22189 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USt !{ALL FUIN 1 ren VIVLI
BulMin Project Idenlllttalon p10 -{ PC) PERMIT NO. 2
219
RCr �E 1 MA-NCr"d (40S) o2S'1• -9 o Y Cr) q5oiq 8
nen ares. we. .
O Ar'7m E_aS MNSO11 R4 # 3ofF0'-F 4 CITYOFCUPERTINO-BUILDING DIVISION
C.ntr.dai.N.me: Lta.Na: APPLICATION / PERMIT �n 1
BUILDING-19.P.CTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL a
Archited/Engineer: LIc.No: _
- run. BUILDING PERMIT INFO
QTN %�, EI.EQ'1'RIC�'R A�1' " _ REE ` a,—y
Addreast PFRMITISSUANCE y N__1 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under Imebalcnsol Chapter 9(mmntene APPLIANCE-RESIDENTIAL )ON DESCRB'710
Ingw[Th Section7000)of Dlvie.3oflhe Bue[nemand PmfesslonsCode,and m
Iken.is In full loneand effect PANES
License Clam LILI ��
Dale Contadar
ARCHITECT'S DECLARATION 201-IODOAMN — .
OVER 1000 AMPS 3/ .EI.
7. I understand my Alam shall be used m public eemrd.. N
{`{`0 Licensed Profemlonal SIGNSELECTRICAL O �I n T
O Z ER
OWNERex ELDER DECLARATION 51'FGULGIRCI3IT/MISC 'V' g�
T., Thereby dorm tOWNE -BUILDERxempt the DECLARATION
Llanse law for the
Z following moan.f5edl.n 7M115,Balnese and Pro(emione Code:Any city or TEMP.METER OR POLE INST. g�
C~p county which requ lees+perrrdt to mmtmc%alter,improve,demolish,or mpalr
�a[[ any structure prim to its Wus me,also requires the applicant for such permit to POWER DEVICES
C file a signed statement that he k licensed pursuant t.the Provtilon of the
Qq C.nlrad./.License Law(Chapler9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC VALUATION
sO slon3of lM1eBu.lneu and Prolerlon Code)orlhal hekeaempttherc(romad
15 S2 the basis for the alleged exemption. Any violation of Section 70X5 by any O(TILETSSWITCI B'S FIXTURES {iZ
6n applicant for a permit subjed@ the applicant to a dvll penally of not more than
5 five ho nd red dollars(S5011). NEW RESIDENTI Al.ELECIA_SQ FT. SIOWIS 'TYPE CONS IRUC IION
I,.s owner of the properly,or my employees with wages as Their sole
compensation,will do the work,and Ihestruclurc Is not Intended or offered for
Onee le(Sec.7W{,Business and Profrm[am Cade:The Conlradoes License Taw _
B dors not a pply to an owner dpmprny who but Ids or Improves thereen,and _ OCC.GROUI' HITS.UNI iS
soh roveeeuch worn t Ine=If edhmughedsowne.If,however,
owe provided that such
tmpm,anmrA arcnot Intendedorolfered Ireale.ILhowever,thebuildingve TOTAL:
ImprovementbwMwahln oneyear b:lmis[dllmt pefmpuullderwill fuhave
Kids
enol proving lhrt he did nol6ulld urlmpmve l«purpose olakd. QTY. PLUMBING PERMIT FEE p,00070NE AI`N
a owner of the properly,am exclusively contracting with licensed pIRMIT ISSUANCE
I
to contend the project(See.7014,Dust..and Profmioa Code:
lndor'a License Taw don rod apply to m owner d properly who ALTER-DRAIN 4 VFM-WATER(EA)
r improve@ therson, and who contracts for such pco)ed. with a — FEE SUMMARY
< ador(s)licensed pu nano to the Contractor's License Law. BACK FLOW PROTECT.DE VICE
IJI am exempt under Sec. B A P C for this reason
/— DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Uccle RFGEIT{
WOR MAN CL
PENSQ. ION DECLARATION
IDOL TAX Y N
Of hereby affirm that I have s and Ikate of concent to sell-Insure,or• FIXTIIRFS PER TRAP RPLFRT s
certificate of Workers Competwllon lesunnceora certified copy thereof(Sec. GAS Fit,SYSTEM-]INCA OUTLETS PARK IFR Y_ N
3800,lab C.) RECEET a
P.1 icy T GAS-EA.SYSTEM-OVER t(EA) BUI L131NG DI VISION FEES
GoreP+ny
1-1 Certified copy 1.hereby[..[.had. CRGSC/INDUSTRL WASIF.INIFRCE'TOR PLANCI I ECK FEE
Cerllf[ed copy le filed with the city Inspection division.
CERTIFIT:ATE,OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTARYSTORM FA.2001-7. Date Recel till
(Ihlaedion need not becompleted llthepermit leforone hundred dollar ENERGY FEE Y N
(SIM)or lea.) WATER 11EATER W/VENT/ELECTR
I certify that In the performance of the work for which this permit la Issued,
I shall nor employ any person In any manner so as to become subject to the WATER SYSTEM/TRrA11NG PAID
Worker CompenuttonlaweofCatlfanla.Date
Z Z NOTmaking
RT:cei UI
ICE 10 APPLICANT: aking this Certificate of Exemption,you RESIDENDAL PLMB
NFW ._SQFT.
O should become subject to the Workers'Compensation p.vblons of the labor TOTAL:
F N Code,you must forthwith comply with such provklom or this permit shall be
K j deemed revoked. SEISMIC PEE
W CONSTRUCTION LENDING AGENCY
d Ihereby affirm that them is a construction knling agency for the perform- TOTAL: ELECTRIC FEE
Z ante of the work far which this permit is t xued(Sec.3097,Civ.C.) PLUMBING FEE
L.1 O lander'.Name
IL F- [ender.Addreas p7Y. 'MEC/IA(VIC�LI.PERINI'�, • REE MECHANICAL FEE
O w Itertifythdlhave read this appilallonadMate rhattheaboveinformation FEES PAID:
k correct.Iagree to comply with all city and county ordinances and Mate laws PERMIT ISSUANCE
Q. relating lobullding construction,and hereby•uthodse representatives of this
>. N cit to entero n the tbovemenlloned r1 ler Inspection AL9ERORADUTOMECIL
F Z y po keeps Ypurposes. Date Reccl tR
(We)agree to save,Indemnify adkeephmmdm the inceity y ayaccc. AIR I[ANDLING UNIT I I00 CFM)
V against liabilities,Judgments,colla and expenses which may In aywayaccaue SUBTOTAL:
.g.wT ami City b ...q.ence of the granting d this Fame). CONSTRUCTION TAX
y�,/-��� L/= AIR HANDLING UNIT(OVER IO,OWCPMI
"`�`' "'�'9'']" �-I- E(1lAusrn(xntw/D(xT) CONSTRUCTION TAX PAID:
Signature of Appllanl/II ontndor D to
HA7.A DOUSMATF.RIALS SCLOSURf
Will theappliant or future building occupant stareor handle h..rdoua FIEAiINC UNIT(TO IMI,OW OTU) _ Date ReceIPta
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I kelth and Safely Code a Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
T�1 Yro (_I No
Ilithe applicant ar(umre building ompant use equipment or devices
VENTILATION FAN(SINGLE RESIU) �1$Su�NCE DATE
=� whlchemil hnad...ir cons+Mnanlsade0ned by the flay Arra Air g0(LER COMPp11i'OR I OO,WO BTU)
QudOy Managentod Distrk17 ,"/
❑Yet ❑No n
(have rO.dth,haardousmalerlabmqulrenent.under Chapler6.95o1 BOILER-COMP(OVO(IOO,DMIJ 1) {� lJ9
the Ullfornla l lealth k Safety Code,S dloa 25505,25533 and 2553{. 1
understand that tithe Wllding doanot mrrenlly have a lenant,that 11 Is my NFWRFSIDPNTIALMECI i.
rmponsihtltly to nollfy the occupant M The requirements which must he met
prior to Issuance of a Cerllflcalr of Oorupancy. _ (((\''-""'�}������,,,...a
Ownrr,nr aulhnrlmd agrnl Wt. '—' ISSIR?D BYE
TOTAL:
OFFICE COPY