21374 (2) I ILL HrrLIlaM1. VrI11\ 11\rw"Mm a lV r• varrnr• nwr a_ aarsr.. rvnsa . .�.
Building Pro IdentificationNO./A&19 ywlu ��� "" 21374
BulldinAddress:
L
e ane: One:
re ` Q/J t,�a A/dpN bG!'�i CITY OF CUPERTINO-BUILDING DIVISION C�
Cr,gmcm ?N.me: // APPLICATION I PERMIT q --u [ 0
f "N/L�a4 4/FLY1L��+'✓ y��r`. BNLDING-TLECTRICAI.PLUMBING-MSCI IAMCAL CATEGORY CONTROL
Aechlted/Gglneer. LIc.Na:
BUILDING QTY ELECFRIC PERMIT.,' - FEE-.
PERMITINFO
Address 50 J.; hl7t . •rc s PIRMITISSUANCE MI
MI
:1LICENSED CONTRACTOR'S DECLARATION - �1 11
I hembyafllrm that l am licensed under provisions of Chapter 9(commene- APPIIANCGSRGSIDE AL JOB DI.SCRIP1 10N
Ingwhh£edlon 7000)ol Dlvlslon3ofthe Buslneasand Profem onsCode,and my
license Is In full force and effect. PANT3S
License Class-[_Lic.A C h,tnll t yip
Dale Contractor Sa14IQB /sem I r
ARCHITECTS DECLARATION 7U1-1000AMPS {
oc7. 1 understand my plamahall be used a public record. OVER1000 AMf5 ,f SQ.FT.FLOOR AREA S/SQ.Fr.
wttO
V 0 Licensed Professional SIG 513E L�/
6o, OWNER-BUILDER DECLARATION
In a SI' Tj CIRCUIT/MISC
1herebyaffirmthatfamexempt fmmthe Contractor's Limn. Law fni the
p following reason.LSedion 70115,B.Mc...d PrefenbnsCode:Anycityor
O].1. P:'.�IETER OR POLE IN
K anyntycture pequlresa peeMtto also
1�1� any structure pdortolts hat he In licensed
sed pormant to the retia aofpermit e 7 DEV v'
rL +1 lSI�� Ble a signed staterrcnt that he 611censed pursuant to the pmvbion Ofa�rtgh'e /
30;! son3 of the 6ut.Innesse end Proleslosu Code orthaBhe h..amlpt t7h(e�n(/om am -• MING r t:ELrCTRIC VALUA110N
me basis for me a0eged esAmption. Any al.1.11m Sealep Mj:t by any O Ers TCHISFIXTURES
appllcant fees permit subjects the applicant to.doll Ily Nnut more than 1 live hundred dollarsh
O
O `
❑L..Ownrraftgroperty,ormyemPI r(wl Beasthebsolr NEW RF DENTN.ELECTR SQ.FT. STORES Llt
TYPECONS'IRUION
C Q
compensation,Business
andwork,pr and(hes Cdure;cC fie oronrmp lot " 41UMUING
q ❑ sale(Src.70x4 Bualnem and Pro(eml.m Code:TTiv Con d slJmn/e(Aw Vy$ d«sn.tapplytoanownerdpmperty who buifdsorlnHet.whodmsuchworkhlerselforthrwgh hisownemIt eeaIdldlhatsuchI OCC.CROUP RIS.UNI rS
Improvements are not Intended...Ifered for sale.If,howevcq the bu llding or TOTAL:
Improvement Issold with In one yea rofcempldlon,the owner-build er will havet relent of proving that he d ld not bund or Improve for purpose of sale.). Q7y, PERMIT- ' . FEE HDOD]DNE APN
L1,as owner of the property,am exdusively contracting with licensed PERMIT ISSUANCE
contndon to constructthe project(Sec.7014 Business and Profemlom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(U)
W ro
lid.or impvn thereon,And who..read. f«A.&seProled. with a
oqa1 aloe(s)Bcenaed Pursuant to the COmndrea License Law. gACK FLOW PROTECT.DEVICE FEE SUMMARY
I_I I am exempt under Sec. B& P C for this re
Owner Dae
DRAINS- T P,ROOFEA,
,ARCOND. SANITARY Y— N_
RECEIPT N
WORKMAN COMPCIJBATION DECLARATION pp[Nw;S PER TRAP SC{COL TAX Y_ N
❑I hereby affirm that 1 have A certificate of consent reset(-Insure,ce a
�� artiflcate o/Worken'CompewHonlrourana«a artlfled ropy thereof(See GAS FA.SYSTEM-1 INCA OUTLETS PARK I1-M Yam NPT N
polis lab CJ -
llry N GAS FA.SYSFEM-OVER d(EAI RINGER N
CoCBUILDING DIVISION FEES
�IOrd copy b heed with
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCIIECK FEE
�CertiOed copy b filed with the dry Inspection dlvlslan.
CERTIFICATE OF IXrAPfION FROM WORKERS' GREASEIRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM G.700FT. Date RCCCI (b
Qhlsaedlon need not becompiled lithe permit b f n one hundred dollars
(5100)Oeless) WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
I cent that In the Any Person
in any manner
fo As to b co Permit
subj c booed,
1 shall not employ any person In any manner at u to become subject to the WATER SYSTEM/TREATING
Walicant ompematlOn hws o(Callfornb. Date PAID
O Z Applicant NEW RESIMMIAL PLMB. SQF. Date Recel ill
Z Q NOTICE TO N'PLICAM:IL.Rer nuking this Certllkate of Exemption,you
eh.uld become aub}d tO the Warken'Compematlon proWlOro of the Labor TOTAL:
N Code,you most forthwith comply wlthmch provisions orthb Everett shall be OU,-
K > deemed revoked. 4DIN E —da-/t-
W CONSTRUCTION LENDING AGENCY SEISMIC FEE ]a1
I1 I hereby affirm that there is a comtmdi.n lending agency for the perform ELECTRIC FEE
-7 Z ance ofthe work for which this permit b Issued(Sec.3W],CIv.C.) TOTAL
02 lender'.Name PLUMBING FEE
LLF Fvnder'a Addmas QTY, MECHANICAL PERMIT FEE MECHANICALFEE
O W Icertlfythatl love read thbappBauon and Matethauhubove lnformauon
Isco'red.I dgme to comply with all cityand countyominanmand Mate laws PERMIT ISSUANCE FEES PAID:
r U) relating to building construction,and hemby authoeloo repreacetatives of this
F.. W city to enter upon the above-mentioned properly,for bapedion Purposes. ALTERORADDTOhl
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Dale ReceiPIN
O against liabilities,Ndgmenb,coMoand expenses which may lnany way.«me NR I IANDLING UNIT HO 10,M CTM) SUBTOTAL:
agaimt �City In conaLgUence or the granting..this permu. J1//? AIR I IANDLING UNIT(OVER IQ=CrM) CONSTRUCTIONTAX
Signa of Appliran/cram oJ
r �I at./ IXIIAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
II AZA R DOUS MATERIALS III SCLO SURE
Will the a ppllca rat or future build Ing coat pant store or ha nd le hazardous I[EATING UNIT(TO 100,000 BTU) Date Rccel IN
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the - P
I Iealth and Safety Cal r,SMIyrZS537(a)i I IFATING UNIT(OVER 100,(1(10 BTU) TOTAL:
n Ycs Q,rF
`Cy ill the Applicant cefutun building«xupart use equlpment or devices VFN'ITIAI'ION FAN(SINCLE RESIDE ISSUANCE DATE
which emit W.,dous air cents cries Ata As deft ned by the Bay Area Air
• Quality ManagementI)isbld7 BOILER COM POIIPOR100,0(DBTU) PAID
4 Years
haves )lehazu ou.mac.,Sb l.ulremenb5533e.hapterb.9go1 BOB.ERCOMP(OVPR1W,00001U) ff 1 1 1590
the Gliand hat Ifth Wilding
Code,Seduruntly have
vea tennis25534.,that
OCT I d
empmAunderstandthat ifthebule occupant of the rrentlemArt.which at
It i. et NEW RESIDENTIAL hfEC{. SQ.IT.
rnporoibility t.nalfy the occupant of the requlreercnts which must be met
(pTr(lor��/ss,,�,,,re Ara Celina .f oacopa�nq. City Of
Cupertino
TOTAL: ISSUFDRY:— t �\ATO tK
P
OFFICE COPY