22949 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22949
3o3aiS � e
ante: NsS� aTD
�s o -\.t CITY OF CUPERTINO-BUILDINGDIVISION
• tl¢'sName: Ix.No: APPLICATION I PERMIT
BUR.DING-dRC7RICAL-PLUMMNGMECEIANICAL CATEGORY CONTROG It
A ketl/Fagivem Lie Na
C-5310(0
CITY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PF7thRT ISSUANCE ❑ El LICENSED CONTRACTOR'S DECLARATION
Iherebyagbmtbatlamkwreedundes prwWwa(Chapter9( AIRfIANCES•RF9DENML ]pB N
Ingwlih5etlbn7o 0)I DIvWm3o(1heBuWumudi'ro(uslmsCade,sad
Ikeme ts In fullfur¢and dktl. PANELS `
LImmeCha Llr_a
Dale Camrttlor
ARCHITECTS 13ECLARATION2014
2 f understand my plausmBbe used an mEQ.
publlenmda OV1WDAMPS FE.RMRARFA S/SQ.FT.
Lkenae Pr aLwal SR:NSEBCTRXA_ B_
«<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC D C IN '
Ih atticmlbatlame¢mpt(mneheConlaRo/�LI¢me faw!¢the
pp muawmg,scar,.(5etl1m 7811 Buslnese arW PmfnsbnsCade:Any tlry or C R
Z e
PP SO 3 wnly whW requiwaa pemtltmmmWgalleylmpmvgdemoWh,or rtpalr TEMP MEFERORPOLELNST.
ER
a ■
y anyMmWmprlorwi%bwr a&wrequb¢Meappbmntf¢urhpemtltm POWER DOCS DA E
% 5 file a rgma btsmmt thM h b Ilaenscd pursuant m the prevldme of the
CanlntloALkesse Lw g:hapler9(mrrnrendng with Satlkm 7000)of Dlvl- SWIMMINGPOOLEL.RCIWC Gam•
�I§5 smn3ofthe Bushn mdProfmi aCode)¢the habemmI theMmmand VALUApON
X the basis for the alleged uempebn. Any violation of 3eebn 7031.5 by any OUILE75SNM17CFLFSFDOl7RF5 -I'
applicant fora permit ubjecb th applicantm e Mall penalty nine,mme llun
ndrd dawn H500).
S2 I,uownernilhapmpedy,on my emplaye¢with wages as lheb sole NEW RESWI]NTIALELFICTR SQlsl'. SIOIB6 TYPECOP'SfRIX:DON
S2cmpenukon,will dothe work and thearmade a lease intended or agreed(as
ink LSea 70K Busmen and PMesebu Code:The Comnctors LI¢ue Law
$8 does not apply to an owner of property who builds orimproan debar,end
who doeaurhwarkhimseg¢ m
Ihugh wwWd
ownemployeekprthatsuch OCC.GItOUP RIB.IIN175
Improvements Me net intended oroffend found,It hewever,the building TOTAL:
ImprowmemiswMwhhin n yearofo=Vldkb themmpbuBduvAUlaw
tmenofpmdng that he dM not build or improve(¢purpoae ofaabJ. QTY. PLUMBING PERMIT FEE I7.00YZNE APN
tI L as owner of the property,am exclusively oonbxYing wtlh 11¢nsed
wnttaclre,,—,eutl the projen(See 701 ,Busmese and Prnie 1maCade: PmMIT156UANCB
The Contractor,Lkense Ladoma apply m an owner m property who Its —
The
Liv, es
builds or Improves Manan,and who women for aitch pLojem with a ALTER-DRAIN&VENT-WATERMV
agBRao¢(pll¢md pumuntmMeCmlradoeaG¢nse Law. «�W DEVICE PROTECT• FEE SUMMARY
I am exempt under See B&P C f¢this non
DRNNSW.00R,ROOF,AREA,GOND. SANITARY Y_ N_
Owner DMA RBC}RT F
WORKIdAN COMPENSATION DECLARATION FD(T11ffSPm•IRAP SCId00L TAX Y N_
dU hereby a(fbm that I haw a IMUM ni consentmenWi m MWnun,¢a to RECFRT a
¢0QlAb Worhari Comperwtlmimunrr¢¢a¢nBbd wpytheraniDice. GAS PA.SYSTEM-1 INCH OUTLETS ZRFER Y_ N_
3800,IabCJ
IWLY S GAS RA.SYBPFM•OVERN(11A) R�F1PT a
ny BUILDING DIVISION FEES
rWid copy b henbyfuntshd. GREASE/INIwb7RL WASTE INTERCEPTOR PLANCHECK FEE
CedNed copy b filed with the tlly Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREAETRAa ppjp
COMPENSAT ANCB SEWEIt-SANITARY-SfORMFA.2WFE Date RL'cei tN
Owrectm Ifthpe tsf¢one hundred dollen
Ol W)¢I WATER NEATER W/VENTT/ELBCTR ENERGY FEE Y N
I¢rtl that inch 1 k wldehthls pemdtblrred.
I shall employ m n es to bemme ubjad to the WATm SYSIIId/772Fi171NG
Works Coope PAID
ZD.D.iICR a rmkinglwCe tsofFaemppttlun,yue NEWRESIDINMLPLME SgFL Date Rebel t#
should to Me Workers'CorrgrenMebn proWabua(Ma tabor TOTAL:
Ix N
Codeyou must forthwith comply with such providom orthb permit"the
BUILDING
LU > domed revoked.
FEE
tl O CONSTRUCTION LENDING AGENCY 'SEISMIC Ihembyaglrm that them b a construction kndingsgemy mrlhe pedorm •EO•AL. ,� _ ELECTRIC FEE
Z ameofthemrklorwhkhthbpeemgbbsred C9m3D97,CW.CJ
O G Leaders Name PLUMBING FEE Z L —
LL F Iandee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I ¢dlfythmlkawrudtwappB¢RonaAMWihmtheabmm m Uww
LL homeag
s.IMWwmplywkhaBMna
tyarA=ntyardinmmmdtelxw PFRMrissuANCE FEES PAID:
M
H relming lobullding wandlon,and hereby authorkst reprometatly¢oflhb
j. U) city mems,upon the ahovemenaoned property for Imporion purposes, ALTERORADDTOMECH.
z (We)ago to save,indemnify an d keep hamden the City of Calamine Date Reeei W
against WbWllenjudgment oodaad upenesewhich may Inanywayaavue AIR HANDLING UNIT CFO 10,WOCM) SUBTOTAL•
meb-6-III.Ptir momaequ the greeting ni rids perm&. AIR HANDLING UNrimm IQDWCFhO CONSTRUCTIONTAX
a
Sigrumnaf Appll¢nt/Cent tl¢ �— FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furan building ocupont Mom or handle haardous HEATING UNIT CTO 100,000 BTU) Date Rceci tR
mMeAlndA Nd by the Oupedlm Municipal Code,Chapter 93Z and the
Health and Sa(elyCde Sool.75531041 HEATING UNIT(OVER 100AW BTU) TOTAL: a%
Yen No
WDltha ippilnam¢haturrindidbig acwpam useequipmem¢devlaw VENTILATION FAN(SINGLE RESfO ISSUANCE VTE
whkh emithaardona a4 contsndrume as deilrud by the gay Am Airr' Al
D
. Qualfty.Management District? BOR.PJLODMP GHPOR 10"M Irm
Yes ❑No
w end the besardonametertsb requirements uderChapler&ES of BOR.ERCOMP(DVm IW,WORTIR
theCalifomtsliealth&Sofely Cade,Setlbna 75505,25573ad 255M.1 NO11 �$ 1991
understand the
I lithe Wilding does not currently have a tenant,that it lsmy NEWRIDDQN7IALMECJI. Wr N YY v v/J
responsMskym mtBy the owrpam o(the requiremerdswhkh=sth met . r
pdortohuzmeniacedlfl¢teniOwrpamy. CITY OF CUPtr.....
Owner¢authorized agent Date
TOTAL: ISSUEDBY:
OFFICE COPY