22648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulid[nA Proert Idemi(irstian PERMIT NO.
Building Address: r�
6 5 I R�►CE 'D� 22648
K ,�..L� _roe. CITY OF CUPERTINO-BUILDING DIVISION /f'� l�i` t� '
e t oe'sName: Lie Na CONTROL.
APPLICATION / PERMIT `C7 lfl
r S BUILDINGS,ECTRICALPLUMBINGMECHAMCAL CATEGORY
Arehhea/ ginter. i Lie.Nce
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PSthOTISUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
a(flrm that lam BcmeedumerprovWom of Chaptes9(mrrvnm APPLIANCFSRFSn)EMTAL pg ROm
ingwith5 n7000)af Di .3oftheBwl¢usnd Prol ..Codgand II
liee.isinftu-f. ameffect. P,vms tiP0.�(- �0.TL0 £j,/UO�Vf
Lkenc Cl+p LILY y
DaleI'��e Contractor :_ . ',^�� Z.S�,x 1E (•,}tj �j 1 q p
ARCHITECT'S DECLARAMN 201-1ODO AMPS
fou a0o Z I uMer nd my plain sham be wed u public recmda OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
FrLicemed Pmfeabnal SIGNS ELECTRICAL LED IN
«<< OWNER-BUILDER DECLARATION SPEQALCIRCUI.I.
/M1SC
NST.llowinIherebyafBrmihat l am exempt from the Contractor'sl,i¢nse Law for the UTE R
FO fog mum.(S dim 7O'315,Bualnm and l Pmfmm Code:My dtyor TII'8'MEfFR ORI'O1,E]
Z c ntywhk requlraape Wmmtm"ter,Impm ,dem lWh,ormpar
YSYQ a nyatm=mprlortolb6 amgaborequ4 theappbantforsucnper wCO f /file a signed statement thrt he is 11¢med punoaot to the provbbm of the me DEVICES
�Ouu.G Contractor'sLice.Law(Chapter 9(cu.eing with Sectbn 7000)of fhv SWIMMING POOL ELECTRIC VALUATION
O ebn3of the Buslnm and Pmofmlou Cmde)orthu kris exempt therNromam 5O
SSI S the basis for the alleged ezemplbn. Any vidatbn of Seabn 71315 by any OUILET&SWITCHESSFDCNRES d Ov
<^ app0mntforaperrd bie theappWanuuadvflpemhyofnam mtl n
favh hunci ldebuts MM. NEW RESmEN IAL ELECTR SQ}7. STORIES M'ECONSIRLCTION
�n u I,as owner of the property,or my employees with wages as their sole
��j rompematlm,will Bothe wwkand theetmctarcbnatlMerred or offend(or
F� sale(Sec.7014,easines,am Pmfesbro Cmr.The CoMnctots Ll¢me Lw
dm
5^
who dwoessuch wtoorakMowmeeeeBr oofrighromwpegh Mit vownemplovrylemg.provided that
rovdmthatsaundd
OCGGROIIP RES Ilfi7-IS
improvcmew are eat Intendedoroffered for idea If,however,thewllding¢ TOTAL
impmvemembaaldwhhinomyearofcompleH theownerb Merw l w
t mden a proving that he did not wild or Improve for purpose of ula.). QTY. PLUMBING PERMIT FEE
L a owner of the property,am excwNely contracting with 11¢med FLOOD ZONE APN
ronmetorstommtmet the pm)ees(Sm70K Bwinesard Profmlam Code: PERMIT ISSUANCE
The Comractori Lieeae law does ea apply to an owner of property who
Wilds or Imprwu thereon,aM who mmncts for such p5a)em with a ALTER-DRAM&VENT-WATFR(EA)
qnza,etm(a)urenael pursuant to the Coommra Lice.Law. BACK FLOW PRQI'ECf.DEVICE FEE SUMMARY
LJ 1 inn e:<mpt under Sec B 6 P C for this .. OUTSIDEFEES
Owner Date DRAINS FfUOR ROOF,ARPA,COND. SANITARY Y_ N_
WORMAN COMPENSATION DECIARATION RR8=Krm
❑I hereby affithat 1 haw a¢rtiBeate of consent to self-Wu �¢,or a STRAP SCHOOLTAX Y N_
RECSPT I
¢0,Lao/Workers'Compemationlmunn¢¢a¢rtBled mpythemeo((Sec. GAS IA.SYSTEM-I INC4 OUTLETS PARK FFR Y N
Pette lRECEIPTabb C)
I'ollcy♦ GAS EA.SYSTEM:OVER 4(FA)
Com ray BUILDING DI VISION FEES
cradled ropy b hen with tis Ned. � GREASE/INDUSTRL WASTE INTTRCEPTOR PLANCHECKFEE
CertNN copy h/lied with the tlty ImpMbn dlWalm.
CERTIFICATE OF EXETI PE ION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER. EA 2DOFT Date Remi tit
(This serbon nem not be completed B the permit Is/or om hundred dollars
($1OO)Of1tb WATER HEATER W/VENT'/F7DCTR ENERGY FEE Y N—
I ¢rtuy wt b the pertem,.n¢of welt brwhlct,this,pem,B l.l.ded.
I shag not employ any Perm,to any manner so as to become eubjM to the
Workers'CampenutLawsn Laws of UlHornbwATFR SYSITY/TRIATINn.Date PAID
—
z
Z Applicant NEW RFQDFNTTpL DIMS. SFT. Date Recd Hf
NOTICE TO APPLICANT;If,after wrtifica
er milking tCertificate of Excmptbw
n,y
should neeenere sub)ect to the wodieri Compematbn provbbm of the Tabor TOTAL
~ N mo
Code,you at fort hwacomply mply with auch provbbu or this permit shall
2 — deemed revoked. BUILDING W CONSTRt IONLENDINGAGENCY SEISM] FE
CL ]hereby afflrmthet then Lsammtmctlm bmingege�y bathe perrnrm- ELECTRIC FEE
M Z an¢oftheworkforwhichtwpernhb Wiled e3097,Civ.CJ
TOTAL:
U O lemers Naine PLUMBING FEE
IL F Lemc/s Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW I¢rtlfythnlbuw madtwappllotbnam aateth.rttha above ln(omvHm
1 bect,cm Icgn tocomplywkhaBckyammuntyomdimnmad etatelaws PERMIT ISSUANCE FEES PAID
>- 0. tobalWing mmwMm,and hereby authorie representatNes of this
Z cllytoenteruponthe awve-mentbrud propemtyfor Wb
pectn purposes. ALTFRORADDTOMECH.
V _ (We)agree to saw,imernni/y an d keep harml the city of a bee Date Remi tp
agalmtllabi0tfes,' gmew,mes ea Ick may banyway;M AIRHANDONG UNIT(IO IO,000CF'M) SUBTOTAL:
egaiut Wd a kgra ge,twpemW.
". Z af/ AIR HANIRINc uMT(OvEe la,000cFM) CONSTRUCTION TAX
SgAittuh, f0phgqnnt/ traetor Die�iAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HA]ARDOUSM ERIALS DISCLO RE
W01t cappocantorfuturt wlldingo pantseoreorhamlehavrdws HEATING UMT(M 1ODSOOBTU) Date Recel tH
restra a defined by the Cupertim M.Ndpal Cade,Chapter 9.1Z and the
I Ieslt,ao Safety Codlre�-Sectloon 25532(.)7 HEATING UNIT(OVER lm'"BTU TOTAL:
WBltheapplkammfuturebolldingoavpant..c qulpmemordevl¢a VENTILATIONFAN(SINGLERFSID) ISJIANCE DATE
which cnJt hanrdws air mntaMmrus u defired by the Bay Area Air vp��
Quality Ma"gemem District?x2 BOILER-COMP(3HP OR 100, BTU) R�w'i
Yee ❑No
� l have read the M1arallow nuterlala requirements underChapter G95 of BOILER-COMP(OVER100,000 BTUs a!
•the CaIff.eHealth&SafetyCme,Sectbm25505,255M.nd2-5SM.i Ni� 0 ��s7
_, umastam ttitif thewllding don of mrren0y havcatevnt,that itbmy NEW RmDFNTIAL NECK. SQ.FT
rmpomibBity,to rally the oaupam d the requirements which most be met Mas,-_ _
prbau
rto lsslmyat�¢ a Certifeate.fOp.ny. W711
�\ fWLJ�6�m�W/tlp
lTv�Kr or�N¢Ivad dgent I
Pat. TOTAL ISSUED BY:
OFFICE COPY