22379 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bull&nx Prulea 16-11 cation PIi1t.MIT NO.
B�uamg naaresa: e G . 22379
coca �o
r, sone. one.
CITY OF CUPERTINO-BUILDING DIVISION �_ {�
A CenlneersName: Lk.No APPLICATION / PERMIT — 1
BMDINGELD=RICA,PLUMBING-MECHANICAL CATEWRY CONTROL
Arel fteei/Englneer. Lac No
QW ELECTRICPERMIT FEE, BUILDING PERMIT INFO
Address PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTLA
OR'S DECLARATION
Thereby
neiIon70that lamllcmaeauMerienssaprovisions of Cssions9(mrrudtr AI'IaT.IANCESRF�ENRAl
B DESCRIPTION
IngwitI Ifull](100)ofd eff n3oftMeguJroaandlioleWm,Cade,and �aY�e -DVAIe,4
L ,,I,In fuB/ d d(ect PANF35 1
Llany? ywL1c/-'-�Q�D�
Date / ''((// ..y �Coritrader C4*- �11J b
ARcxITB s DecuRAnoN �'C la000.arse Yll 1 h
��ppuu dOZ ItaderJand nyplea.helbe used apublIcrecords. OVER 1000 AMPS !�SSQ..FFr..FLOOR AREA S/SQ.FT.
Licensed Professional STGNSFI.ECTRICAL _ t wNlaces '
OWNER-BUILDER DECLARATION $PFLIAI.CIXCUI.I.
_9_a Ihercbya/firm Hut lameaemptfrom the Corarador',LI¢rue Lswfcrthe /M9Sr
FF..❑ f
ollowing reason.6eNon 7(015,Business and P'=lo Code:My d y or
Fey muntywhkh rtqulresapematmmruWd,iltrr,Improve,dertnWh,or repilr ��P'ITER OR POLE INST.
q ^J anyammmprbrtolbba ma ab m-qurntheappBantfa m&pe to POWpI DEVICES
C1 I. Ole a signed statement the he is licensed pursuant m the pmvblom of the
[OS3o� Contndor'a Lfcenle Lsw(Chaptn9(commencingwkh Sectbn7D00)of Divi-O'g SWB,I,ING IDOL.ELECTRIC
sion3o(the Builnesead Pro(mbm Code)orthwhebem therefmmand VALUATION the basis for the eleged eaemptlm. My violation of Sectio 7015 by any OUTLETS.SWTICHES.FTXTURES
appllont fora permit subjede the applicant to a civil pevNy.(nes more than
flvbhun end ddlue($SM. NEW RESIDENTIAL III= SQ SIT CONSTRUCTION
LJ I,as owner o/the property,or my employee,with wages a,thetr cob
rompewH wllldothework,andthestrumtnbrotLaeMe or offered for
Osale(See,7044,Buslness and Pr afmiom Code:The Contractors Wmme law
Sid don not apply tom owner d property who builds or improves thereon,and Co aA..DG
whodoesudnworkhirrnelf«thrcugh hlsowneerpl gees,pmvded that such
ImprvvernenLa nMll ndedorofferndfwmle.I/,howevcr,thebullding« TOTAL:
Imprwcr ntbs&dwl oruyurac«nplet theownm- WerwWF w
l reinnofpreningthathadd cost bund nr lmpmve f«purpae of sale.). Qr . PLUMBING PERMIT
-
"L as owner of the property,am erehuWely cntreding with Ite:nsdi
ost ora to mmlruct the pmjed(Sec 704A Buerm aid Professions Code: PERMIT ISSUANCE
The Contndora Lkeru,Law don not apply In an owner of property who
bund,or impnoro thereon,and who coranm fee such pTjecta with a ALTER-DRAIN&VENT-WATER
Tin rune pursuant to the Contractor's License Law. FEE SUMMARY
LJ 1 am esempt urdar Sec B &P C for this reason BACK FIDW PROTECT'.DEVICE
O Owner Date DRAINS-FLOOR ROOF,AREA,OOND. SANITARY Y_ N_
,...pp{{ WORKMAN COMPENSATION DECLARATION R�EII7Y
01 hereby affimn that I have a certlBute of consent to self-Nsorc,or a �R"��' `SCITOOL TAX Y_ N_
mrtlOo(e of Worken'CompermaHon lruunnco«a certified copy thedof Gee. RECEIPT Y
3800,IAb CJ /a�p�7_ GAS EA.SYSTEM-1 NC4OUTLElS PARK FEE Y_ N_
I'dkyl 7 0 / RECEET0
Co v [�is9s a7 �� GAS FA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
certBlea m reby GREASE/NDUSDBL WASTE IN(FRCI]'IDR PLANCHECK FEE
Cedl/1ed copy b(fled with tM tlty lapectbn dMJon.
CERTIFICATE OF CTEMMON FROM WORKERS GREASETRAP PAID
COMPENSATION ANCE SEWER-SANITARY STORM EA 3gFT Date Remi t#
(I'hbaMbn need rad tr completed B the pemdt b(more hundred dollvs
(SI OTO«ImJ WATERFlEATFRW/VENT/ELECTR ENERGYFEE Y N—
I
Am that emin ploy
anyhe erann to an the nneworr so as to 1,numeesubt b bot he
I ork rad empby any peramt N any manner at es 10 bemrrc subject to the WATER SYSTEM/TREATING
W«licant mpensa[bn L,va o/Gllfomb.Dale PAID
Z 0 nnnceiD APPLICANT:If,after m.kingtwcaduwta of Ewmptbn,you NEW RmDe4TLAL PLMB. SQtT. Date Recei t#
Hshould become abject tothe Workers'Comperustlon provisions of the Labor TOTAL:
cc N Code,you must forthwkh comply with such pmvislons orthb permit shall be
`J deemed revoked.
W — coNsrxurnons LENm le AGENCY SEISMIC FEE `
CL Thereby.RiscoHutthere bamee Isissnd(See. for perform, ELECTRICFEE
.� 2 Lereo/the woh for whkhthb permit bbstted(gee 30Y7,CIv.CJ TOTAL
U O c deraName PLUMBING FEE
LL H Lender's Addresa QTY. MECHANICAL.PERMIT FEE MECHANICAL FEEgr
O W Imrtl(y that l have read this appBatlonaM statethattheabwebfomeeti«
bcomeet.IagreetocomplywlthaDdyardmuntyonlWn and Matelaws PFRMRLSSUANCE FEES PAID:
1 dtytoent rupontheehc m,ntiodhereby rtyfrlurspre:npurpo
Z city res )arupon theabovemnify and pmpertyf«Inspe Cit of Cupertino
ALTER ORADDTO MIECFL Date Re i t#
(We).gra to ave,Indemnify and kap harmim the Clty of Cupedlro ,
againsn,t llabill Ijrdgrrcnts, ata expenses which my Nan wayarvue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against yl o « til antir,g of this pe AIR HANDLING UNIT(OVER iQODOCFW CONSTRUCTION TAX
slgNnnrsn/Ap cont dor ate oft-IAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUSMATERIALSDISCLO RE '
WWtheapp ntmfummn ildingar pantdonorl Mkha ous HFATNGUMT(TO100,0)0BTU) Date RCCeI t#
r ,at lasdeflnedbythe Cupedlw Murddpal Code,Chapter9.17,adthe
I❑ell YnMSifety Cade Nm25537(a)7 HEATING UNIT 100,000 BTU) TOTAL:
WWtheappllca « turcbullding ocevpantuse egWprrcm«devlas VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaandous Jr contaminants.,defined by the Bay Area M
® Quality Marugement 7 BOILER-COMP OM'OR 100,000 BTU) ,
Yes No
I have'ad the h a materials rttrylrerrcnbundm Chapter 6.95 of BOILER MP(OVER 100,000 BM
the Ca Womia Health&SafetyCode,SrV ionla 255M,21533 and 75534. I
urderstaM that if the building does not our rrcntly have a tenant,that It b my NEW RESIDENTIAL MF.CH. SQ.FT
resporumllNylon fythe para of the requlmmem,whkh must be met
prior tvlsay. ace t Parry. n
Pvnrroro h gen to ISSUED
TOTAL
OFFICE COPY