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21968 APPLICANT TO FILL IN INFORMATION WITHIN RED LIIJES — USE BALL POINT PEN ONLY H41ldl"B Pro'ert Identlf cellon -z© PERMIT NO. Building Address: G (I-IA- i* T+> o s z z� s s BL-� CjP0M,.LticA 21968 �4C\ G Aa}t�S\�IO�S l OJT` CITY OF CUPERTINO,BUILDING DIVISION Ca Name: b.Na: APPLICATION / PERMIT Q ✓ BUfLDINC ELECTRICAUMLIMBINGMECHAMCAL CATEGORY CONTROL 046 ArT Iced/Fsgin a Llc No �tfAs�A assaaaaa �1�^ 'Q� �" ''`ELECTRIC PERMIT I",. '�•�i FEEIp+\. I.' ,' i BUILDINGPERMITINFO Addrcm: Y C l\�'•C` / PERMIT ISSUANCE LICIiNSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions ofChapter9(comment, PLIANCGSRp,SIDENTIAL JO RIPTION ingwith Section 700lgof Dlvlslon3 ofthe BuslnessandProfesslonsCode,and my -r..s _ r.0 l c�D � I icense b In full fops end effeR--„ P N "�/ V I.Ironsc Claes !'S Lle _Z Date Contractor ARCHITECTS DEC N fit-1000 �' 9Z I understand my plans shallbe used as public records OVERT PS SQ.FT.FLOOR AR� S/SQ.FT. iu 0iu I Od pj Licensed Professional SIGNSELEC CAL Q OWNER-BUILDER DECLARATION SPECLILCIRC /MISC z � I hereby affirm that l am exempt tram the Contractor's Llmneehw forthe o Q following reason.(Saddon70115,Buslndeand Professions Code:Any dryer D FZI"ty countywhlchrcquimsaperrt'dtiommtmc"ter,impmve,demolbh,ormpalr TEMP METER OR LEI T. Ob0 anystructure pdorto its Lesesne¢,also requlreathe applicant for such permit to - (y ryE file a signed statement that he,licensed pursuant to the provisions of the POWER DEVICES - 'g3wfn Contractor'.LicenseLaw(Chapter 9(commencing with Section 7000)of Divi- SWIMMING LELE C - - H�O�. e(on3ofthe Busineeand Professloru Cade)orthat hebexempttherefromand VALUATIONO O. Sn the base,for the alleged exemption. Any violation of Section 70)15 by any OU7LE TCFIFSFI FS 7� < applicant fora permit subjedsthe applicant to a civil penalty of out rmre than4A, v ( ea five hundred do[]..(S500). - NE ESIDENTIAL ELECTR SQ.FT, STORIES TYPECONSIRUCl ION .. ❑I,as owner of the property,or my employees with wages as their sale' compensation,will do the work and the structure is not Intended or offemd(or C O sale(Sec.7044,Business and Professions Code:The Contradol's License law $ doe.ace.pplytoanownerof propertywho Wilds or improve.thereon,and who doessuchwork himself orthrough hlsown employees,provided thatsuc - TS Impeave.ets am not Intended proffered for.ale.If,however,thebulidleg or TOT improvement,sold wlthiermayearofcompletion,the owner-builderwlll have .. . .. , tlillkurden of proving that he did not build or improve for purpose,of sale.).N QTY + . PLUMBING PERMIT, LJ I,as owner of the property,am exclusively contracting with Reversed F7.00D contractors to mmtrud the project 014, PFRMR ISSUANCE '"2 (Sm Business and Pro(mlons Code s The Cdntndor's License law does act apply to an owner af property who Wilds or Improve thereon, and who contracts for such Piojecte ALTER-DRAIN&VENT-WATERwith a 2x, cgp(factor(n)Bernard pursuant to the Contractor.License Law. .,•r', '.� FEE SUMMARY LJ I am exempt under Sea B& P C for this reason BACK FLOW PROTECT.DEVICE / 011TSinp FEES D NS FLOG ROOF,A GOND. SANITARY Y N Owner I Date R C� RECEIPT N l WORKMAN COMPENSATION DECLARATION FIX SPER TRM' r-'�, SCFIOOLTAX . Y_ N ❑I hereby affirm that I have a certificate of consent to selMnsurs,or a RECEIPT N uAificaeofWorke Compensatlonlnsuranmoracertlfledmpythemof(Sec. 3800lab CJ GAS FA. INC.40UTLETS', PARK FP.E Y N , - PoIIryN GAS EA.B OVER4(EA) RECEITN ' - Com an - IB UI LDI NG DIV]SION FE ES ' ❑ ertBled to furnished. I GRFA /IND L WASTE INTERCEPTOR PLANCIIECK'FEE Certified copy is filed with the city inspection divisloa. CERTIFICATE OF IXEMPTION FROM WORKERS' G ETRAIP PAID, COMPENSATION INSURANCE I SEVVFR-SANITARY- RM EA 2o0FT Date Recei t# (Thbsectlon need not M completed lithe permit b(or one hundred dollars ($1I oil that WATER HEATER W/V /ELECTR ENERCYFEE Y_ N_ 3��.p I certlly shat in the performance of the work forwhlch this permit ise,aed, �. I shall not employ any person b any manner m m to become subject to t WATER SYSTEM/TRGTI Workers Compensation Law.of California. Date PAID O Z Applicant NEW RESIDENTIAL PLMB. Fp. Dale Remipt*' Z U NOTICE TO APPL[CANT:If,after making this Card is of Exempt) you Fshould became subject to the Workers'Compensation provisions of t Labor TOT a N - Code,you must forthwith comply with such provisions or thiaper tshall be BUILDING $ III ] deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE D Z+ , (hereby orkf.hatthere,aco ruction lending agency for the pdr(ornF TOT ELECTRIC FE Z once of the work for ,evened(Sec.3097,Civ.C.) � ' LL TandeexAdd ax, , . PLUMBING FEE L) Lenders Address N QTY. ,o hfECHANICAti PERMIT . _ ' ,FEE LL - MECHANICAL FG' U Icrect.I agree the reaty with allcittanand dcunty o nfleeaboved Asia tionlaw. a-1 C• 2 ,coingto agree complywlthall adhered rouhodan,lnanceeand tlalelawa PERMTT LSSUANCE Item FEES PAID:/` -T cityrelat oenterupon t ronsue-crenendhereby authorize rcpreaenpurposof this V' N city toenter upon the abovementioned property for inspection purpose. A TER OR ADD7D MECH. t 2 - Date Recei t (We)sgrcc ssve,Indemnify and keep rMesthe Clty o(Cupertlno P U agalmi bill a judgment;mat ander n which may In anywayarorue ' AIR ]SIDLING UNIT(TO 10,000 CFM)' (� SUBTOT L• ag.i Id 1 In consequen o(tM n gOf fhb it. _ AIR HA N NG UNIT(OVER I D,ODOCF CONSTRUCTION TAX c CONSTRUCTION TAX AID: SI t .(App HAA car— Date IXI-IAl15TH (W/DUCT) i HAZARDOUS MATERIALS store LOSURE, IltheappllcdbytlutumbuB M.nfo ipantrtomorhandlc hazardous HEATING UMT 100,fA0B Date Rece f# Chard definy CraleeCupertino Municipal Code,Chapter9.17,and the - - —/ F�hi�h Yas yCode,Se`NNo 75531(.)7 HEATING UMT(OV• 00, BTU TOT J --. _ the applicant or❑future Wilding occupant use equipment or devices VENTILATION PAN(SI :REBID)' L ISSUANCE DATE eManage Mous altrict? Mnante as defined bythe Bay ArcaAlrity Management Ulslrid7 BOILER-COMP(3,76R100, TU) 4Yea ❑No haverl.Ile.th&SafetyCodria,requimmenlsun33 aChapter d25534. 9oof BOILER-COMP VER 100,000R U4 y the Callfod that lithebSafetyCode, or currently have a tend,that I 0461 V resp.tmdrretandthat notify the ing doesoccupant of t errentlyments tenant,t--------It Is my NEW REST Al.MECH. SQ.FT. - rrior(a lolity issuato of aCeheicteofOcfparry.iremen(ewhich mustW mel a ,^ prior to Lssuancc ofa Certificate ofOnvpancy. Owner orauth.naed agent Data TOTAL: ISSOEU BY e\\�CY4 i % OFFICE COPY