22900 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PFRMIT NO.
Building Address: ��- I O 2 2 9 0 0
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S HCITY OF CUPERTINO BUILDING DIVISION t O N 1• ` 1
. coyraNa ��, 3 � I N.: APPLICATION /PERMIT —
tCrr BUILDING-ELECTRKAL-PLUMBING-MECHANTCAL CATEGORY CO ��
Architect/Enginrer. Lic.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE n
LICENSED that
IarCONTRACTOR'S DECLARATION L.� IJ I/J
I hereby afti700D)olam licensed3oftheunder prvvisions..dP fagE...0 dc,mmenc APPLIANCES DE OB DESCRIPTION
Inerse is in full force of Divfect. !the Busivssand Por(essioneC.de,and my
liana istos rota and erten. 1 `A a %``t 'n,Tel
ELS
Liana Cpn Lie.N aR"f�l`elV
Date CHITECr 1
! e
A PS
ARCHITECTSblicotDECLARATION 1000 AM FS SQ.FT.FLOOR AREA S/SQ.FT.
0 0 I understand my plan stall be used u public records.
d U Licensed Pmfessiovl SIGNS ELECTRIC
OWNER-BUILDER DECLARATION SPECWLCIRCUIT
1.., 1herebyafflrm that l am exempt form the Contractor's Liavelawfor e
ZO ^^ following reaaan.(Section 70315,Business and Professions Code:Any city r 7{2,Ig MENi0 LE INSI.
7' c.untywhich requires a permit tomrutmct,alter,improve,demolbh,o'repa
q'�Ss anystructom pdorto its issuance,also requlresthe applicant rorsuch permit to POWER DEVI 5
6 d V file a signed statement that he b licenced pursuant to the provisions of the
3 w G
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VAI AT ON
O e1Dn3 of Business and PMemlonsCode).rthat hebesemptthemformand ATION
Sn S the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWI'1'CFIESFI%2URES (GJ
`u�Gn aPPBant for a permit subjects the applicant to a civil penalty of not more than 10% ���
p� five hundred dollars($500). NEW RESIDENTIAL ELECTR SQFL ���SS�9tttT1DOOOO/{g�1I\FS TYIP L'CTION
❑i,as owner of the property,or my employees with wages as there sole O V O� L E ��
C7Q compensation,will do the Business and kandthe s ruclum,Is Code:The
et Conttendedo License
ed for Law
5 0 sole(Sec.apply
to an owner
df property Code:The orimpctols License Law
$g
does not apply torn ower of property who nWilds
mporimprovesthereon,thatand
whoaoements.such not
for edorough his owfor ale.K mseprovidedildingor
Improvements. )d tntendedearofcompleamthhowevegthe Wildingw TOT N
Improvement baold within oneyearofcompletbn,the owner-bullderwttl have12
t burden of proving that he aid not bunTY
Wild or improve for purpose of sate.). Q . PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70rN,Business and PrvlessiensCode:
The Contractor.License Law does net apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilda or Improves thereon,and who contacts for such pWjens with a FEE SUMMARY
�gR!(�do,(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. e k P C for this reasonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RECEIVE N
WORKMAN COMPENSATION DECLARATION FD(TLEES PER TRAP
SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a ceni0ate of consent to self-Insure,or REC=N
cenifiateofWorkers'Compensation insurance as cernfled mpythx.f(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,lab Q ftFGEI'T N
Polity# GAS EA.SYSTETt-OVER 6(EA)
rmpny BUILDING DIVISION Ft
edified copy is hereby famished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE?,—
, riffled copy It filed with the city inspection division. q �J
CERTIFICATEOMPE SATION NS FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARY-STORM EA 200ET ab Recei t#
Rhiss.ctlon need na W completed If the permit b!.cons hundred dollars
(8100).'Ioss,) WATER HEATER W/VENT/ELECTR ENERGYF Y_ N du.
I certify that in the performance of the week forwhich this permit Is Issued, O L
I.hall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensatw.Law.of CAIfomb.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
Z NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
I" N should become subject to the Workers'Compensation provisions of the Labor TOTAL:
C Code,you muatforthwith complywithsuch provbtovorthbperrrdtshallbe B IL TNG
W _ dm
eeed revoked.
CONSONLENDING AGENCY SETS I
CL Thereby affirm that thereem Is,Lsa construction lending agency for the perform ELE
7 Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
V O Lenada Name U"B GFEE
F- Lender's Address QTY. MECHANICAL PERMIT OPEEMSCI A L
Ow cediythatlhavcrcadth appllationaWaatelhattheabovei "nootion FEES I
O. beorme.l agreeto complywith all city and county ordinance and state laws PERMIT ISSUANCE
relating to building construction,and hereby authorise representatives of this
N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree le Ify and keep har less the City of Cupertino Dat Receipt#
V agaWtllabllI ,mats and ex .which.yioa.yw.ya.c AIR HANDLING UNIT(TO IO,OW CFM) SUBTOTAL:
ago' eme of the Ing ofthbpermit. CONSTRU TAX
`a�'L—g CONST
AIR HANDLING UNIT IO,000CFM)
S v IAppll n/Contractor L4 Date EXHAUST HOOD(W/DICT) RUCCIO PAID:
KDOUS MATERIALS DISCLOSURE
Wthe app leant orfuture building occupant store or handle hazardous HEATING UNTT(TOI0(f00)BIU) Date Re to
mat 'alas defined bythe Cupertino Municipal Cede,Chapt.r9.I2,and the
tie thand SAvlyC a n1.n25532(a)i HEATING UNIT(OVER 100,000 BTU) TO
❑ Yes o
Willtheappllanto fw core ildingo panluseequipmcntordevices VENTILATION PAN 61NGLE RFSID) ISSUANCE DATE
which emit ha,arelousaircontsmivntsas de0ned bylhc Bay Area Air r A ! D
Quality Mavgemem Dist 7 BOILER-CAMP OtD'OR 100,0008TUI K
4Ys
have read theh ous materials requirements under Chapter 6.95 of BOILER-COMP(OVEf 100,000BN) 'Novthe California I lealth f.tyy ,Se vt..25S05,25533and2.SS36.] 1N1I -_ 7 1JJ�
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. v JJ1
ropons�b Itytonalfy theo of of the requirerrenls which most be met
olort. ceofaCertific of Omupanry. - CITY UI' uut',,,....
nL z
Ow for authoriseD tV TOTAd a get / ISSUED BY
46zOFFICE COPY