22701 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Wentlfbtl® PERMIT ND.
Building Address:z l I lcomey • 22701
�� �111 �= L7F�: one:
c) CITY OF CUPERTINO-BUILDING DIVISION
Lk.Nn APPLICATION / PERMIT
ArthDect/Fngircer. Llc No: BUfLDlN ELLCf1UCALPLUMBINGMr.CHANICAI. CATEGORY CO
BUILDING PERMIT INFO
- QTY ELECFRIC PERMIT FEE
Address:�� peW� -[I CUI�eRIUO PERMITIS5UANCE
LICENSED CONTRACTORS DECLARATION
lh mbydfbmthatlam Bcmaedurderpr Wb OfChapter9(mmnlrn APPLIANCE JOB N
ingwlth Sedion 70W)of DlvWon3ufthe Businessand ProlessionsCode,and my
If..In in fifflzf2F.and eff Y. ay PANas
• LI¢ C Lk./ Cl C�aFpw Dale Contractor
ARCHITECTS DECLARATION 'A•M�
pQ+02 Iunderatanderypleashal3beuwdupubbc muds 1000 AMP$ SQ.FT.FLOOR� S/SQ.FT.
E�� Lbeved rmfesolovl SIGNS EfPCfRICAL ��� aL_58
• <«<�< OWNER-BUILDER DECLARATION
IherebyafBrmthat l ame.empt fmmthe Cmdradora Lkv
ee Lawf¢the SPECIAL CRtCUIT/ . 'a O �/�
q folbwbg reason.Patio 9(015,Bushes ant Profmbnn Code:My dry or LJ�► (�j
r•9C� muntywhl rh qui apem tows d,eter,lmpn dennlbh,orrepdr ��' RPOLEINST.
,55��7 a nyatrununprbrto Rabeva alaomrybatheappUu ifmm pcmdt to GFS
O0.s Ole a signed statement the h h licensed purmant to the pnwis of the
+u,� Contradah lJcenu l�w(Cluptrr9(mnurcndng wlrh Seabn 71100)of Dhl- hg NG POOL F3RCI'RIC VALUATION
F�OQ don Wothe Business and Pro ptbro Any lrthahrb Se<mpl theref70315 by and ���
4 �'•a the bests for the alleged evemptlan. My vldatbn of Section 7Q)15 by my
Via+ QOM appliontfora perMt wbjectslheappBcwtroa dull prvlty dnd morarhun 0[TILE]SSWITCHFSFP'ITJRFS `
E g rave hundred ddlan(SSM. NEW RFSIDENIALFT TR SQXT. STORIES TYPE CDN'"TRIICTION'
❑1,as ower of the pmperty,or my empbym with wages an theb wLe
NX pcvation,willdo the work,and the strudu¢b nes Wended or offered for
1< sal-;77'Z Buslrcas and Pmlembro Code:The Contradoe.U.law
Sg docs not apply to an owner d property who beIWsor improves the.,and
^ who doessuaworkhlmrelfmthrough hisownemplryov
ees,prided such that
VNITS
impmvementaam rotlntendeloroHereelforsale.ILhowever,thebuildingor TOTIL:
improvementbw)dwlthinomrardcunplet mthea er-b Werwlllhave TER
tF-I bmorpmsdng rear h<am rorbnua or bnprweforparpoaeefaae.). QTy, PLUMBING PERMIT rN
4 u
owner of the property,em eecluawcly omtrading wish Oceved PFRh1R ISSUANCE I
mntradm to construct the pmjed(Sec 7044,Business aN Profession Code: 1J'
The Contractor's Ll¢ve Taw dm not apply to an owner of property who AL7II2-DRAIN&VINE-WATER Mk)
Bds or impnve therton,and who mnvnns fee ouch p(ojrcv with a
-x4acter(a B¢nsed wmnant to the Ccntradora License Law. FEE SUMMARY
Ll I am exempt antra Sec B&P C for this reawn BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,CONT). SAMTARY Y_ N
Owner ECL RECFIFI'#
WORKMAN COMP F3JSATION DECLARATION TION FD(�S PER TRAP SCI O TAX Y.N
❑1 herby•/Orrn that I have•¢rHfl¢te d rosrnt to self-Neurt,a a RECEIPT 0
¢00,1.bofWorsrn'Cornpevadmlrouran¢as¢rcHled coythereof C:ec. CAS EA.SYSIEM-1 IN'C.4 OUTLETS PARK FTE Y N
P. / `�%Y GAS FA.SYSTEM-OVER4(FA) DINCDRJECEIT1'Y
CoCram ied py 6�1�.�i4T/ /rim BUILDING DIVI510. FS
CertiO copy is hereby tumbhed.
eGREASE/INDUSIR,WASTE INTERCEPTOR P HE
CrtNed py
mbfiled with the dtylnpedbn dfvWm. ^ ,
CERTIFICATE OF EXEMPTION FROM WORKERS' CRRA.SE TRAP p ✓�
COMPENSATION INSURANCE SEW F.ILSANfI•ARY-STORM EA I(IQ•7, ate I I#
(fids section need rad tr eompleted if the permit b f¢one hundred dollars
(SIMorlese.) EN RfpC N
l¢rtlfy that b the pedoman¢of the work for which this permit is Weed, WATER DATER W/VENT/FLDM
1 shall not employ any person b any manner w as to become subject to the WATER 5ISITM/TREATING �\
worter: w
Compensation Lawa of CamoU.Dae PAID
PP NEW RESIDENTIAL PLMB. SQFr.
A llcant
Z ZO NOTICETO APPLICAtothe ager rs'Comweelon pre ,[ Exemption,of the
Date ecci tis
ahold become subjcYbthe Warkeri Comperortbn provhbro ofthe Labor 'I' l
~ _y Code,you nvat(¢thwlth comply with each pnovbbv orthh permk shah be
LU ] deemed revoked.
W o colvsleretsa n LENDING AcwcY EISMIC FEE
CL e of the a(firtnthat hthammtsuctlsu hi ding agency lorthe pedorm E CFEE
� Z area of the work(ar which thio perntltbbmned L5ec 30ff/,CW.CJ TOT
O O Lender's Nam NG FEE
IL I- Leruler'n Address Q7Y. MECHANICAL PERMIT FEE' C ANI E
O W I¢dlfythalhaveread this appllarbnaM statethattheabave lnformaOm
bcormet.Iagree to comply with all dryaM county ordloanm and late laws PERMIT ISSUANCE S FEES
} U) relating to building ismadion,and hereby eathorbe represn ntativof thin
N dty to enter upon thr co above-membrcd property for Wpectlon pe rposes. ALTER OR ADD TO MDCH.
(We)agree to uve,Indemnify an d tcep harmim the City of Cu pert bro Da02Apt#
V agalral BabWtle,ydgmew,cosrsaM nape rtuyinanywayamus AIR HANDLING LIhITf(TO 10,000 CPM) SU OTAL:
agaitut said Citybcove oft gdthls pemdt.
AIR HANVL1NG UnTr(OVFR l 0,=C") Cop ON A
Sig u anl/c�a der Det WiAUST HOOD(W/DUCT) CO TRUCTION AX PA
M(/ HALCRDOU ATERIALSDISCWSURE
I theapplkant or future bui3dlng a pant Blore or handle hazardous HEATING UMT(TO 100,000 BM Date ecci
material as defined by the Cupertiro MuNdpal Code,Chapter 9.17,and the
Heahh and Seery Code Section 755376)7 HEATING UNIT(OVER 100,000 BTU)
ca
Yro No
Will the appll¢nt or tore Ina
«spent use equipment or devices VIN'IILATION FAN(SINGLE RESIT)) •ISSUANCE DATE
whkh rent hazardous ab oomend ants as defied by the Bay Area Alr
Quality Management ddtrkr7 BOfIFR-COMP OHP OR 100,0D BT[q PA ' D
4Yn No
havcmad ea haa�materials Seeequlremenb under Chapter G95 of BOfI.EiLCDMP(OV6t 100,0m BTU)
the GOlomV HeaDh&Safety Code,SMbro 75505,25533 and 75534. 1 � •
uMrrNardthat If notify
theoecdm not a requirments tenant that It boy NEY•'RmDFNf7AL Iv¢CH. SQ.FT AN 10 1992
mapovmWtyto n¢Bytheing pamdoes of the mntly have wench mass brmetsm
prior to Lmnan¢d a CertiO¢te olOmvparscy. CITY
OI CUrtHII1VU
Owner or authodud agent Date
TOT ISSUED BY: '
OFFICE COPY