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22365 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —. USE BALL POINT PEN ONLY jBuildin PmW ldenHfbation - I'FILWTNO. Bulldingzdl�� , S La�{e0012. 6, )Tj- 31 "G E 22365 r. .me. one. CITY OF CUPERTINO-BUILDING DIVISION . emtnao .Name: LlcN. APPLICATION /PERMIT '2-q Lie Na BUrLDING-ELECIRICALPLUMBING-MECIC HANAL CATEGORY CONTROL/ Architect/Engleeen Q ELECTRICPERMFF FEE BUILDING PERMIT INFO Adtlreaa PERMITISSUANCE ❑ ❑ 5 El' LICENSED CONTRACTOR'S DECLARATION I hereby aHlrm that l an,lumosed urder provision,.(Chapter 9APPLIANCFSRESDEN71AL �' V"a. N Ingwlth Settien 7000)of Division 3 ofthe Bustneeeand ProfeesionsCode,and my - 6 II¢rue a In fuB d effect. ^ PANELS ✓ �Ind / LI¢,se Clam Lice � —i DJ IG/' Date Coritraaor_A1'..`�'p RATION ARCHITECTS' ECLARATION - AMPS q�q�ry¢O Z2. f uMemtand my phresshalthe owd as pubc nerds. OVER 1000 AMPS !�SQ.FT.FLOOR AREA S/SQ.FT. Fi LI¢rued PN®lrvl SIGNSELSCIRICAL «<<6 FLAu OWNER-BUILDER DECLARATION SPECIALCIXCNT/MISE OZ029Il ML.G J Z Ihercbyaoflwtlutlameaempifmmthe CordradoraLberuelawfathe o Q frilowing recta©.6calon 70715,Bushes and Proferbv Code:Any dty or �er✓�le• son which hes« rnat tomsarru alter, TEMP.MEIFR OR TOLE INST. ! e ty requ pe 4 prove,derroWh,orrepdr _ 4 6 any at rudunpmeemnbhat he alliamna,d pursuant provisions the POWER DEVICES ��aL L"C a V Ilio•afgned statement that he h r9(.cud p acing it the po.7") sof the - Q Contndos eve Lw Cuphr9(mmnendngw with dines 7IX 0)o(Dd- SWIMMING POIN.ELECTRIC Mona dthe the A hand Pmlesbrt. My virllut M1ef exempt therefrom and VALUATION �"_ the basis for the Maged jee Chimp Uc t t..del p Section rot r by any L E D fi6j dmddoermitmbjedstneapplbanttoa d�llpavh7'dnd moreuhen OUiLEP'S4VfICI�SFIXTURFS C. flv�hlmdrtd dollars �^�n u I,a owner of the property,or my empbym with wages as their sole NEW RE9DFNI1'\L Fd'ECIR SQ'M17' CONSTRUCTION compensation,will doth wok and the ntm=m h cot intendd or offend br sale(Sec 7010,Rustem and Pr fi sines Code:The Coneradot•tAm.Lw ( $ does son a pply to an owner of property who holds or improves thenoq and 0. whoit..6 work himself or through his own empiy.,provided that such IN tmproaemeM m mt btendd aroffemd for sale lL however,the building or TOTAL: UnproverrcM bsdd whhln oreyearofcmrpldbn,th<avner-builder will have tfajZurdenol7provingthathedid nmtbulldorimproveforpurpoaeo(aale.). QTY, PLUMBINGPERMIT FEE FLOOD TONE ApN- ,. L as owner of the property,am esclu•ively oor r g with lirenad mntractoa to mrotrutl the project(Sec 7011,Business and Professions Cdr. PERMIT ISSUANCE The Contnawri Lloas Law does not apply to an owner of property who ALLIIt-DRAIN kVENC-WATER(EA) builds or Improves thermos, and who mntnm for nuch ptoje_ with a niWractor(s)B¢nsd pursuant to the Contnaar's Limrue law. I1AaC FLOW PROTECT.DEVICE FEE SUMMARY LJI int r exempt uo,! Sec. B h P C for this mason A DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N n[Frq.11r,FEES Owner Data RECEBrT WORKMAN COMP aN5AT10N DECLARATION FDI�S,PER TRAP SCI100L TAX Y— N 1 hereby aHlrm that have•¢rtlfl¢te d<oruent to rlf-Iwrc,or a 3 ed Worken'Compematlmlwran¢aa¢rtl(led mpythe�mf(Sec. R_ N 3800,Lab CJ !! GAS EA.SYSTEM-]INCY OUTLETS PARK FEP Y— N_ mhya TC.2—G9 /����7 RECEIPT. GAS A)EA.SYSTEM-OVER I(E Cw v 4 BNLDWG DIVISION FEES MlCcrtUIN'� rFI�A'i / py b flkd with the city bpetlbn divWon. CREASE/WDLN USTRL WASTE TERCEPTOR PLANCHECK FEE rtNed co CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATIONINSURANCE SEWERSANITARYSTORM Ek 7<IU,"1. Date Remi t# (This sectbn need n¢be compldd Hthe pamat b(a oris hundred dollars (Sl tiBale:.) WATER IFIRATER W/vest./otr1.R ENERGYFEE :Y N Inrtdy ttatoy any orsoni an th<work brwWch uta pemathblued, — I o(k not employ an�.Lawa f any wooer at a to bamw vb)ed to the WATERSYSfEM/TREAT[W Wakea'Compenuulon laws olGWornh.Date PAID ' O Z NOTICE OTICE TO NEW RESIDENTIAL FLMB, SQFT. Date Remi t# _Z 0 NOTICEvoons bjdtot a aflerwbngttb Celoo proo(Fae oftheI you skaldbecome forth to thewwiteneumpevatbn pmwis peroute Ithe 'TOTAL: LU _> doomed inked.forthwith comply with Leis pmvbbru orthb pemat shall be � > dmmd revoked. BUILDINGrFEr LU G CONSTRUCTION LENDING AGENCY SEISMIC FEE Iherebyafflwthat then baconaurudlon kMingagency(orthe perfrmm ELECTRIC FEE 1 7 = ancLoftne wwrkforwWh thin perrtat b Issud(Sec.309'/,CN.C.) TOTAL' _ Gir U O Lends".Naw PLUMBING FEE LL ~ Lsderandd. QTY, MECHANICAL PERMIT FEE MECHANICALFEE� O W lmdifyttatlha me thbappBa nardetatethmthe abwelnf.r . bmnea.lagreemmmplywfthatidtyaM muntyordlnanoesandetrtelaws PERMIT ISSUANCE' FEES PAID. } N nlatingtobuldbgwwmu s,a� mbyauthrrbenpresnutH o(04 _—�h arass/fM F Z sty to enter upon the above.mentload property for hupc ion purposes. ALTERORADDTOMECYL Date Recei t# •a N,1 — (We)agree to save,IndemW/y an d keep harenles the City of Cupertino P agoimlhbl�oyJ ,pdgwnts,m as iipenaeswhkhwylnanywayacaue AIRHANDINGUN1T(IV10,0)0CFM) SUBTOTAL: aga��C�l tis antingdthb Pe—�7 1 AIR HANDLING UNIT(OVER 10•DOOCFM) CONSTRUCT10N TAX Signature Signature of�u nn a EXHAU5r HOOD(W/DUCT CONSTRUCTION,TAX PAID: - RDOUS MATERIALS DISCLOSURE Will the appllorn mfuture building occupant Mort or handle hazardous HEATING UNTT(TO 100,00)BTU) Date Reeei [# wlcrial as defied tin by thL Cupertino MuWdpaI Code,Chapter 9.17,Sad the Health and Safety Coder-Smion 2532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: FF��Yee rq��.[-!�.J3 W �JW the appB¢ntprTptun building oavpant use equlpwntadevkx�s VENTILATION FAN(SINGLE RESID) ISSUANCE DATE whkh rout luzallou-.air ictnarunts as defined bythc Bay Ana Air . lay Mgemen aiut District? BO000 B OILER-COMP HP OR 100, TU) +LJ Yes, 52 No Ihave mad the ha"fbads materiab requlnwnts under Chapter 695 of BOR.EILCOMP(OVER I OO,ON BTU) the California Hsofth k Safety Code,S ntlo u,25505,75533 and 255M.I urdenard that if the budding dm not cvrrmntly,have a tenant,that It Is my NEW RESIDO-MAL MECH. SQFT - resporumHty,to natty the arvpard of the requbownts whkh mtM he nrct prig to arced IR ed pa^ty. n amuhariM Dat TOTAL ISSUED BY: OFFICE COPY