22380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
11u11din Project Idencilk.tlnn \
BuildingAddress: PF�thLT NO. \
0o V ( � 5 1cr)dor Un!i-sb 55 5 TyPP 2238O
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CITY OF CUPERTINO-BUILDING DIVISION j� ^
CminCmr'.Name: Lk.No: APPLICATION / PERMIT _ G� "I
BUILDINGELF MCAL-PLUMBINGMCCHAN'ICAL CATEGORY CONTROL Y
Arddtess/Ergluxr: Llc N.
QrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PFRMITISSUANCE ❑ 1:1 ax El -
LICENSED CONTRACTORS DECIARATION
I hereby Mfirm that lam llceaed uMn prwWoru of Chaptn9(mmmenc APRIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith5ccilon 7000)OMMsioi3ofthe BusiwsandPrefesionsCode,and try �I U m1^
, z is W fu dL n �rLP PANF]5 U
Dale_- �Contnnnr /OC�s'W A- TY�� Ie
ARCHITECT'S DECLARATION
NZ IoMerMandmypUns,h.UbeuseupubUcremrdd OVER 1000 AMPS SQ.FT.FL RARER $/SQ.FT.
GD Ike l ca.yes
b:cu U Lkxnrd Pm/embrul S)GNSELBCTRICAL '/J�
<<�a OWNER-BUILDER DECLARATION SPECIALCIRCIRT/MISC 1 _
F'g{3 Iheebyifgrm that l ameaempt from the Co traia.r'.Lkxnse Law for the
P^ t�
p Q q follow(ng reason.(BL�YiIXI 70315,Bu.lnea and Prolessbns Code:My city or e-rrYl 1
�'�`` countywhlchrequbeapemdttomn d,Mtenbnpmv,demolbh,ormpalr TEMP.METER OR POLE INST.
4�:.1 anyrmci mpr toiWb aux,al mquirotheappbmntf¢sudtpemltto� POWER DEVICES 0k a signed statement the he b Bcen.e i pursuant to the provWlans of the
ContraCal.License Law(Chapter 9(commencing with Smion 7000)of qd- SWU.4hfING POOL FIECITtIC VALUATION
1- O e1on3 ofthe Bu.ineuand ProfessionsCode)orthe held esempttherefromand
p N Y7 the bomb for Ne alleged esemption. Any violebn of Senion 70315 by any
�5w+ applicant fora Permit subjtatheitppllcant too civil penalty dna morcthsn OUTLETS-SWIro11E&NXTURES
�..
five F11,hundred ddWfthepro NEW R®DENTIA,ELECTR RI TYPE CONSTRUCTION
k,6 1,u owner of the property,or my employee with wage r thele.ole
compensatlon,w111do Lr vmrr,and Nerrotlure W Trot Intended or offered for
$ O sale not pply Bu. owandfpropebro Code:The Contracioh W¢neTaw
dourest applytorkhw if pth gh whn Wlldaoy.,p ret the t,and RES UNITS
A• whodmeuch workhlm eUwthragh hlsownemIf,huw p the dthatng or
Improvemew rest w"Ind,dor,.fe d(¢sinr If,haver-WildWilding¢ /
Mproverrrm W.ad wllhNoneyearolcvmplebn,the owner-buuderwlil have
I"rdto of proving the he did nes Wild or impro,e fee porpo.e or..le.). Qn. PLUMBING MIT FEE
LI L as owner of the property,en exhm
uively ntrsCing with lice urd Fl-OOD ZD AM
contract.to mnslroci the proj ei(Sec.70K Businessand Pro(®Ions Code: PERMIT ISSUANCE
The Con radoe.License Law doe not apply to an owner 4 property who ALTER-DRAPI&VIM-WATER ffA)
Wilds or improves thanes , and who mntreta for such pC
lvje .wIN a
71.1C¢(s)honn
eed puuantto Ne CorinCal.Llmrue Law. BACK FLOW PRO1FCf DEVICEFEE SUMMARY
I am exempt under Sec B k P C for this renin
OUTSIDE FELS
DRAINS FLOOR A,ROOF,ARECOND. ' SANITARY Y_ N_
® Owner Date RECEIPI'a
W00.KMAN COMPENSATION DECLARATION FIXNRF_S PER.T.RAP SCi10OL TAX Y_ N
hereby affirm the I have•¢euireu of cemsen.amilt to copy
ora RECEIPT F
eofWorkan'Compenaeim lrm'vn¢¢a¢rtilkd ropy Nenmf bee. GAS Fw.SYSI17.1-1 INC. 0UTLETS PARKFEE, Y_ N_
pockwifi, 0 C) 'T_ % X08 RME1PT.
Paky� L
as
Co rev �1f GAS-EA.SYSTEM-0VERA(TAI BUILDING DIVISION FEES
xeriffiedCeeuled ropy In hereby rolty InpeCbn dIMNm. CREASE/WDIOSIRL WASTE INTERCEPTOR PLANCHECK FEE
CcrtUie ropy W filed with thee city '
CERTIFICATE OF ID(EMPTION FROM WORKERS' I GREASE TRAP PAID
COMPENSATION INSURANCE SEIVF.R.SAIVTI'ARY-STORM EA.31Qrf. Date RCCCI IH
(TMs uciion nee nct becompleted if the permit bra wit hundred do0an
($1m)olmJ WATERHFATERW/VENT/ELELTR ENERGYFEE Y N
1¢rflfynot that inemploy
the Pere.in n Ne wok so as t obecW permit c issued,
I orlu1hall not employ any Peron in any rrunner so u m become eubfc3 to the W,ATERSYS1EM/TREATING
Wwken'Compensatlon lrwa of GlironW. Date PAID
—
zZ Applicant NEW RES DFNMI.PLMB. SQFf. Date Re ci til
ZO NOTICETOAIRR,ICAN .U,mhErm ngthla CeHYf of =r,you
F N should become subject to the Workeri eompensatb prodabnsorthe Labor TOTAL:
Cade,yourt forthwithcomplywithsuGprov morthWpemdtshallbe
Uj ] deemed revoked.
a' tj
O CONSTRICTION LENDING AGLNCY S I IC FEE
Therebyellmthat there b a mnstsuNRn lend lngagency for the perform ELECTRIC FEE r
mofthe rkf. rwhlch NWpemdtbla 5ec3097,CN.e.) TOTAL
02 PLUMBING FEE
LLF- Tender's Addree - QTY. MECHANICAL PERMIT TIE MECHANICAL FEE
OW Icon By Natl l�vereethW appOcatbnand rate thelhe above Nlormrtlon
S bmrsaC.I:gree to comply wdh ailtltyaM muntyordbunmand Mate law. PERMIT ISSUANCE FEES PAID:
relating to building mrwruCion,and hereby authoiLm representativn of this
F z tlry to enter upon the abavcmrntbrcd property for Inspection purpuam. ALTERORADDTOMDM. - Date ,Recti til
_ (We)agree to rove,Indemty nian d keep harmless the City of Cu pert wo
agonisi uabWtks,Ndgrrceq cors MexpersnwhichrmayinanywayamroNR FIANDONC IJMT e (TO 10,()(Y)CFM) SUBTOTAL:
againstaaI Ity in a En the granting of tNa pe
AIR HANDLING UNIT(OVER I0,=CFAO CONSTRUCFIONTAX
Signa rear pp can n EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
tl lA R DOLS MATER IALS DI SC4SE
Will the applicantorfuture Wilding omni pant More or hard le hazardous HFATING UNIT(TO 100,"ITT T) Date RLCeI tN
material as defined by the C.PrAlno Municipal Cod,Chapter 9.1Z and the
Health and Safety Code Seciiw 25532(a)I HEATING UNIT(OVER 100,000 Bill) TOTAL:
Yn No
dltheappli¢ tore Wilding arm pant usea,ulpmurt or deWm VWfILATION FAN(SINGLE BERD) ISSUANCE DATE
which emit I i ardws air mnta mbuntn as defined by the Bay Area Air
• Q.alLLy Ma rugement 7 BOILER{OMP DFIP OR 100,Om BTU)
No
lhava read the hA52F3&.matertesmci.hements under Ch.pter 6.95 of BOILER-COMP(OVER100,000 BN).
the CaulamW Health A Safety Cade,Sections 25505,255D and 25530.1
understand that if the building don net mamntly hive a tenant,that it b my NEWRFNDFNTIALMECIL SQFT.
responsmullytonaify heocmpeu oftherequimmerda whkh be
P rior to an¢ rti! t - panty
¢a . *41e
/r
uth gent ISSUE
TOTAL. -
OFFICE COPY U.