22503 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification --- PERMIT NO.
Building Address:
/fizz.-
owners Narrc:� a{�+� 4 !'hone: - At9'wuwUN bUOmu,Ab OA U:
(�3� CITY OF NPERTIN0.BUILDING'DIVISION
" C.
C° a name: LIe.NO: ' APPLICATION / PERMIT C C
��GS :BUILDING ELECMCAL-PLUMBINGMECHAMCAL CATEGORY CONTROI.N
Architect/Engineer. { Llc.No: I L
- QTY ELECTRICPERMIT° .I � t:CE',r' BUILDING PERMIT INFO
Address: PFRMITISSUANCE ICfI ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I V-`-J
I hereby affirm that l am licensed under provisions of Chapter9(commene-I APPLIANCES-RESIDENTIAL - JOB DFSORII'HON
Ingwlth Se ion�{70�r0c0�)uf Dlvlsim3ofthe BusineaaandP fnslons Code,rdm ,
license ie//in V�effect. PANELS -
LkenseC�y ,� _LIc.N �• ENV-,`e
Date IC nctor -rj('>`N�Ir 111 IWO A A,hm5 r _
ARCHITECTS UECLARATIO OVER0ON)" - 9 I.
WZQ' fund tand myplamshailbeu sedaspublleremrdw 1201
OVER 1000 AMPS (( ���y- ' - - ,FL S/SQ.FT.
od i Licensed Professional IS1GN5 ELECTIUGL `/ V O V 1' 1
6 f!g° OWNER-BUILDER DECLARATION R
I"m SPECIAL CIRCUIT/MISC
1., khercbyafllrn that]am exempt fromthe Contractor's Llanse law for the
Op following reason.(Section 9031.5,Business and Professions Code.An city or
ZI-•� . y ty T[MP.METER ORPOLE INS(.
�•,� , a. at- i- oortoispermittvmtutmuires the applicant prove forsteh,orrepalr
g .a anyswcturepKmtoltahat he i,lice requires to the lorisiona of the POWER DEVICES
file a signed statement that het licensed pursuant to the O.A 70ore of the - I
4B1 u,� Can 3 ofthe Licences law rofesser9(mmmentlat he is 5emptthemfiram and
the busts the alleged a and Professions Any virlation f exempt therefrom and] SWPTMING POOL ELECTRIC I VALUATION'A
the baale for the alleged exemption. Any violation of Section 7031.5 m re any I O
applicant hudmddolla.($500). the applicant toa tivil penalty o(na more than] DfTTLETSSWBTG1iCSFTXTI7RF6
O tl 1, a owner on i
�u• ($'�. NEW RESIDENTIAL ELECTR Fr.I .
�n ❑I,asownerof the property, myrarmueenwithwagesrtheirsole e•Q STORIES TYPE CONSTRUCl'ION
,t
compensation,Business a work ProfeutheatmdUre brie Intended or offered 1lor wifl do the
D sale(Sec.p py to a Business Professlore Cade:The or imp Awes herein Law I I
does rim apply to an owner of property,who nempor improve thenmry and
c+ whodoeeeuchwork himxlf orthmugh his°wnemployees,provided that each I � OCC.GROUP RFS.UNITS
Improvements are not intended orottered forsale.If,however,thebuilding or TOTAL:I
Improvement 6sold within oneycarcefcompletlon,the owner-build er will'.
tF19J,iuMeno(proving that he did not build or improve for purposcofsakJ. IQTY, PLUMBINGkPERMIT.,",I.,, I:•, .,FEE:1 FLOOD ZONE APN
Lf 1,as owner of the a pmjed,am exclusively contracting with licensed PERMITLSSUANCE I 1
contiaelas toner of the lbe project am 7016,Business and ing with licensed
Code; __II
The Contnctols License Law don not apply to r-owner of property who ALTER-DRAW k VENT-WATER(EA) _
Wilde or improves thereon, and who contract, for such pt-ojecis with a I ' { ' „ ''FEE°SUMMARY-
�q➢IfactoKs711ansed pursuant to the Contractor'.License Law; BACK FiOWPROTFOT.DEVICE I�.
LJI am exempt under Sec B k P C !or thh reawn' I r -()I ITGlfll:rs'I:S I
Owner Date I DRAINS FLOOR ROOF,AREA,CONO. I, 1SANRARY RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTfIRF_S PER TRAP I SCHOOL TAX Y N
❑f hereby af(Irtn that I have a artlBcate of Commat to Belt-inmre,or a RFOERPT N
mAiiiateot Workers Compewatio Il mnm me certl(k:d copytheleof(See.
3800,lab CJ S G CA ,SYSTEM-1 INCA OUTLETS I �PAIiK FEE Y N_
Policy N RECEIPT N
Coma GAS EA.SYSTEM-OVER4(EA)
I I Bf11LDINC DIVISION FEES
O Certified copy b filedwththehed. I CREASE/WDUSIRL WASTE INTERCEPTORI PLANCHECK FEE I
Certified ropy H filed with the sty Inspection division.
CC HIGTE OF"C1`TION FROM WORKERS' GREASE TRAP I PAID
COMPENSATION INSURANCE SEWER EA 200HT Date RCCCI to
ffhbae tonnes otbecompletedlfthepermitta(orone hundred dollars I p I
(8100)or1 ssJ ' WATER[-@A]TA W/VENT/ELECTR I .I : ERGY FEE Y N
I cemf t e performance ofthewmk forwhl this permit is Issued,
I tinier, anypen f n.I.. at cpq, s9y' to the WATER SYST[M/TREAnNG I (PAID'
W1tilln t nsslonla °(Cal role.Date r�l W
O Z Applla ti/)p NEW RESIDENTIAL ELMS. QFT. I Date Receipt#
Z O NOTICETO ICA If,after is Certif teol emption,youl I.
should become so ject tot War rs' ompevallon prow I mofthe Labor I ' ' TOTAL: I
CO Code,you mu at forthwith pl t suchpmehit.a orthh permltshallbe _ I (BUILDING FEE 00
W >_ darned revokm' I SEISMIC FEE CONSrRUCT10 LENDING AGCNCY r
1 thereby
affirm that there b a construction lending agency for the perform] TOTAL:) IuLECTRIC FEE
Z acts of the work for which this permit 1,issued(Sec.3099,Civ.C.) -
V O Lender' me -s,• - ;PLUMBING i PEE
ly I— 2 e aAaa == IQTi.I'''' .,MECHANICAL PERiv1IT" +.' FEE,' MECHANICAL FEE
O W I rtl(y 4-d e read this application and gatethatthe above information 1 Is cor ct.I me complywrth alltltyand county ordinances and state laws PERMIT ISSUANCE I�i7EES PAID.
} W rclat, glob construction,and hereby authorize representativn ofthis
(— Z city enter above-mendowdpropartyf orimpecttonpurpoaea. ALTER OR ADDTCI MECH. I '
e)a eve, an d keep harmless t e City of Cupertino - Date Reeeipttl V N eta; and expenseswh maylnany ayacavel AIR HANDLING UNITIToiomoOCFM) I SUBTOTAL: I gain nsequen he grantin M1l permit. AIRHANDIJNG UNIT(OVER 101100 G1M) CONSTRUCTION TAX
bl m nt/Con a - I / to EKHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:Z R OUS ATERIALS DIWill the r ure Othatioaupant store or hand le hazardous HEATING UNIT(TO IOQOOO BIM material as dt rtI.Municipal Code,Ch after 9.12,andlhe Date' ReceiplN ��i
Ilwhhand Safety Cad a Section 25532(,)7 HEATING UMT(OVER 100,000 BTI)) I TOTAL: IOC-/. Jfi
.,❑ Yes M No
Will the applicant or futum building occupant ux equla tordevlces I VENTILATION FAN(SINGLERESID) I ISSUANC'DATE
which emit hazardom air contaMmnh as defined by the Bay Area Alr PAIR
Quai agemcat District? BOILER-COMP(31R'ORIOO,CMBTIn ,I WB _
Yes ❑No
havem. the hazadous materials requirements under Chapter 695 of BOILER-COMP(OV)R 100,000 BTU) Q
/ lh GlIforn la leaphk Stfrty Code,Sectlans 25505,25533 and 25534.1 I JUL $ S
on erstandt tifthe building does not currently have a tenant,the ltbmy N'EWRESIDENTIALMECH. e.Q.Fr{
Acts o iblli lonotilytheoccup'a quirementa whit ust be met
Es ante Dice Certificate OccvPa. I / lg4
N -age t ' TOTAL: I ISSUEDBY: `yp��NL
VOFFICE COPY I '