22889 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification .NNS PUZIAl'I NO.
Building Address: �e 1 N �_ 1 I..�J 4 22889 2 8 8 11
215-� a Flo_1✓f�//j 'qfQ G G J
mN me: A A A
� =TTY OF CUPERTTN66UILDING DIVISION
a ttar •'came: I=.Na:— APPLICATION / PERMIT
'�
BLTLDINGE.ECTRICALI`LUMBING-MECFTAMCAL CATEGORY
s19rchJ2jL%EngJn r Lk.No:
`QTY - ELECTRICPERMIT ' FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaftbm that l am licensed under provbionsof Chapmr9(commenc APPLIANCES,REMDEMTAL JOB DESCRIPTION
ingweh Section force
effect.
BusineuandProtesslonsCode,and my C O�
U.. bins force and dfeci. PANES {ice
Limnsc Cha
Dae Contont
nttor
ARCHITECTS DECLARATION 201-100ANIPS
p 2 I understand my plans shall be used n public records. OVER 1000 AMPS SQ.FT.FLOOR AR 211 �/ .
U Q Licensed Prolenluvl SIGNSEIFG7RIGL
ti zag9
11111, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/h(ISCO LOL
DZ Ihereby affirm am n
that l emm s L
pt frothe Contractorl¢nse L wforthe D
following...(9ecdon 7015,Busmen and Profenbns Code:Any city orN
78 county which requires a parent to mmtruat,alter,bnpenw,demolish,or repair TEdP.METFRORPOLEINST.
: :1 anyatruaurt prbrto lb lseuan<e,aLsorequirm NeappBcant Gorsuch perMtto POWER DEVICES
u.U file a signed statement that k b licensed pursuant to the proalIons of the
'� Contractor's License Law(Chapter 9(mmmencing with Section 700)of DIA- SWIMMING POOL ELECTRIC VALUA/Ti'I7p�ON
O� xon3olthe Busine»and]ardmlons Cde)orehrthebexeia.7WI.Sby.ed ��� ®V ^ '
-yrs^ tk kris(or the ai4ged eaemptlon. My viclrtion o(SMbn 7015 by any {`�J(
appBcant(ora Parrott subject/theapplicant too dWl pevltydna more than OUTLETS-SWITCHES
m five hundred dollars(1 M.
oO1,as owner of the oremployees with wages as their sole NSW RES[DFMIAL ELECTR SQFT. STORIES TYPECONSTRUCTION
nvdoN, ldotMwor"ndl�tmmr nwt tedM or offered for O
psale(Sec 7014,Business and Profeniom Code:The Contractors License Taw
does net apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
whodoosuchworkhimselforthmugh hisoweempleyen,provided that such
impmvemenbamnotintendMarofferedtorsale.If,however,the building or TO s
mpro emen[baold wltM1inoneyearolcomplttbntheowneobudderwlll have w
eno(proWnI the did not baud orimprove for purpose o(ule.I. QTy, .)�,. PLUMBING'PERMIT, : ��'-u FEE FLOOD ZONE APN
L__
a owner of the property,am exclusbely contracting with 11¢naed pP�MpP ISSUANCE
to construct Be project(Sec 7014,Businm and Profenions Code:
Tk Coarsctor's LI¢rae Law don rot apply to m owner of property who ALTER-DRAIN&VENT-WATER(EN
bu BEs or Improve thereon, and who contracts for such ptajem with a -
ot'lF+am(s)b¢ra d pursuant to the Contractor's License Law. FEE SUMMARY
LI I am eaempt under Sec B& P C for this reawn BACK T. E -
S/fNITARY Y_ N_
Owner Dae DRAIN R RECFRTN
WORKMANCOMPENSATIONDECLARATION 504WL TAX Y_ N_
• QI hereby affirm that I have a¢rtlfiote of consent to self-mare,ora RFGEBT N
mft imteotWorkenom
Cpvr honlmu.0 ma¢rtlt4dmreo
pythef(Sec. GAS EA.SYSCFM-I ING40 P. IsI FEE Y N
380,Lab C.)
RECEIPT N
Policy
r N nGAS FA. BUILDING DIVISION FEES
�Celfid copy b hereby furnished. GREASE/INDUSTRL WASTE INTFRCQ'TOR LANCHECKFEE �5
Certified copy 4 filed with the city inspection division.
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP PAID
COMPENSATIO7 INSURANCE SEWER-SANITARY-STORM EA MET Date Recei t#
(Thlsscction need na k complxd II the perm[b for one hundred dollars
(510(SIM)oiled.) WATER BEATER W/VENT/E-ECTR ENERGY FEE Y_
¢ddytti rrta
�O
1 rtifythat the perfon¢o(the work farwnch this permit b loved,
I shau na employ any person y reanncr so as km su to tk WATER SYSTEM/TREATING Workeri Cwnpp��n t�'/n1. f Wom4.Date PAID
A Ilam /rJY4 n /r Date R
Z PP �1 NEWRESIDENTIALPIMB. SQ.FT.
NDTICETO.�IIANT:B,Act making that Certiicateof Exemption,you
should become subject to the Workers'Compensation provisions of the labor TOTAL:
N
Code,you=at forthwith comply with such provision or this peau shall be
BUILDING —
j deemed revoked.
0 CONSTRUCTION LENDING AGENCY SEISMIC FEE 511,024.0
i Z Ihembyaffirm that there b a covtmetion lending agency for the perform- ELECTRIC FEE
an¢of the work for which this permit is tested(Sec 3097,Clv.C) t w
O lenders Name - PLUMBING FEE
F Lander.Add. QTY. ` MECHANICAL PERMIT , FEE'" MECHANICAL FEE
U I¢dilythatlhavertadthbappIt tionandwtethattheabovelnfornaHan FEES PAID:
G bcormet.l agree to complywith aBCty and county oninan¢s and state laws PERMIT ISSUANCE
Mating to building construction,and hereby authoaxe representatives of this
Z city to enter upon the above-mentioned ER
Property for inspection purposes. ALTORADDMMECH. Date Receipt#
(We)agree to save indcmnfy an d keep harmers the City of Cupertino AIA HANDUNG UNR(1'010,1%10 CFM)
agal expenses which may in anyway accrue SUBTOTAL:
d n¢ofthegrantugotthispermu. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER I0,00CFM)
ttor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfunam budding occupant store or handle hazardous HEATING UNIT(TO 10,000 BTU) Date Rece
ruderal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(x)? HEATING UNIT(OVER 10,000 BTU) TO
❑ Yes M No
Will the applicant or nature building occupant use equipment or devices VF1,FILATION FAN(SINGLE RESID) I$$L(9t E(D FE
which ennt hazardous air contamivnts as defined by the Bay Area Air
Quality Mamgcmcnt D4tAd? BOILER-COMP DHPOR 10,000 BTU)
F?Yes No DEC
E C
.1 ` Health
oe tde,Sections
b5533 anCh.Iner 2S534. I of BOILER-COMP(OVER 10,000 BTU) GlJ 1991
the CaliforniaCslitoHealth&building
Code,5ectiom550,ve a tenant,that
I
derstand Rthe bullding does not Pa.cy currently have atenahL that Bbmy NEW RESTDEN'77AL MECH. SQ.IT _
respomibllityto pati to swhich must be met GI11 Uh '.•I.IPtrll jlV(J
prior t e or;
Ce ccvpanry.
GD
ri Date ` ISSUED 6Y:V
OFFICE COPY