23627 (2) ^ "v^Building Pr en Identificationr• , r PERMI I'NO.
Rullding Addmsc v,\• `-F�\(C w(C��C',,v r4sau
r r'� 23627
)ern one: S -1 `/`{ A.
NE4S� G 11 Ra CITY OF CUPERTINO-BUILDINCDIVISION
I rQ.1
c°ntra"m °Nasse: 1le.No: APPLICATION I PERMIT U I ?
'V• SUILDING.ELECTRICAUq,UMBING MSCI IANICAL _EA ETCORY CON (Y7
rcFlted/Gglneer. LIe No: `1L �
'QTY ELECTRIC PERMITiFEE BUILDING PERMIT INFO
Address: HLU� F11 17179117 7
PER ISSUAN�E e"�I � � El
LICENSED CONTR under provisions
NATION �r� u
I hereby affirm that I U)oflamllrensed 3ofthe erinessannsofChapter9(cemmrnc- APPLIANCE" MEAL OIIDIiSCRII'110N
I ngwllh infull 7IXq)and effeon0orthn Buslnessand Pminslona Code,and my -
liceras Is in full(Dere and N P
hlanx Clare—1,1c.M
Dale Contndor Q�Qp.A 1
ARCIIITECPS DECLARATION 2(11"1000 I
07O I understand my plans shall be used as public mmrds. OV I II r I.00JIR AREA SM.Fr.
- g
Fe �j Llrensed ProfealOnal _ 51 ,f 'TRIGAL
�<<'4 OWNER-BUILDER DECLARATION SEFEI IIIT/MISC� / _ 1�•J
owing r ason, that{a 7 31.5,B/mmthe d Profdorb l.lrenx for the _ {�_
op pq�y loltowing reaon.($edlon 7011,5,Business and l'mfealona Code:Any ctty or '' J OD
)2�❑ coantywhkhnqulrcsapOrMttemnstmd,Ategimprovgdemalleh,or repalrg •I7](ORI'OLCI �V
S°"I ❑Q any structure prior to 10 lssuance,abo requiresthe applicant for such penelt to
1 U Elle a signed statement that he I licensed pursuant to the provisions of the OWrR DEVICES Al� -
Oju,r Cme'-d°r'sl.111.law(Ch.pmr9(commendng with Sectlon 7000)of Divi- _
5 0;7 doOofthe Business and Prnfealo"Cods)orthat he is exempt therefromand SWIMMING IVO). RIC ^ VALUATION
s
The basis for the alleged exemption. Any violation of Section 703 1.5 by any F / s I I O
<S applicant lora permArnibjeds the applicant to a dvll penal dna more than %)UILETSSWTTCI IESIO%TIfRFS I�FTr
I drecidollars(8501). NEW RESIDENTIAL ELFiCiH �- ---
1,as owner.11 he properly,or my employees with wages a Ihelr sole �•IT SIUI2115 IV I'IiCONSIRU(:--PION
rep ation,wllldothe work and the structure is not Intended or offered for
CFD .Ole(Sec.7044,Business and PeAramm Code The Conlndo/a License law -
Ijr$ fines net apply to an owner of property who builds or improves thereon,and (X:C ' --
E whod°essuch work hlmselfor through hbrown employees,provided that such — .GROUIHI3.LINIIST�
Improvrmernsare not intended orolfered for sale.ILhowever,thebulldingor T .A
Irnpnwement is sold within onerarorcomplelion,Iheuwner-bullderwlll have - 4
Itnrdeno(pro°Ingthat hedld nolm,gd°rlmpro°e(or purpose of sale.). QTY. PLUMBING PERMIT FEE n<x)u in"R —ni'N
LJ I,as Owner of the property,am exclusively contracting with licensed pp:RM1T ISSUANCErontnd°n to mnalmd the project(Sec.7044,Businessand Pr fealons Code:
'Ihe Contractors Hrens,law does no apply to an owner Of property who — ALIIILURAIN k VUNT-WA77Et(G)
Wilds or Improves themon, and who contracts for such pWjeds with a
r,badore)Rrensed pursuant W the Ccenvd
aori LicenseLaw. FEE SUMMARY
[_f I am exempt under Sec R k P C 1nr this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N_
Date
WORKMAN COMPENSATION DECLARATION RECUIT N
41
❑1 hereby affirm that I have a refit Rcate o/consent 1.self-Inure,ora I7%TLRFS PER TRAP SCI
1001.TA% Y N
mdiflcateof Worker Compensatlnn Insuranceoramdllledmpythemof(.a . RECEIPT
3800,lab C.) CAS FA.SYST124-1 INCA OUTLETS PARK 1g9i Y N
Policy N - RLCER'r N
Com an GAS-RA SYSFEM.OVER4(FA)
y BUILDING DIVISI( 1'illi5
Crdlfled copy E,heed with the cit. GREASE/INDUSIW,WASTE INTERCEPTOR PLANCI LECK F- 5
❑Certified copy V filed with the city inspection division. /
Ii O 1
CERTHICATFrXEMPFION FROM WORKERS' CREASE TRAP PAI
COMPENSATION INSURANCE SEWERSANITARY-STORM HA."FT. Date Remip 0
Ohbstolon nerd ndMENSATI N INSURANCE
R(r(Drone hundrOJ dollars _
(8100)nr lea.) WATPRI{PATQt W/VPM/IIl,GCTR GNEI2CY FEE Y N
Icertlfythn In the perfornunreofthewod forwhich tFb permit is sawed, - —
label[not employ any person In any manner era as Io become whjed to the WATER SYSOM/TRG77NG
Wmkers'Comrenxdhm awa°f Calfmnla. Data pAlp
Z Appunnt_
z Q NOIICETO AI'I'LICANT:ILafter making this Cedlfiale of lSempllon,you NEW RESIDIM1ALPIMB. ;Q.pL Dale R IP
t#
becomesuhjed to the Workers'Comprnemlen provbiona of the i.ahor T TAL_ _
xIn Code,you must forthwith comply wllhwch proetslonsOrthla petmRehall M -
❑ > deemed revoked. B �.
i G CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a cone mdlon lending agency for the perform 'LE 'RI F'
Z anceoftheworkfurwhichlhispermlt is(rwnd(See.BW7,CEv.C.) TOTAL: _ )`
O I"'de's Name PLUMB ,PEE
y 1 de.a Addmv_ QTY. MECHANICAL PERMIT FEE A
O I redifythal l have read this-ppliaunnanddalethd MECI NICAL FEE
thvabove Intermark,. —'
bcormd.Iagree to comply with all city and county ordinances and date laws PERMIT ISSUANCE
>• N rnlatlngtmhullding curt+Imdlmn,and hereby suthnrUe reprexntallvca ofthL+ ,—
Z rity to enter upon the above mentioned propedyfor LupMlon purposes ALTIRORADDIOMECEL
- (We)agree to am
ve,Indenify an d keep harmleas the City of Cepedlno IC Ref
against liabilities,pdgments,rods and expenses which may In anywayaecme AIR I IANDI.TNG LINE'r(r010,000 CIM) __ SUBTOTAL:
agalwt nald City Inc saquence of err�gram�/sqp�(Ihls perm0. pp AIRIIANIJLING UNrf K)VER IO,IXp CfM) CONS RUCTION TAX
at
EXIIAUSr1100D(W/DUCD CONS UCTION TAX PAID:
II AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occepant stem or handle hazardous I ObUTNG UNIT(r0100,000 H RA -
erlalaa defined by the Cupertlno MunldpeICode,Chapmr9JZ and the --- _ DalC RC Ijxluy�
Ilrall yes Safely COdr S•di on 25572(.)7 I IrATING UNIT(OVER 10(1,0(10 BTU) Tt ALL I `
❑ Yes Irk-,N°
Will the applicant orfutum building Occupant use equlprrcnl or devices VPN'IILA'IiONI'AN(SINGI.Ii RFStD) ISSUANCE DATE
which emit haaardnm air contaminanta as defined by the Bay Area Air 0 E'
Quality Flanagemrnl Did dd2 WATER COMPOIIVOR 103,000 BTU) ir
4Yes ❑❑No
haveread the h arJnusmlerlalsrequirement%under Chapter 6.95of IK)ILER-COMP(OVINIfq,000BrU)
Thr CalilornlalleallhASofelyC°de,5ediens25505,255))and255J4. 1 JAN
let n� I(I(t,)
understand that if the bulling does net currently have a tenant,that it is my NEWRILSHNNI'IALMECI1._ SQ.FF. AN N 1993
,,p°nsibillly to ndify the occupant of the requlrerrcnb which mull M rtml _
priorblssuanceofaCedificateof Ocmpancy.
CTvnrnad
n hnrirOJ agent Ihle -- --- ISSUIiU
TOTAL: ---
OFFICE COPY