22568 APPLICANTTO"FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:/ /a./1 - 22568 .
nen ante: one: _ A ..
w CITY OF CUPERTINO-BUILDING DIVISION
,."J�/LI=N=� . APPLICATION I PERMIT
'/12 7d �e/'-s� BUILDING-Fl TMCAL.PLUMBINGMECFLIMCAL CATEGORY CONTROL N
Arch tett/ Biker. Lie Na r1 '
BUILDING'PERM'. 1 .
QTY ,,�° ELECTRI,C'P,ERMIT FEE trBL� ..
Add .•.PERMITISSUANCII hiQ
LICENSED CONTRACTOR'S DECLARATION /rte"' ([ }
I hereby affinn that i am licensed under provisions of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth SecHon7(g0)atDlvftbm3 ofthe Businessand Professions Code,and my
license le in full force and off ad'. q PANELS TL•'�-�{•.. 1ZFi6 Fl;� .
Llocalse Class Lic.N
a Contra o-� LTu 1'L�oil
ARCHITECT'S DECLARATION WI-1{00 AMPS
2 I understand my plam,hall be used as public mords. OVER IOW AMPS SQ.FT.FLOG AREA - $/SQ.FT.
pqqP!!m❑O SIGNS ELECTRICAL
Licensed Professt°ml - �- "al E D -'.N .
<<� 'OWNER-BUILDER DECLARATION' SPECIAL CRiCUfT/ SC
zf, � Ihereby ason. that lam31.5,Bfrom the d Profcioos Lionx taw fort he P UTE R
oo following reason. 700 I5,Business and Professions Code:Any city or
07t.,u� TEMP.METQt Oft IA VC
CqS� countywhichrequimsapermlttoomtract,aller,lmpmve,de=liah,orrepair
qqqmm anyatm=m ptlorm its issuance,also requlrestheapplicant for uch permit to POWER DEVICES /
rG file a signed statement that he I,licensed pursuant to the provisions of the
3m Contractors License Law(Chapter 9(commencing with Section 7000)of Dial-
�Og pon3 ofthe Business and Profoesom Code)orthat he la VALUATIO exempt themhomand SWIMMING POOL ELE C
O the basis for the alleged exemption: Any violation of Section 70315 by any OUTLETSSWITCHESH FS O�
applicant for.permit dubjectsthe applicant to a civil penalty of not more than
$
five hundred asownerofthe pro NEW RESIDENTIAL ELF.CTR SQ.FT. STORIES TYPECON5TRUCl'ION'
❑I,ea owner°f the pwillclothe work,and or my employees with wages r their dole
�9, ass&c.compensatlon,B..incassand mfmihms e:mbConnot tadoeended oroffe Uw
d for
� O does
oe nova ply man
propcty Co Wild&orimpoves License law
5$ doesnn apply torn owner of trough his oitemporimpmovided that such
OCC.GROUP RES.UNITS
whodoem nts am khlmse Intended
hisowneered .If,however,
thatsuch
improvements
ithindroycar fcomplotim.If, cwmrrer,thcbrwill havg ore - TOTAL:
Improvemenl6eold within oneycarofcomplett°M the ownerbulMerw111 have - -
th,e_ja�rden ofproving that he did not Wild orlmprove for purpose ofsale.). QTY, ='i7>PLiA1 9ING,PERMIT',i� 'FEE ' FhOODZONE APN
Lj L as owner of the property,am exclusively omratting with thensed ^ ,
contractors to construct the project(Sm 7044,Business and Professions Code: PERMITISSUANCE la
His Contme°re Llcenee Law dace nab apply to an owner of property,who pLTQt-DRAIN Na VENT ATTR ) /�
Wilde or improve themon,and who centimes for such pto)ecb with a eZ s-V
- :ctor(s)licensed pursuant to the Contractor'.Llonx Law. BACK FLOW PROTECT.DEVICE `t ' FEE SUMMARY
I_I1 am exempt under Sec, B_k P C for this reason
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
I WORKMAN COMPENSATION DECLARATION RECEITT N
FIXTURES PER TRAP SCHOOL TAX Y 'N
❑I hereby affirm that I have a rertNcale of consent to self-Insure,or a RECENT N
cemflcateofWorkers'Com tion lssura ecoracertlfiedopythemo!(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
3800,tlb C.). � 7f��
ry 7 o GAS EA.SY9fEM-OVER6(FA) RECEIPT
BUILDING DIVISION FEES
�Cen4Red'co 6 e ytt
Certified copy with the city
irspettian diviaion.ehiGREASE/INDUSTRL WASTE INTERCEPTOR - PLANCHECKFEE
❑
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-STORM FA 2001-7 Date RCCCI t#
Rhlaeettlon need not W completed It the permit la forone hundred dollars
($100)or leas.) - ENERGY FEE Y N
Imrtifythatinthc,d.manceoftheworkforwhichthlepermitle6sud, ' • 1'`'ATER HCATIR W/VENT/ELECTR —
I.hall out employ any person In any manner so as to became sub)ect to the WATER SYSTEM/TREAT[NO
Workeri Compensation Laws°f California. Date PAID
.O Z Applicant NEWRFSTDENTIALPLMB, SQ.FT. Date RCCC'1 t#
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workem''Compematlon pruvisimo 'the Labor - TOTAL:
CC Codeyoum must forthwith comply with such provision,orthls permit shall be 1}�1 I
`' cleansed!
,ystN FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a`Z Ihereby affirm that there is a cosstmctlon lending agency for the perform- . - TOTAL: ELECFRICFEE
7 Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) - - -
02 ]ander'.Name PLUMBING FEE L( 7
LL f Lender,Address - QTY: MECHANICAL'PERMIT' .FEE+'• MECHANICAL FEE
OW Icertifythatl have read lh6appliratlonand nate that theabove lmormatton �y
fl lacerrect.I agree to comply with all cityand county ordbummsand pale laws PERMIT ISSUANCE ['2—CX) FEES PAID:
} relating to building construction,and hm
erebyah.mr.representatives ofthis
F Z I 'city to enter upon) ove-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date ReCCI f#'
V _ (We0�_>;
indemni n d keep harmless the CIIy Cupertino P
agaInems endexpenseswhich ma 1 ywayamueAIR HANDLING UMT RO]0,000CFM) SUBTOTAL•
fthle t
AIRHANDLING UNIT(OVER 10,W0CFM) CONSTRUCTIONTAX
_ Wt- 1d1'8occup.rug.m.ihrdl�h.cd...
Data EXHAUST HOW(W/DUCT) CONSTRUCTION TAX PAID:
NF.RIALS DISCLOSURE
WilltheappBna .doud HEATING UNIT(T0100,000 BTU) DateRCCCI (#
mterala.de0nedunicipal Code,Chapter 9.12,and the
I Whit and Safety a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: f
❑ Yes ri No -
Wllllheappilontorfm.building occupant usenquipmem or devices VENTILATION FAN(SINGLE RESID) C ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air -
alityManagementDistrict? " BOILER-COMP OHP OR 100,000 BTU)
• Yen ❑❑No
have read the hazardous matalala requlremenb uhder Chapter 6.95 of BORER-COMP(OVDi1W,000BTV) PAM
the Cell(ornia Health building
Code,Sect currently
have
a ternd25534. I
uspoasindtlut notify theca- does not of ecoqulyments Mehl that it is NEW RESIDENTIAL MECH. SQ.FT.
r prior to biu nc ofaCeheocte of ccupa rcqulmments which must be met `•`u dt
prior to Issuance of a Certificate of Occupancy. '
' tRBl��f
Owner or aulhori.ed agent Date
TOTAL:
OFFICE COPY