22458 (2) APPL_ICARIT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPFRMITNO.
Building Address: - 22458
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4T1:'G%A SG Wan So tJ Z S$ /j f ? CITY OF CUPERTINO-BUILDING DIVISION
a APPLICATION I PERMIT ( C
BUILDINGF],ECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROLX
1 r Itect/Engineee Lie.No:
' • Q'IY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: __ OI e•t^k'k` PERMITISSUANCE BLDG❑ F-1
�PLUMB ❑
LICF.NSF.D CONTRACTOR'S DECLARATION I, �04'
I hereby affirm that l am licensed under provisions of Chapter 9(rommen APPUANCESRESIDF.NTIAL JOB DESCRIPTION
Ingwtth Sect1on7000)of Dlvislon31lthe Budnenand Pro(esslonsCode,and my '
Iceve la In Po d E/m� • , /O p, _ . PANELS n
t
Llcen Clan o ^Lic.p
Date -- Contractor UPT02DOANTS
ARCHITECT ECLARATION MI-IOVERI"AMPS SQ.FT.FLOOR AREA S/SQ.FT.
�Z' I understand my plan ahaB be used ns public recgrda.
NUBqN`'U O SIGNS ELECTRICAL
�j Licensed Pmfessiovl ,
<6c% OWNER-BUILDER DECLARATION
In SI'ECIALCRCUIT/M15C
' owing rason.(ealiam 13,Blromthe Contractors License Law for the
79 pN followingichr ufmaue7 ttocusinenand Pimp a e=le hnydtyor
OLi..� countywhich requlrnaperMtlocovbuct,altegimpmve,derrolbh,orrepalr T�P.METIXORI'OLE INST. '
�`'0 ¢ anystmMmprortoltsl ancgaborequimtheappbantforsuchpermitto POWER DEVICES
p re l O file a signed statement that he is licensed pursuant to the provisions of the
Pgg,,Ow Contractor's License Law(Chapter 9(commencing with Section 7000)of Dwl-
sion3gfthe BusIni.and Profeel^vC^de)orthathebexem themfromand SWI ]v[ING POOL ELECTRICVALUATION
'
the task for the alleged exemption..Any violation of Section 7031.5 by any
^ « B tfora permit sub' theapplicant to a civil Sal of not muctiun OUTLETSSWITCHESFIXTURES
p five un Ix Ifdfpenalty
feu five hundred dollars� 001.
he pro SQ.FT. STORIES TYPECONSTRUCTION❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELFGTR'
QQk7¢ - pe nstlon,w111dothe work,and thestrumne is non Intended or offend for ,
5. O
.1-(See.7D14,Business and Professions Code:The Contradoes License law
K$g does not apply to an owner of property who Wilds or improvestherem,and - OCC.CROIIP RES.UNITS
EE whodoeswchworkhimselforthmughhisownemployeegprovidedthatsuch
Improvements are not Intended orofferedforsale.If,however,thebuilding or TOTAL: '
Improvement Resold withinoneyearofcompletion,the owner-builderwill have
t"oden of proving that he did nm build or improve for purpou of Sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed % pF-gh(LT ISSUANCE
/S
contractors to mnslmct the project(Sec.7014,Business and ProfenmloCode:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT (EA)
Wilda or Improves thereon, and who contracts for such p,jects with a FEE SUMMARY
o t{actor(s)licensed pursuant to the Contractor's License Law. BACK FLOWPROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason FEES
Owner Date DRAINFLOOR ROOF,AREA;GOND. SANITARY Y NEIPT 0�
S
WORKMAN COMPENSATION DECLARATION - _ ftFG
❑I N
heFIXTURES'PER TRAP SCHOOL TAX reby affirm that I have a c^nificate of consent to self-insure,or a RECEIPT N
Owner to of Workers Compensatlonlvurancc oracecti(kd ropynhereof(Sec. S FA TL
GA .SYSTEM-]INCA OUTLETS PARK FEE Y_ N_
3g�Xb C.I]; q - GAS EA.SYSR7d-0VERd(EA) RECEIPT
Com an IL�J.X � BUILDING DI VI SION FE ES
rtill��y'Vherebyeby T.misheel. GREASEANDUSTRL W
WASTE TERCEPTOR PLANCHECK FEE
esX fund copy Is filed with the city Inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASE TRAP PAID
COMPENSATION INSURANCE /,. SEWER-SANITARY-SMRM EA.2DOFT. `
(I'hlascctionneed not becomplcted lftheperrot tilorone hundreddollars IS Ud Date RCcei t#
s]m)anlna wprFRFEATFRw/vFxr/F3EcrR ENERGY FEE Y_ N_
I cenlfythat Inthe performance ofinework forwhich this permR Is lased.
I shall not employ any person in any manner so AS to become subject to the WATERSYSTEM/TREATING
Workers Compensation Laws of California. Date - PAID -
z Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
Z NOTICE TO APPLICANT.1Lafter making this Certificate of Exemption,you
Should become subject to the Workers'Compensation provisions.(the Labor TOTAL:
~ N
Code,you=at forthwith comply with Such provisions or this permit shall be BU NG •
Wj deemed revoked.
CL cCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmnhat there is a construction lending agency for the perforrry TOTAL: ELECTRIC FEE
7 Z are of the work for which this permit is Issued(5ec.3097;CIv.CJ .��D
U O L nder's Name PLUMBING PEE ? Xp
1— Leadrea Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W anter.cartiftagmet complye read is with all ety and county
ordinancestion
4 is coned.building complywo ,alld hereby
inancesand Mate laws PERMIT ISSUANCE PEES PAID:
>. W citytrelatenterg to
t coabova- gn,andherebyauthee inspection
of this
f.. city to enter upon the above-mentioned pmpecty fee
ivpenlon pucposea. ALTER OR ADD TO MECH.
Z (We)Srj.Save,indemnity an d keep harmless the City.(Cupenlno Date Receipt#
V aliars,
W It d me , cats andel nxswhIchma i wa accrue AIR HANDLING UNIT(TO 10,000CPM) SUBTOTAL:
gr ,FNB R y nanY Y
gal is d yin ron ce of the granting of this permit.
AIRHANDLINGUMT(OVER10,000CFM) CONSTRUCTION TAX
SI of Applicant/Contrador ' - Date IFInLaTHOOD(W/DUCT) CONSTRUCTION'TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO1W,000 BTU) Date `Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Seetion25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: D.GO
❑Yea M No
Will theXpplicant or future beading ocmpant use equipment or devices VFNIILA770N FAN(SINGLE RESID) ISjVQ&R DATE
which emit hazardous air contaminants as defined by the Bay Area Air
lity Management District? BOILER-COMP QHPOR 100,000 BTU) C
Yes �No S P 1 191
have read ttie M1azar gUS materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF. pt /s /'
responsibility to notify the occupant of the requirements which must be met City of CupgrtlQ4
prior to Issuance of a Certificate of Occupancy. '
Owner or authonred agent Date TOTAL: :� k ISSUEDBY
OFFICE COPY