22574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro ed Identification PERMIT NO.
BuildingAddress: 22574
10321 p a bre. ��'�
wrenName: I Floor:
_�1 S �-7 7'S2 "ITY OF CUPERTINO-BUILDING DIVISION
• Contras reNane: I L'�ic,,aNassaoaa: `� APPLICATION if PERMIT
Wa AIIILDINGQ.ECTRICALPLUMBINGMEC}IAMCAL CATEGORY CONTROL
Arngln�e6 O�
GIG$LIc.N.1 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add—A-SO3 NIQ � PL-• �M PERMITISSUANCE El ❑
LICENSED CONTRACTOR'S DiCLARATI N
I hereby afflrmlhal l am heensed under provisions of Chapter 9(mmmenc APPLIANCES.RESIDENTIAL JOB DESCRII'ITON
irl; th5ectlon7(Xp)of Dlvision3 ofthe Bu neaandprofeasionsCode,and my
license Is In s force and died. p L 1 " `
cen�e�lam�y—Lie M - ' V V VJ
Date�tia.I t CoNra r fps
ARCHITECT 10 201-1ODO AMT'S
ct0 2 I understand my plans shall be used s public records. OVER 1000 AMPS SQ.FF.FLOG AREA b/SQ.FT.
O c
Licensed Professtmral SIGNS ELECTRICAL
L `
F, a Thereby alOrm tptfrom the Tor'e License law forthe SPECIALCI4CUIT/MLSCOWNCR-BUILDER DECLARATION 115
` W
o lo0owing reason.(Section 7m1.5,Businessami Professions Code M d or
OZy ep TEMP,METER OR TOLE INST.
p45@ muntywhkhmqulresapermlttomrutrunalter, apmve,dennlbh,ermitto
anystmcturc pdortolts lsaance,elso requlrcethe applicant fonuch permit to
O file a signed statement that he It licensed pursuant to the provisions of the POWER DEVICES Q aye
Contmaor's License Law(Chapter 9(commencing with Section 7000)of Divi- O
3 0s4vIHhINc root ELECTRIC
uon3 of she Businevand Professions Code)orthel he V exempt tM1emfromand VALUATION
F'$� g the basis for the alleged exemption. Any violation of Section 7MI5 by any�g �"���1+�aar��� �Av"�,,.s'�.!!���applicant lora permit subjects the applicant to a civil penalty of not morethan OUTLE7SSWITCHESFIX7TJRFS J - - �/
Epi five 1,as
dollarshepr. NEW RESIDENTIAL RLECTR SQ.FI. STORIES TYPECONSIRUCTION
GW7 p I,as owner of the property,or my employees with wages a thele sole
compensation,will Bothe work and Prologue.Cdare Vnot Intendedo roes,Lfor
O docs saie(Satappl.to ainess owendfprpeywho builTheds
Contractors License Law
3R whodn"a such
loan owner o(throug his one morimprwntedthatand OCC.GROUP RFS UNITS
whodonaucM1 workM1Mselorthtwgh hbownemplgen,provided that such _
Improvements are not intended craffered for sale.If,lemveveq thebuildleg or TOTAL:
Improvement issoldwithin oneyearofcomplMlon the owner-bulklerwill have ,
thr„jnvden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,cue owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
cumeaders to mnelrua the project(Sec 7044,Bushes and I'mfessiov Code:
The Contractor's License Iaw don act apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or improves,thereon, and who comment for such pWieats with a FEE SUMMARY
mdor
rn4a (s)Lessard Forecast to the Contractor's License Law. BACK PLOW PROTECT.DEVICE
L j I am exempt under Sec B k P C for this reason
lWo
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� _
Owner Date RECEIPT B
• WORKMAN COMPENSATION DECLARATION FD(T1IRE-PER TRAP SCI100�TAX Y N_
QI hereby affirm onse
that I have a certificate of cnt to calf-mare,m a RECEIPT N
cediflnteoi WOrken'Comper tionlruuranmmandlfledmpythereof(Sec.
MM,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
ComryB RHCEGAS.EA.SYSTEM-OVER 4(EA) p
BUILDDINGING T
OI V ISION FEES
Codified copy 6 herebywith the city GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�CcrtiRed copy V(Ihd with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRM PAID {'(�
COMPENSATION INSURANCE SEWRXSANTTARY-STORM EA.200PP. Date Rccei t# �vt70
Ohtssectlon need na he completed If the permit Is(rn ane hundred dollars
(5100)orlmJ WATER HEATER W/VENT/F7•ECTR ENERGY FEE Y N
I certify that Nthe person
in any manner
as t ob co permit is WuM,
I shall not employ any Ferwn Is any runner at s to become subject to 1M1e WATER SYSTEM/TREATING
Works.'Compensation Gwa ofGlifomla.Date Pplp
C• Z Applicant NEW RESIDENIAL PLMB. Date Remi t
Z O NOTICE TO APPLICANT:If,akar nuking this Certificate of Exemption,you SQFL
Fshould becomeaubiect to the Workers'Compensation provision oflhe Labor TOTAL'
cN Code,youmustforthwithmmplywdhsuchprovimstonorthbp. tahallbs a
> desmid revoked. IL
••
W
C CONSTRUCTION LENDING AGENCY SEISM] E
l hereby affirm that there b e cowtmctlan lending agenry far the perform ELECTRIC
� O ante of the workfor which this permit is Issued(Sec 3097,CIv.C.) TOTAL: '
V Lenders Name PLUM I _
ly F Lender'sAddres QIY.j MECHANICAL PERMIT FEE MEC ]CAL FEE
OW 1certlfy that have read this application and pate that the above information
1 I,cormd.I agree to comply with a0 city and mu my ardlnasces and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize reprnenlativnofth6 yC
U) city to enter upon the above.mentbned property for Wpecibn Purposes. ALTERORADDTOMECH. ( Reeei #
— (We)agree to save,Indemniy an d keep harmless the City of Cu petition
against liabilities,judmenta,cede and expenses which may In anyway aceme AIR FIA NDLING UNIT(To 10,000 CFM) SUBTOT L•
ago Wt City In en nofthegrantingofthlspscret.
AIR HANDLING UNIT(OVER to,WO CFM) CONSTRUCTIONTAX
Signature of Aplicam ontractor I Dae EXHAUST HOOD(W/DUC7) CONSTRUCTION TAX PA
k__±[A,WDOUS MATERIALS DISCLOSURE
Will the applicant orfuturc building occupant store or handle hazardous HEATING UMT(TO]Of1,000ITU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the 'Date RCCCI t#
Health and Safety Code Seaton 25532(s)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ YnNo
Willlhea pplimnlm w.bulldingamepantusaequiprmntardevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua llty Management District? BOILER-COMP FHP OR 100,0010 BID)
r 4 Yn �No
have read the haza ousrwtedals requlrermets under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU) L�c'YY
the Calliornla I Iralth k Safety Code,Sections 25505,25533 and 25534.I OCT
understand that lithe building don TI
not currently have a tenant,that It it my NEW RESIDENTIAL MECH. SQ.FT. `J •l T 1991
emiu nsiblllty to notify the occupant of the requirements which mud be man
1
prior to Issuance of a Certificate of Occupancy.
Owner or authorlad agent Date 155I1ED BY:
TOTAL:
OFFICE COPY