22293 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
buildingad Pm Idemlfleatlon PLILWT NO.
Bu�bg Address 22293
X54,4 . Goo Elf 31VD,
IUv,, lIiA" 152 -X&C, CITY OF CUPERTINO-BUILDING DIVISION
traamfs Na
APPLICATION I PERMIT
sE/Go '� 9� CATEGORY coNrxa.t
AmMtea/Englm . Lie Na BUfI.DINGELECTAICALPLUMBINGMFTHAMCAL
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Addma-.21.51STc4d AV • T44-1ose- PERMIT155UANCE
'LUMU At
LICENSED CONTR ACTORS DECLA RATION D El ALJ
I hereby affirm that l am Ecen ruler p,mist sof Chaper9(commen APPUANCESR6SIDFNHAL
bgw(h Seabn7MO)o(Dlvlslon3oflhe B.M.a ProfmlonsCocie,and BD6C N
lianas le In N forye�^d d(ea. (1 PANELS
UP TO 200 AMPS
LlvrueC ^rf J Lka L
Dante- -,-r—Corrtra,
R
ACHITECTSDECLARAT 4, N 701-1000
p�vOQZ Iundemard myplea.helbeu.eci asp.1,kremtda OVERI()00AMP5 / .LEAREA D $/SQ.FT.
!i Ltanaed Profmlonal S)GNSELEC RICAL
«<<< OContractor'.NERBUILDER DECLARATION U T E
F. Z IM1ercMm
hereby tlutlam xemptfrom the Contractor'.or's LloensLaw w(a S'ECIALCIRCUITIMISO
the M P
qq martyngreasae.gireWon saprmitto slnuandPImprovmCode:Mydtyor
y coup hkh ion• rmlltommhv aniP f 1o.Co e: TEMP.METE3(Oft POLE INSI.
FS� tyw requires pe d. P or 1,or ^-
anyanmaurepdarmltahe bt,e,sbor pursuantines the to
rovignofpermit e POWER DEVICES vA
O
file a dgned elee trent than he b Ilamed pursuant t the Section
of the
y, Con3ofo LlcemeLaw(Clfpt (ode)ordngwllhmmpt7(100)of Dtvi�
marui
1.,30 ebn3ofUr Butlnessand Profenbm Code)orthan hehexempt thereOomaM SWB'fMINGIWLELECTRIC
VALUATION
S" the bola for the alleged exemption. Any vlolaHon of Seaton 70315 by any
appheant for a permit aublecta the applicant to a civil penalty of not more than OUDETSSWIICEESFIXIURFS
By ndreci dollars(E50).
..�, Lf 1,as owrcr of the property,or my employ.with wages as,their sole NEW RESIDENTIAL ELEC7R SQFr. STORIES TYPECONSTRUCTION
eumpenselon,wlll do the work and the stmoture is not In 1Moi or of rr d for
5 0 aakCkc.70K Buanceand Prof®lom Code:The Contmaoes Uoams,l.aw
016 does not appy to an owrcrofpropertywM bulkia orlmpmvnth<reon,and OCC,GROl1P RFSUM75
as whodoeeaurhworkhl lfe thr ghhbownemplay.,pm Wedthatwch
Improvemenla are not Intended oro(femd fa ask.If,however,thebuMing or TOTAL:
Improvement I.s dcl withinoneyearofcompletlon,the owner4budderwW have '
t den of proving than he dol not bud or lmpmve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
L es owner of the property,am exclutwely mntraaing with lloemed
coPERMIT ISNANCE
ntractors b mmwd the pro)ea(SecN,70Businees sb
and Prefem Code.
The Comnao/s L4erse"w don nor appy to an owner of property who ALlyg-DRAEJ&VENT-WATER(EA)
lellda or Improves thereon, and who comnm for such p(okm with
+dor(a)Brensed pursuant to the Contndo's License Law. BACK FTDWPROT'EST.DEYICE FEE SUMMARY
U 1 am exempt uMer Sec B k P C for this reason
OUTSIDF
DRAINS FLOOR,ROOF,AREA,OOND. SANITARY Y N
Owner RECEIPT#
WORKMAN COMPENSATION ECL conseRATION FDnIJRFS PER TRAP SC1400L TAX Y N—
❑1 hereby eft.than I have•txrtl0ute of consent to seB-inson,a a RECEIPT
reaBimte of Workers CanpemaHanlmuranreaaadlfled ropy thereo(6ec. GAS EA.SYSTEM-1 INC41 OUTLETS PARKFFR Y N
3gPut
b Isis C.I
Gma GAS EA.SYS OVER,I(FA) DING DIVISION
,_fa�Y - BUILDING DI V IS10N FEES
SIC ttifkd copy Is heref1tol fumlahed. CREASE/INDUS[RL WASTE INTERCEPTOR PLANCHECK FEE
�CertBied ropy b(fled with the dty Inspection division.
CERTIFICATE OF EX EM PTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONINSURANCE SEWERSANTTARYSIORM EA.700FT Dale Reed 111
(This session need rad be canpleted B the Permit b/more M1undred d.11.
momatha WATERHFATERW/VFNT�ELECTR ENERGY FEE Y N
Irertiythan tithe performance of b
o(the work for which this peJtfsvad, —
I shaIL not employ any penson in any manner n sato h w 9ubjea to the WATER SYSTEM/TREATING PAID
Wakens' eon o Cell Is. Date O�{�
O Z AppIL � I"L NEW RESIDENTIAL PIMB. FT, Dale' Recei lfl
Z O NOTICE AIIIICA 1.11,after mXng lhb Certlftrate of Exemption,you '�
should become sub}et to the Workers'Compematlon provlsmm of the Labor CC TOTAL-
CC N Code,you mostfatM1wdm
h mpy with sueh provbbrs or this permit"I be '
] .deemw
ed reked. WILDING FEE
CL W G CONSTRUCTION LENDING AGENCY SE MIC FEE
I hereby afllrtn that there is.comr.erI.leMbg agZy for the dorm
Z arm of the work/or whkh this pernNt b lswed(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
(,) O Tenderi Naar PLUMBING FEE
LL ~ Lerdcre Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1artifythat l have mad thbappllodbn arul seethe lheabove Infer
mtlon �''3 FEES PAID-.
b norma.I agree b comply wtth all city and county ordbunm and state laws PERMIT I$T)ANCE .a.�
} 1 relating to building corutnualoryabu herebyelthorlu representanNn
Z city to enter upon the abov ftrcntbned property for lvpeabn purposes. ALTER OR ADD 70 M. Date Reeei tM
V — (We)agree to esus,LdnmNy an d keep baronies,the City of Cu pen W
against llabBitles,P dgments, rd P r.v,hkh.ybt.y,v.y..e AER HANDLING UNTT(TO 10,000 CFM) SUBTOTAL:
.gall t ecirybmn a oftUng of this permft. AIR HANDLING UNIT(OVER IO,iltal ) CONSTRUCTION TAX
igneture of Apphant Contras Date
Date / EXt-soar HOOD(WiDucn - CONSTRUCTION TAX PAID:
l,AZARDOUSM TMIALSDISCLOSURE )
Will the appBont or future budding o pant store orhabule ha:arduus t HEATINGUMT(T010D,0DOBTU) lY Date Recef IN
material as deBmd by the Cupertino Municipal Code,Chapter 9.17,and the
He.hhaod Safety Code Sealon2S537(.)7 HFATING UNIT(OVER 1W,"BM TOTAL: t v
❑ Y.
Wlllthe.ppllrsma tumbu0ding onvpant use equipment ordevkcs VEN`I ATION FAN(SINGLE REBID) ISSUANCE DATE
whirl,emit hasardous.k couamWntsn deBrad by the Bay Ams AIr
Quality Mavgemem District? BOILER-COMPOM'ORIM(a)( TUI k—"j :
:
Ye, RLN
have read thahvtM.•matedab tequiremrnEs under Clopper 6.95 of BOILER-COMP(OVER IOO,OOD BM JUN 0 1111
the California I Icahh A Safety Code,Seabm 25505,75573 and 75534. 1
understard n that it the building donot eurrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT "C
rapomiblky to roily the pm of the requirements which must be mitt
u ra 0, 1 cited panty.
ofCCupps�rt;Ql
(Tuner a authorised agent Date
TOTAL ISS(IED BY
OFFICE COPY