22173 aArrua.na�a av rack.n• mrvmm�a wr• • — �•• �••-'•
Building Noted Identification PERIAl l'NO.
Building Add.,,: 22173
6 2 ,4 -
one:
wC, CITY OP CUPERTINO-BUILDING DIVISION
E. sea 176e
APPLICATION I PERMIT t_
6 Al .l (,a• �,�/ BUILDING-ELD27RICAI-PLUMBING-MYCIIAMCAL CATEGORY CO L K-7SI
rchl—ien (neer k.No: -` `
(�d/ 'a ^ 7i' 'w""' �"c iFE BUILDING PERMIT INFO
Q_TY:., - ELECTRICPERMIT-ic!tr. .'. FEE,
Addmaeq� y3 PQIMITISSUANCE 2-00
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmrac. MPLIANCESRESIDEIYPIAL 1011 DItSCRiI'i ION
Ingwlth Sralon 2L00)of LHvIslo.3ofthe Buslnessand Pm . ata Code..d my
time.1.in fu0 fie rad effect �J(p PANELS may- `3
Llmna�Chass
Dae Contractor 0109
ARCHITECTS DECLARATION 2014000AMP5
q�q�++M ZZC I understand my plain shall be used u public records. OVER 1000 AMPS SO.FL FLOOR AREA ,5`tea./m.Fr.
k�U Licensed Professional SIGNS ELECTRICAL � , l2'
�<N OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC _Eli I /_g I
F, 7 Iherebyaffl.that l am exempt irom the ContractorLAW License w fm the f�J/�j L PD
Z � county hichrenufac,a er",ft7031 ,Buanessand,Improve,de e:Anycttyor p�T E
following
eaon.(SesapermWocowtmct,adProfesions Code:hyena or TEMP.METER ORI01-EINST. _.
anystrodure pciorto Its bmance,aono requlmethe applicant for such permit to
1Y a POWER DEVICES
K U Ole a signed License
that het licensed pursuant it the pmvblom7000) of the
Contractor'susleaeLnd Pro ens Codercncin IISxemptthe00)o(Dlvl-
"'I"n � gsv SWIMMING 100E ELECTRIC 05 Stan of the Business and Professlom Code)orthat hebeumpt themfromand TE VALUATION
y the basis for the alleged exemption. Any violation of Section 2m IS by any OUTLETSSWITCHESFIXfURES
�y0 Applicant for.permit.idn"the applicant toss civR pvutty of not more than
t5$ five hundred dollars($50Q. NEW RESIDENTIAL ELECTR
owner of the I with wagesas their sole SQ.FT. SIOWIS TYI'ECONS'l1tUC1ION'
I,as
property,or my employees w
7a compensation,will d a the work and the storms re b not Intended or offered for
❑ .sate(Sr<.20C4,Business a rad Professions Code:The Contractorm s Limnlaw
�$ does not apply to an owner of propertywho builds or lmpmvesthere..,and OCC.GROUP RES.UNFFS
whodoe...ch work hinu elf.,through h6ownemployan,provided that such
Improvrevents are not Intended or offered for sale.if,however,the building or TOTAL: 7,06
Improvemr.tbawJrg1hin.neyearofcompletbn,Iheowner-bullJerw111 have .- .,..... . ..
try��.L as owner
of the
propehcdnd not exclusively
contra ting with lmese QTY. U=PLUMBING PERMIT- FEE FlAOI3 PANE APN
Ltr L a.owner tr the property,am exdu,Bush si and mg with Ikemed PERMIT ISSUANCEconI 1 d
The Contractor's
LAW doe(Sec.apply t an nand Pf prop rtCode: I U_
Th<Cont actor's Lices thereon,
on, don not apply to an owner d property who ALTER DRAIN&VENT-WATER(EM
Banda t r improves tPursua,and who contracts ries ouch pSojero wOM1 a '- ; FEE SUMMARY
cq➢_tractor(n)licensed Pursuant to the Contnctorf Llanee Law. BACK FLAW PROTECT.DEVICE + t '
LJ I .m exempt n.aer s.. s A r c far this reaao. OUTSIDE ILES
Owner Date DRAINS FLOOR ROORARFA,COND. SANITARY Y N_
RECEIPT a
•
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRA` SCITOOLTAX Y_ N_
1 QI here'ry affirm that have a and Ocate of consent to self-Insure,ora REC14Pr R
cerifinmof Wmkeri Cumpematlon Insurance m a mnlfled copy thereof(Sec. GAS.EA.SYSTEM.1 INCA OUTLETS PARK FFM Y N_
380QLab CJnn (7 ( RECm'rg
Policye Y'� 8 �-1 I GASEA.SYSR9d-OVER<(EA)
Com any _ CQ,' BUILDING DIVISION PEES
{cnl0edc py b heed With the ual.city GREASEANDUSIRL WASTE INTERCEPTOR BUILDING
FEE
•1['7�`(ertl0ed copy b filed with the city inspection dlvlalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID a �J
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F1'. Date Recei IN l /,�
rrhls aMlon need not be completed 11 the permit Is intone hundred doll..
(s100)mWATER HEATER W/VENT/Fl TR ENERGYFEE Y N
Ittnlfy certify that In the performance ofthewmkfor which this permltb6sued,
I shall not employ any Person In any manner n a to become subject to theWATER SYSTEM/TREATING
O . U
Wo,kerd Compensation'A.of Callforela. Date PAID dJ�
Z Applicant NEW RES!DEN IAL PLMe. ;QPI. Date Remi NI a
F_ O NOTICEco esubI tothe orrmakingpen Certnlpro is Exemption,you
should become subFct to the Worken'Compasnal.n provblomofthe Labor TOTAL: �1�Z
CCN Code,you most forthwith comply with such provisionnorthls permit shall be BUILf�ING FEE �f�• OD
LU > dnmea revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE a l
CL hrrebyalflrmthanherebecovmctlonlcndingagengforlhepe .rm OTAI: A�1 ELECTRIC FEE /7 pQ
Z ante of the workfar which this permit la Issued(Sec.3092,Clv.C.) F^/
O LendefL;I!
(� r.Name - PLUMBING FEE f1
LL F- Lendernndamaa Qat: - ..'MECHANICAL PERMIT',:' :;:FEE, MECI IANICAL FEE
OU IexAfythat l hav,m.d thb.ppileatlonand atatethauheabove lnfarmaJon
fU Lscorrect.I agree to comply with all dty and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hemby authorise representatives of this
F N
city to entero .the shove-mentioned property for lnnpe a epos.. ALTER OR ADD TO MECi1.
Z Date ReceI NI
— (We)a c save,Innemni(y an d keep harMem th City I Cupertino F t"—�—
agaimtlia IIIc a,Jud ,cosbandexpenxa whlchma n yw.yaccam ARIIANDMNGUN11"RO10,000CIN) SUBTOTAL:
agalm Sal fly In encf or the grantng.flh�pr
✓✓��/�J -� AR I MNDUNG UNIT(OVER IQ"CIM) CONSTRUCTION TAX
sl nanre.f pp < Uc.mnrt.r Date Ext iAusr 110013(W/DUCT) CONSTRUCTION TAX PAID:
HAZA RDOUS MATERIALS DISCLOSURE
Will the Applicant or future building occupant store or handle h=ndous I BEATING UMT(TO I QQ(00 BTU) Date RCeel tb
materlal a,dcfi ned by the Cu penin.Municipal Cods,Cha pier 9.12,and the - -�(
I411thard Safety Code Srctlon25532(a)} IIFATINGUMT(OVER100,0(IOBTU) TOTAL: + r/
❑Yra No
WIIltheapplIaat orlon building om pant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haardoos air mntamlnants as defined by the Bay Area Air -
l� Quality Management District? BOILER COMP UHPOR 100,000 BTQ
OYea No
Shover,Ad the hva[ amateriabmqulremntsunderCh.pter6.95.1 BOILER-COMP(OVER 100,000BTU) {
the Callou
forala I Icalth A Safety Code,Sect tom 25505,25533 and 2S536.I
anderstand that if the ba tiding does not m mently have a truss nL that It h my NEW RESIDENTIAL MECI L S0.1T.
nesp.exiblllly I.notify the occupant of the rrqulmments which most be met
prior to issuance of a Certificate of Occupancy. (slty./aI'k'( CUPWFIT(I
TOTAL
Owner or auth.rlmd agent Date ISSUED BY fL �Y �v
�/— —
OFFICE COPY