• 3 / I
..on applicant for a permitsubjMs theapplicant too evil pe a yof not more than
c live hundred dollars($500). NEW RESIDENTIAL ELEcu .I.7. � //
..�n ❑I,as owner of the property,or he employeca wit ages m the"
aolc p�'�
I 'E CONSIRUC'fiON
t~d¢ compensation,willdotheworkandthestructurc boot int tied or offered for 8 -:Z Sid kV R -Tnw516 .}.
�cO nle(SucJOM,Business and Professloa Cad e:The Contin .Llo law �xll�� I
u �$ does notapplytoanownerof propertywho buildsorimpro .thereon,anti 5'ft Ps KTR 6-(o I•{P ,SSS .exoln> xrs.UNITS
whod oessuchworkhim Adforlhraughhisownemployees,pr dcathatsech
Improvements are not Intended oroffered forsale.If,however,t ulldingor ego f-} He 'iq�
'mprovement is sold with in one yearo!completion,t he owner-buit Elhave r ( - `3� •p 2
thesrdenolprovingthat he did not build or improve(or purpose e.). Q7y, Il+'_'),PLUM GIPER ytr ' 4FEtwp
E'+2 FT.00D ZANE MIN
�I I,as owner of the property,am exclusively contracting with d PERMIT LSSUAN
fon—tracmn to construct the projed(Sec.7N4,Buslnessand Nofesslons e. Si L2$
The Contrador's License Law does not apply to an owner of property wh
btlld. or Improves thereon,and who contract. for such ptojecta with a .D - ATER .. q+.,:
ro,,IlIl�L,ador(s)licensed pursuant to the Contractor's License Law, �,.' I ' FEE:SUMMARY;-„':-
[5I am exempt under Sec. B &1'C for this reason BACK ILOW PROTECT.DEVICEOUTS1 DE FEES
,• Owner Dara
IN HAOAROOF,AREA,COND. SAMTABY Y_ N_
D RECEIPTM
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self-Insure,ora PER?RAI' SCI{OOL TAX Y N
emit uAte of Warkers'Compmuation insurance ora certified copythereof(See. RECEIPT M
3500,Lab C.) CAS EA.SYSTEM-1 INCA OUTLETS 6 . PARK ITS Y_ N_
Policy p RIt=x
CAS EA.SYSTEM-OVER 4(FIV
Cnm any BDILDING DIVISION FEES
ffCert[tied copy is hereby furnished. GREASE/INDUSfRL WASTE INTEtCF7'TOR PLANCHECIC FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID G3�G7-�Q,3 'L{p
COM1IPENSATION INSURANCE S[WER-SANITARY-STORM FA.200fT. Dote Accci Nl �J tZm
(Phis redden need not be completed If the permit b for one hundred dollars ,r--
($100)ar)a..) � Wp77:R HFAITR W/VENT/ELECTR 'Zl J() ENERGYFEE Y_ N_
1 certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner so as to be..subject to the WATER SYSTIN/TREATING
Workers'Compens,tion Taw,of California. Date PAID
ZZ Applf.at NEW RESIDENTIAL PLMB. SQIT. Date Rccai tN
O NOTICE TO APPLICANT:If,after rocking this Certificate of Exemption,you
should becomesubjed to the Workeri Compensation provlsionsofthe Labor �i TOTAL: ..
H N Code, ou must forthwith coin I withauch owlsiom or this ermit shall be {. SEW F_e I-W'T6TA RL 3osa
j seemed revakaa. Py P P BUILDING ITE
LU CONSTRUCTION LENDING AGENCY 2su l�,6 lVtll � ` '1 nes T1333a SEISMIC PCE3 a
Iherebyaffirm that there b a construction lending agency for the perform- TOTA ELECTRIC FEE „ 3eZ
Z anceofthe work for which this permit iseseed(Sec.3097,Civ.C.) Z.IISo
U O derrN,me PLUMBING FEE 2 LSb
LL I- Lende'.Addm.s 'QTY. " '-.MECHANTCAL•PERMIT, ,+` FEE,e MECHANICAL FEE L
OW I certlfythat l have read this.ppllc,tfonand state that me.1, information
a bmrrect.I agree to comply with all easy and county ordianeeaand reale law. PERMIT ISSUANCE (SQ7 FEES PAID:
} relating to building construction,And hereby authorize representatives of this
H N city to enter upon the above-mentioned property for Impaction purposes. ALTTRORADDTOMECH.
L (We)agree to save,indemnilyand keep harmless the City of Cupertino Date Receipt#
V agalat liablitics,Jadgmunts,consand exptcws which may in anywayaccmue AIR IIANDLING UNIT Pro male CFM) (t 0 SUBTOTAL:
,go[nat sa Cityincu Sul of t �� g he t h t -
r�� t , AIR NDNGUT(OVER 10,000CPM) CONSTRUCTIONTAXZCb (Z,
9Y• Is e INIdM
CONSTRUCTION TAX PAID:
nature f p ca / ntrador Dat. EXHAUST HOOD(W/DUCT)
IA OUS MATERIALS DISCLOSURE
Willth a pl nt r future building occupant store or handle hazardous FIEiATINC ( Date RCCCI IA
:cA
aterial de' the Cupertino Munidpzl Col,Chapter9.IZandthe //
and Safety Code Section 25532(a)? ItLTINGU t B TOTAL ?L4C
n Yes M No
Will the a pplicant or future building occupant use equipment or devices VFNHLATIO FANSINCLEI D ISSUANCE DATE
which emit havzrdous air contaminants as defined by the Bay Arca Air
Quality Mawgemcnt District? BOTLE -COMPVA41too.0
PAMNo4hYesrcadthehitru smatemlalarequirementsundr,Chapter6.95of BOILER-COMP(OVER 100,000BTU)
the CMetria
Health&Safer Code,Saef.r,25505,25533 and 25534. 1
staItis
undernd that If the building does net.,,unity have a team that It is my NEW RESIDENTIAL MSCI I. SQ.FT.
ruponsibllity to notify the p.ctof the requirements which it be met ` ` ``�
prior to issuance of a Certificate of Occvpa ney. '� GFI-,L�QS eeYJLa' 382
p- Cil al
UWB�S IbOtLECupp,
OT rcrcr author[uTOTAL,d agent Data �' ' y T DRY.- OF, 1`^'\y��
�C2<=S_e7• �I S/e SSU�:
OFFICE COPY