22051 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro est Identification PERMITNO.
. 'B. I AaeI MIT t � _ 22051
nen• ante: Phoran .
Ag4—dr&a CITY OF CUPERTINO-BUILDINC DIVISION
e" vaso .Name: I Lic.No: APPLICATION /PERMIT l U L
BUTLDINGELECTRICAL.nL BINGMECHAMCAL CATEGORY CONTROL/rl—zG
rchltect/Engineer. Lac Na C9_l•
, FEEE E "" -,BUILDING PERMIT,INFO'ces'�' ,,
.QTY, 'wELECTRICPE
Address: PLUMB M�h
PERMITISSUANCE h�P(-�
LICENSED CONTRACTOR'S DECLARATION `--�
I herebyaffirm that l aml:ceved under provisional Chapter9(mmmenc APPUANCESRESID L JOB DFSCRFMON
ingwith Ss Ioo 7000)ofDn6swr3.fthe Businessand ProfmionsCode,and my PANS I ,
license iCl.. force and c.#ff. 11 II ?
LI rase Cbss LLCM � )V 1\ J
ate Contractor
2VIARCHITECT'S DECLARATION d )a
pp ne 2 I understand my plaro shall be used a public records =Oyu 1000 ML'S SQ.FT.FLOOR AREA �7$/SQ.FT.
zU Licensed Professlovl \ SIGNS EL �,�,e 1
OWNER-BUILDER DECLARATION SPECIAL
Z ?hercbyalirmthat l am sectmgrfrom the Contredor'sLlrense Law for the
'� Qp following reason(Section 70)15,Business and Pro(mion.Code My city or
Gsy county which requires a perouttomvtruct,alter,4npmvq demollsh,orrepalr TEMP.METER O POLE INST.
77 anystru=mprlortolle Lsaamc alsomquimtheappB..tf¢suchp.r ito )pW,pRO
O F U file a algned statement that he is licensed pursuant to the proWlons of the
SO
Contractor's License law(Cha a 9(co .can with Section 7000).!DIA. VALUATION S slon3ofthe BusInmand ProfmbaCode)arNrt heberempt Nertlromand SWIMMING POOL ELECTRIC I 1
C the basis for the alleged exemption. Any Aoladon of Section 7015 by any OUTLE7SSWrICHESpTXNRES 2`�L,.0 / �Q C yam
fNehu diorapermit$SM.bthe applicant too tivil pesky.(not more thin 1 O J (� s �•V
flue hundred dollars(S°iWl. NEW RESQ7ENTLU.ELECTR SQFr. STORIES TYFECONSITIKTION
F11,as owner of the property,or my employees with wages as their sole
C7.t mmpenertlon,will do the.,k,.nd thestrocturs b not intended or offurd for O
5 O sale(Sec.7044,Business and Profeaela s Cade:The Contractors License Law
52 does nmapply to an owner of property who builds or improve thereon,and OCC.GROUP RFS.UNITS
a'^ whodoeseuchworkhlmsslforthrwghhisownempluym,providedthatmch
Improvements are not Intended.coffired finials.ILhowmagthebulldingor TT
Improvement hwldwithlnoneyearo(compleB mtheowner-builderwill have _
thq,kurdenof proving that he ardent build or bnpnve for purpose of sI CITY. °PI. 'IBINGPE6Mit :.FEE
LJ L as owner of the property,am esclely contracting with ommad FLOOD ZONE APN
vlv
contraciorsto¢rotact the project(See 70M Bvinmand Pealmv bCode: PERMIT ISSUANCE
The Contractors License Law dm not apply to an owner of property who '
Wilds or Improves thereon,sod who mnmrts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
�scUs )licensed Pannone to the Committees Line.traors LLaw. _ ' 'FEE SUMMARY
LJI am exempt under Sae B J,P C for this reason BACK FLOW PROTFCf.DEVICEOUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y _ N_'
COMPENSATION DECLARATION RECEIPT a
WORKMAN COM
S� FIXNRES PER TRAP SCHOOL TAX Y N—
OT hereby affirm that 1 have o lmu.e of consent d pythn art,ora RECEIPT
cenlflvteofWorkeri Compevatlonlvurw¢¢a¢rtikd wpythereof(Scc.
3800, ab C) GAS EA SYSTEM.1 INC4 OUTLETS PARK FEE Y N
RECE
Policy p DING D[1
Com any GAS EA.SYSTEM-0VER4CPA) BUILDING DIVISION FEES
IRed¢pyb hereby tumished. GA.eCC/INDUSIRL WASIEIMFRCEPTOR PLANCHECK FEE
Certified cagy b(did with the city Inspection dlWalm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.201 Date RCCeI LM L
(11lssee lin need not be c¢nplemd Bthe permit Is!¢one hundred dollen
(5100).rlm.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y_ N—
I certdythat In the performance of thework forwhich this permit is Weed,
I shall not employ any person In any runner so as to became abject to the WATER SYSTEM/TREATING jFL
D
Workers'Compevatlon Lawsuit Cahiornia.Data
Z Z Applicant NEW RESIDENTIAL Pum SQFT. Date Rete) tp /L+"
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provbiov ofthe Labor TO s
N Code,you crout forthwith comply with such provlsiov orthb permit shall be
,� > deemed revoked.
CONSTRUCTION LENDING AGENCY MIC FEE
a Ih.mbyafR mthatthemba mrotactlon leMing agency for the perform Op CTRIC FEE
Z a nceaftheworkfor which thuya rmrt b awed(See 3097,Cl,C.)
LL O
Lender's Name MBING FEEH Lendcr'aAdareat 41�
TY. MECHANICAL PERMIT FE<L HANICAL FEE
U Icertifythat l havereadthb application and stamthat Neabtion
W It. a.Iagree tocomplywith all city and county.rdlnanme laws PERMIT ISSUANCE FEES1 relating to building construction,and hereby authorize repreof thisZcityto enterupon the abovrmentloned progeny for Wpectlo . ALTERORADDTDMECH. DatC Reeei(We)agree to save,indemnify an d keep harMess the Cien lnoagalnath bilitles ' dgmenI mtsa expenmwhi maylnceras AIR HANDLING UNIT CTO 10,000CFM) SUBagainst said Clcnnsequence� Itgranting. spermiAIRHANDLINGUMr(OVEx1go1)BCFM) CONSTRUCTION TAX
u pp ¢n earEXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
ATERIALS DI SUR
Will thea Iia ` tuarebuildin . ant reorhadcus HEATING UNTT(TO 100,000 BTIn
PP R P Date RCcefplN
matedata defln the Cupertino Municipal Code,Chapter9.12 and the
Iicalth and SafetyCade Seniors 25532W)? HEATING UNIT(OVER 100,000111 TOTAL:
❑Yes r�No
Willthe applicant or tuturebuilding occupant meequipment ordevicca VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hoz rdous air mnt.mianna denned by the Bay Area Air
Quality Management District? BOILER{OMP Oki'OR 100,0(10 BTU) TT�� a�
4Yin F�No T'- A ID
havemadthe hazar`hiousmaterlabrequirements under Chapter 6,95of BOILER-COMP OVER IM,001)BTU)
the California Health&Safety Code,Sections 75505,25533 and 75534.I -JULunderstand that if the budding does not currently have a tenant,that It is my NEW RESIDENTIALMECH. SQ.FT Jf]Iy �^
responsibility,to notify the oraupam of the requirements which must be H v` FII L9
prior to issuance of a Ccmficate of Occupancy. -Cr4�.�'T{L� l•II t , , 1..
(Tuners aiib.nu agenr Date , ISSUEDBY: U
TOTAL:
OFFICE COPY