22309 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identfkaklon PERMIT NO.
Building Address:T.3 [ `-� 22309
orrs rz= ei
7313v.1 e-5 CL BL-t,)p_7 CITY OF CUPERTINO-BUILDING DIVISION
Contneora Name: Na APPLICATION / PERMIT �\
Archk /Engiorer Inc No: BUII.DINGELECIRICA4I'UJMBINGMECHAMCAL CATEGORY COm"St s
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aaaneac
IERMITIS5UANCE }�/'� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
aRbmthatlam L'cerueduMerprnatanevof Galles ode,anm APIrWANCESRE9DEM7AL )Dg DESCRQ•f10N
Ingwee Is 1.tbn 7000)ofDWfeet 3 !the Budrc.+aand AafeWau Code,and my
lic�noLicens Is 1.toil(or¢and d # PANELS Keg
'A'V?
Danac Cts Llc/ 'IA` (j"C— I\,
Date Contractor —UP TO 200AMN
ARCHITECTS DECLARATION .201-1000AMPS
W Z I understand my ptsrm,haB be aced u public records, OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
6 Lkenaod Profewbnal SIGNSEtECtRIGAL ALE D
N OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M19C
E, M P U T E
7 �5 I hereby,ffirenthat I am exempt from the ContnCor's License Law fee the
FgO^o following uue.(Seelon 701315,Boameaa and Profmnu bCode..My city or
'y msnty whittle requires a permit to me utt,alter,improve,demolish,oreepair TFMP.METEROR POLE INS.
aanyehumu pr wirowanes,,alaorequr theappBontforsudipermltto POWER DEVICES
af
file a signed statement thrt he b licensed punusm b the provisions of the
3cCormneor:LlcemelAwlChaptm9(mmmendng with Senbn7000)0f Dw` SWB, VALUATION
POOL El
GI tln3oftheBus and Pmfembrm Code)orNathebeaempttherehomard
•:] the hub for the alleged eaemptbn. Any Wdrtbn o(SeGbn 70015 by any GUTLFISSWI1CHESFLXTURES 1 ,.��qG u i.
OA appli.t for.pemdlaubjedatheappllcamtoadvll penalty fraterme Hun I I Vim+ LN
�c 116undred dollars,OM). NE
$^ LJ I,as owner of the property,or my employees with wages u their sets W RE9DENML ELEC7R SQ'FP' STORIES TYPEODNSTRUCTION
t comperwHh w
or,willdotl9 and Nwb Wended eamrrs not Weed or offered for
7'�p Bale(Sec.70K gushes,and Pnefevebn,Code:The Comntlors Llave Law
$ doe not apply to an owner of pmperty who builds,or Improve thereon,and
who doeasuch work himselforthrough his own employees,provided that such OCC.CROUP RES.UNTIS
improvements am rot Intended oroHered faeale.If,however,thebuBding or TOTAL:
impmvemam Isseldwithmouycarofcompldbntheowner-0 aderw love
tlAlZrrdenof proving Hut he did notbuild or improve fee purpose ofaa3e.). QTy, PLUMBING PERMIT FEE
FLOOD ZONE ..APN
LJ L as owner of the property,am essheavely contracting with llarued
mntractmsto mrolruci Wepmfen(See 7004,Bwlnew end Prdeelem Code: I'FRMR ISSUANCE ..
The Contraaor'e Lkerue IAw doe nest apply to an owner of property who 4e.
ALTER-DRAW k VEM-WATER ffA)
builds or improve thereon, and who mntmcta for such ptoFm with a
�ur(d Bcen.xd pursuant to the Contractor's Llerue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I im,vrmpt order Sec B 4 P C for this reawn �TSI DE FEES
Avner prix DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION 4
❑I hereby affirm that I have•cerHOate of consent to self-iwre,or a I`l)(TURFS PER TRAP SCIi001,TAX Y N
anlBate of Worken'Campematlm Imurance as certified ropy thereof 15ec. RE)CEPF
If
3S00,IAb CJ GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y_ N_ .
laky s RECEIPT a
CCm�Ma GAS FA.SYSTFM-0VER4(FA) BUILDING DIVISION FEES
1�Certifled ropy b herebyfurnished.Necity CREASE/INDllSIRl WASTE INTERCEPTOR' PLANCHECK FEE
LrTJt CcrtNed ropy ts filed with the rXY IospeRbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREA-'�TRAIr PAID
COMPENSATION INSURANCE ghN'FRSANITARY-STORM Fa 20IFT Date Pht
(This aemon need nes he rompleted B the pemdt b fervor hundred dollen
MOD)ml..) WATERff HEATER w/vExr/EiEcrR ENERGY _
I certify that In the pedormanne of the work for wMch this permit is Issued,
I shall not employ any en y manner n n )ed to the WATER SYS1T7d/TREATING
Workers C ilfanla.Date P
PP Date R i ted
Z Q NO71'ilCE7O :U,a maldngt Certl! to of semgbn,you NEWRLQDINDALIBI.MB.
should become subject to thea:ri Compeesatbn provisions of the Labor T AL
h N Code,youwstfmthwkh sell hsuchprovbbruorthispermltshallbe
W ] deemed revoked. --
CONSTRUCTION LENDING AGENCY S I IC a O
Il I hereby afTUm tlut them to a mvtmction tsrd Ng agency for the perfomvELECTRIC FEE
7 0 anaof the work for whkh this permit le issued 0rzc.3097, lu.C) TOTAL.
IArder:Name PLUMBINGFEE
-
LLF Lender:Adm>B - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertilythat l haver eadthatappBcetbnand Butethal the above Information
D. bmrre 4.lagmemmmpgwNn.udtyana munlyordlnancn and late law. PERMIT L%UANCE FEES PAID .
} NalingtobulMm
ingnstruGlon,and hereby autherlm representallvesofthIs
F N dty to enter upon the abovo-mentbned property for Inspection Purposes. ALTER OR ADD TO MECK
Z.
(We)agree to save,indemnify and keep harmlm the CRY of Cupertino Date R ci t71
V aga1ret11abWtles,ydggmres. ndeaperue t ehmayinanyw.yamue AIR HANDLING[IMT(TO 1g000CFM) SUB TAU
agalm aid ty T n¢ofthe grantln o ""s permit.
AIR HANDuIvcIMIT(OVER lo,aao CEM) CONSTRUCTION X
Slgnatureof Applintramor D,t MIAUST HOOD(W/DUCT) CONSTRUCTION XPAID:
RDOUS MATER I A L 5 DISCLOSURE
Will the appu future building oavpam more or handle fi vsrdous HEATING UNIT CIO 100,000 BTU) Date R el til
material as,deft the Cupertino Mueleipal Code,Chapter 9.12,and the
Health and Safety Code Semon 25532W7 HEATING UNrr(OVER IMM BTU) TO L•
❑Yro Irr�—,1 No
Will theappBnm orfutum building ar paet use equipment mdev4 VENTILATION FAN ESINCLERFSID) ISSUANCE DATE
which emit hazardous air conumW w as defined by the Bay Area Air
Quality Management Dlatri¢7 BOlf,ER-COMPOITPORIM,000BTU) PAM
4 Yea 1—I No
have read the hares esu,materials requ lremenb under Cha peer 6.95 of BOB.ER-comp(OVER IOLO0BTU)
I CABf.ib I I.lth k Serf&y CM ,Sea .25505,75533 and 25534.I
urdmtandWtiflhebuBdingdoen&t mntlyhaventenanCthatitIsmy NEW RESIDENTIAL MEIN. SQFT �t GYRI
respommBity to edify the occupant of the requbements whleh must be met
priorto LBsuarueofaCediBa ofOmap ncy. WN. M
Owneraauthorl a agent Date ISSUEDBBy-.
TOTAL: V`
OFFICE COPY /