22664 APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Be lid ing Pro ca Identification• y� PERMITNO.
Building Address: x _ Q�'r(� A
e nt :
G y, �CJ� 4
U g e OP CUPERTINO-BUILDING DIVISION
• G°°no-'a°' Lt..N APPLICATION / PERMIT S—
BUILDING-MrCTRICAI4PLUMBINC-MECHAMCAL CATEGORY CONT�1lN/^'
Architect/Engineer. Lk.No: 'O xCIJ
Qry ALECTRIC PERMIT '1, , i , FEC. ;; ',BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE �J� ❑ ❑ ❑
LICENSED CONTR under rDECLARATION - Lam'}•
I heh Sccdoa7000)tl is loor3afunderproviaionsol Cssions9(commmy APPLIANCESRESIDEMIAL JOB DESCRIPTION
ingwlth SecHon7000)ol Division3°lthe Budneuand ProfesslorieCode,and my
Iirense is In(uI form end d(ect. - PANELS gl / ''f'— Poo
Lima.Class
C l
Date Contnaor
—UP TO 200 AMPS
ARCHITECTS DECLARATION 101-1000 AMPS
waOw ZZC-• I understand my plans shall bar used as public records. -, OVER 1000AMPS a ^ II S/SQ,Ff,
Z U Limnsed I'rofealowl SIGNS ELECTRICAL li c s� • � R��
OWNER-BUILDER DECLARATION �D I IT E R
zs' �r�nn Iherebyaffirm that l am exempt from the Contractor's L(mnee Law for the SPECIALCIRCUIT/MISC / V tL..!J u I l
following reason.(Section 7013,Business and Professions Code:An cityor
•Kg s cmntywhichmquiresaper ttommtmd,alter,impmve,dem°Ibh,orrear FMP. METEOR POLE INSf.
Ohi anystructureprlorm lrn Wuance,alw requires theapplant forsuch peroatto POWER DEVICES ( L
file a signed statement that he is licensed pursuant to the provisions of the
3µ, Contractor's License Law(Chapter 9(commenMg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
slon3o(theBusnemand Pmfe iomCode)orthat hearxempttherefromand VALUATION
the basis for the alleged exemption.-Any violation of Stolon 7031.5 by any
p .applicant fora perrtdtsubjects the applicant toacivil penalty ofnotroom than OUTLETSSWITCHFSI2XTURES tf oo.C�
$ five hundred dollars(S500).r NEW RESIDPMfAL ELECTR `-Q'FT
Y
I,as owner of the c STORIES TYPE CONSTRUCTION7 6 property,or my employees with wages as their sole
compensation,will do the work and thestruaure is na Intended or offered for '
O sale(See.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or Improves thereon,and OCC,CROUP ftE.
0.0. whodoee such work himself orthecuw
gh his own employees,provided that riSUNITS
,
ImproveMeb are not intended oroffered forsale.If,however thebulldleg or TOTAL:
improvement Issold withlnoneyearofcomplelokthe owner-builderwill have
OlLiltrden ofpmNng that he did not bund or improve for purpoaeofsale.). 'QTY, :_,% ,' IPLUMBINC`PERMIT ii �� ', FEE pLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the project(Sec,7014,Business and Profealoru Code:
The Contractors License Law does nor apply to an owner of pmperty who ALTER-DRAIN k VFNI'-WATER(EA)
Wilds or Improves thereon,and who contrafor such InaJects with a
mp)laaor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE I I' ..'FEE,SUMMARY
I am exempt under Sec. B A:P C (or this reason
Tar HES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
Owner Data RECEIPT#
WORKMAN COMP ENSATION (comeRATION FTXTUgps-PER TRAP SCHOOL TAX Y N
[]1 hereby-(firm that I have a Insurance
o convent to op(-tnwre,ora - RECEIPT I
38010ateo(Worken'Compewtl°nlmurance oracemfled ropy themof(Sec. GAS EASYSTEM-1 INCA OUTLETS PARKFEE " Y N
polis Lab C.) ,
Col fry M RffGAS EA.SYSTEM.OVER 4(EA) DING Of p
Cany - BUILDING DI VISION FE[S
�Certlled copy is hereby te
Certlfled ropy V(TIM withh the city
inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
� ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID (
COMPENSATION INSURANCE SEWERSANHARYSTOR.M EA.100FT. Date Recci t# (�Ot
(fhissecinot b
lon need ne complaed tithe permit k(Drone hundred dollars
($1(ID)otifyth WATER HEATER W/VENT/EIECTR ENERGYFEE Y N
138not that In any person
In an tm mannework r
as to become
#embusissued, —
I shalt not employ any penwa in any manner w a to become wbjea to the WATERSYSTEM/TREATING
Worken'Compensatbn Lawa of Callfamia. Date PAID .
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQAT. Date ' ReCel t#
shou1,dy= eeobjeato'he Workers-Compematlon provisions ofthe Labor TOTAL:
N Code,you must forthwith romplywlthsuch provlsloru or this permit shall be BUILDING E
Uj j deemed marked.
aCONSTRUCTION LENDING AGENCY SEISMIC FEE.
I herebyafnreathat there his caromiti°n lendlegagency fmthe perform TOTAL: SEISMIC
FEE-
7 ZO ance of the work for which this permit blswed(Sec.3097,Civ.C.)
L) Looder's Name PLUMBING FEE
IL Lenders Address - ,QTY. MECHANICAL PERMIT MECHANICAL FEE
O W certify rtify that l have read thfsappllationand aatethattheabove Warmed..
IL is correct.I agree to comply with all city and county ordinances and state laws PERMIT1SSUANCE FEE-PAID:
r W relating to building comtmction,and hereby autherlae representatives of this -
H Z city to enter upon the above,mentioned property for hespMlon purposes, ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V againstlla Itla,judgmma,mas and expenses which may In anywayacaue AIR HANDLING UNIT(To 10,000CFM) SUBTOTAL:
agalmt d ityIn mnaaquence of graaing Ie permit. -
AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
Sig of ppllam/Contractor Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO UR
W applicant orfuture building occupant store orhandlehaeardous HEATING UNIT(TOI W000 BTU) Date ROCeI f#
matetla as dented by the Cupertino Municipal Code,Chapter 9.12,and the - _
Health and Saf qy Code S aloes 25531(.)7 HEATING UNIT(OVER 100,00D BTU) TOTAL:
❑ Yeo M No
Will the applicant orfutem,h,ilding oavpant use equipnu!nt or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which coat hazanious air contaminants as dented by the Bay Area Air
Qua lily Ma rugement District? - BOILER-COMP(3HP OR 100,000 BTU) '
4Yes n No
havereadl Ith&rafLiyCe S lom25505,BnderCh255M..95 of BO LER-COMP(OVQ2100,000BN) �
the Calilornla Health&Safety Coda Stolons 2550.5,2 tenant shot. i — -
understandthatlithe building does not currently haveatenanLthat It met NEW RESTDENIIAL MEGA. SQ.IT. eia
responsibility to notify the occupant of the requirement which must be met r a,���
prior to issuance of a Certificate ofocmpanry.
Owner or authorised agent Date - ISSUED 6Y:
TOTAL:
OFFICE COPY
ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATION) vnw ioN
eonoix+°c� O �/O
DOORS$ O
OWNERs l/
k)6
S t� ?71610 FEE SUMMARY
,V C r4' r"oxe `
coxTRA BUILDING
LIC
N Nis Cirrllfiw'6
�v uC.xo PLAN CHECK -
WN Rn.T..S
`.J ✓ l '4 rxoxs SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC x�
LIGHTING FIXTURES PLUMBING
—APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. FEamir VALIDATION
MOTORS SEE FEE SCH.
Q SERVICE CHANGE
F °TOTA �
CC ISSUANCE DATE
UJ > OTY. PLUMBING PERMIT FEE ecOc. eE}sec�r. PEO. MECH.
0_ ❑ ❑ Ualr ❑ ❑ �,
CL 2 ALTER-DRAIN&VENT-WATER(EA.)
V O BACK FLOW PROTECT.DEVICE
LL O w DRAINS.FLOOR,ROOF,AREA,COND. .+
FIXTURES-PER TRAP
` ? GAS-EA.SYSTEM-11NC.40UTLETS
V GAS-EA.SYSTEM-OVER 4IEA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.1001[/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAI
TTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 1Q000C.F.M.)
AIR HANDLING UNITIOVER 10,000CEM.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,0006.T.U.)
VENTILATION FAN(SINGLE)
801LER OOMP 13 H.P,or 100,000 B.T.U.)
ROILER-COMP ID���100,00 BTUI SEE FEE SCH.
TOTAL
ADDITIONAL PERMIT ES
BUILDINOPROJECT I DENTI FICATION wwnnory
eunmec
FooNESS�\L•l/ O •, ^ L)AZ
NAMEN SAL
I 5
/M Cil FEE SUMMARY
Y�l
A—
'.ORE
cpNT acTDRs �f ,LSC BUILDING
�y'vM PLAN CHECK
coNTNACTDRS FEE
ADOREs
J �SE r"o"e SEISMIC FEE
CITY• ELECTRIC PERMIT FEE_
OUTLETS SWITCHES-RECEP ELECTRIC Ct Z, O()
LIGHTING FIXTURES
PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL 21O'v
SPECIAL CIRCUIT yz—ao
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Z Z Ptyn
F ° TOT oo J a TRATE (
ISSUA CE DATE
W > DTV. PLUMBING PERMIT FEE BE.oc. ELECT. vac.
a C) �I�((
2 ALTER-DRAIN SI VENT-WATER(EA.) J� 1 11
UL OUL BACK FLOW PROTECT.DEVICE
O O DRAINS-FLOOR,ROOF,AREA GOND.
LU
} y FIXTURES-PER TRAP
F ? GAS-EA.SYSTEM-I INC.40UTLETS
V GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARYSTORM EA.4001[/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
OTV. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10=C.F.M.)
AIR HANDLING UNIT(OVER 10=C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER DOW(3 H.P.of 100.000 B.T.U.)
BOILER-COMP 10v1 100.000 BTU)SEE EEE SCH.
TOTAL
y r ADDITIONAL PERMIT FEES �t � ` /
�^ BUILDING PROJECT IDENTIFICATION - VALUATION ADDAES:2 /� y 4E
NAME
//� .1 /cl k`Y II .V 1 5/
,)^ Y'� FEE SUMMARY
V / PHONE
NAME accrloss /� � f c�cJ" BUILDING
/ /�7 NSU NO.- PLAN CHECK
coNTRACTDR S FEE
ADoBes1`�E.
SEISMIC FEE
CITY. ELECTRIC PERMIT': . . FEE
UTLETS-SWITCHES-RECEP,;'' G( ,rL) ELECTRIC <42. 00
LIGHTING FIXTURES -
APPLIANCES-RESIDENTIAL PLUMBING
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT ?t 33-o' I
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
SERVICE CHANGE '
Z
po TOTAL tl VO .1.F}SnT hovC.L�V`l
CC ISSUANCE DATE
LU > CITY. PLUMBING PERMIT FEE BLDG. ELECT. PLG. i mecH.
CL 0
:D 2 ALTER-DRAIN&VENT-WATER(EA.) 0
0 BACK FLOW PROTECT.DEVICE
LL I
O w DRAINS-FLOOR,ROOF,AREA,COND.
y FIXTURES-PER TRAP
GAS-EA.SYSTEM-i INC.4 OUTLETS
�j GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2001[/
1 WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO I0(100C.F.M)
AIR HANDLING UNIT(OVER 10UC.EM.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.) _
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN (SINGLE)
BOILER-COMP IS H.P.or 100,000 B.T.U.)
BOILER-COMP 10-,100,000 BTLn SEE EEE SCH.
TOTAL