22521 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pmicd identification PERMIT NO.
Building Addrea: - ,e r�I�o 22521
15$O_ Asfi�1' L6tn
actors a e: a -7-APPPCAMON SUBMITTAL
CgYp1 �,aa' Ah M1��til o?.SS 1310 CITY OF CUPERTINO-BUILDING DIVISION �^�
con nd.ra Nam#: Lic.No: APPLICATION I PERMIT J
CATLGORY CONTROL#
BUILDINGF].EC]RICALPLUMBINGMFfHA MCAL
Archited/Eeglosum Llc.No:
QTY ' ..ELECTRIC EERMIT FEE BUILDING PERMIT INFO
Address: ' PERMITISSUANCE _Q ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that lam licensed under provislonsof Chapter9(commeoc APPLIANCESRE5IDENIAL pDPSCRRVI70N
ingwlth Sedion7000)ofDiAsion3ofthe Businemand PmfessionsCodeand my
It...I.in full fors and o fed. PANELS
License Class Lic.ND `..
Date Contrador C'r"�lL
ARCHITECTS DECLARATION 401-t 000 AMPS
PqqP++Q CO I understand my plans shag be used as public records. OVER 1000 AMPS SQ.FE.FLOOR AREA 5/SQ.FT.
E tj Licensed Professional SIGNS ELECTRICAL
<< OWNER-BUILDER DECLARATION SIC IALCIRCUIT/MISC ra B nt
1hereby affirmm thal Iaexempt from the Contrador's License Law for the r ad
ISI OO b E. owing reason.(Sedion 7031.5,Business and Professions Code:Any city TIZMp MEITR OR POLE INST. •� h'
Z� county which requires a permit to construct,alter,improve,demolish,or repair
q�1 a nyatmdumprlortoib Wuamc alsorequlrestheapplisntforsuchpert tto POWER DEVICES
L5 y file a signed statement that he is licensed pursuant to the provisions of the i
Oµ� Conuadors License law(Chapmr9(commendng with Section 7000).1 Dial- SWIMh9NG TOOL F].ECE VAL ATION
30 alon3 ofthe Business and PMesslonaCode)orthat he isexempttherefromand
y.'S the bash for the alleged exemption. Any violation of Seethm 7031.5 by any OUTLETSSWITCFIESFI ES _ _ .
GX
applicant fora permit subjects the applicant to a civil penalty of not more than
t h red
dollars($500). NEW RESIDENTIAL ELFCTR SQ.FI. STORIES TYPE CONSTRUCTION
m owner of the property,or my employees with wages as their sole
C76 on neatin.,wllldothe work andthe stmdure is not intended or offered for
D sale(Sec.70K Business and Protections Cade:The Contractors License Law
$ don out apply to an owner of property who builds or Improves therms,and OCGGROUP RFS UNIT'S
wS^ whodoessuchworkhimsalforthrough hisown employees,provided that such
Improvements are not intended motioned toraale.If,however,thebullding or TOTAL:
Improvement lssoldwithln omyearofcompldion,theowner-bugderwlll have i
t rdenof proving that he did not build or Improve for purpose of sale,). QTV. PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
mntraam to construct the project(Sec.7044,Business and Professions Code:
The Contractors License law does not apply to an owner of property who �TEg-DRAW k VENT-WATER MA)
Wilds or improves thereon,and who contracts fee such p uj. with a FEE SUMMARY
ett[aco(.)licensed pursuant to the Contractor's License I. BACK FLOW PROTECT.DEVICE
u I am exempt under- . B h P C far h4 reason
DRAINS FLOOR ROOF,AREA,GOND. OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPTNN
• RwXN COMPE'NSATIONDD It TIO SCHOOLTAX Y_ N_
pI hereby affirm that I have•comfi.te of .asset to self-insure,or a FIXTURES PER TRAP
RECEIVE N
cenifl.teotW.,kee C.mpxmjo l.a I.nns ora certified copy thereof(5ec. GASYSTEM-1 PARK FEE Y N_
3800,Lab CJ S F.A. 'RECEIT 4
Policy p
Com GAS G.SYSEEMAVER 4FA
( ) BUILDING DIVISION PEFEESany
�Cx ifted copy is hereby furnished. CREASE/INDUSERL WASTE INTERCEPTOR PLANCHECK FEE
n Certitled copy is filed with the city Inspection dlvlalon.
CERTIFICATE OF E(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 7WFP. Date Recei t#
(Chia section need nd M complded If the pemdt 6(or one hundred dollars
ENERGY PCH Y_ N_
]certrtifyifythat In the performanceperformanceo(thewakfor which this permit is issued, WATFRIEEATERW/VENT/ELECTR
I stall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
O Z ApplicantNEW RESIDENTIAL PLMB. SQFI'. Date Recel t#
Z NOTICE TO APPLICANT:If,a fter making this Certificate of Exemption,you
should become subject to the Worksm'Compewtion provisions of the Labor TOTAL:
p) Code,you must forthwith comply with such provisioro orthis permit shall be ],DING
deemed revoked. SEISMIC FEE
(L CONSTRUCTION LENDING AGENCY
d Thereby affirm
work for
them bamrutrodiondl lending. ,Civ.C.) perform- TOTAL: ELECTRIC FEE
7 Z ance of Lcoderthe work(or whkh,hls permitls Lasued(Sm.3097,Civ.C.)
LL O Leader,Name MECHANG FEE
ICAL
I LL ~ Lenders Adtlrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
ImAlfythatlhavereadthbappUmdonandatatethattheabmeinfomutiw
O W
d comed.I agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>'C relating tobulldiagcrostrudlon,and herebyauthorize representativesofthls
H Z dtytoenteruponthe abovo-nvrtuned propertyforinspedlon purposes. ALTERORADDTOMECH. Date Receipt#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNC!(CO 10,000 CFM)
against liablliees,judgment,cwband cxpa..which may in anywayaccrue SUBTOTAL:
against Id City I.conuuuggquuu of the grantingof this permit CONSTRUCTION IAA
'
OIA'a /`� 7131Ig' ARHANDWNGUNET(OVERIO,000CIM)
Signature ofApplIant/Contrador Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFATINGUMT(TO100pWBTU) Date Receil2t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Cade Section 75"I(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
I]Yea No
Will the apple..,
or(utum building ompant use equipment or devices VEND LATION FAN(SINGLE RESID) ISJJj WATE
which emit hazardous air contaminants as defined by the Bay Area Air P
Quality Management Dist(dt BOILER-COMP QHPOR 100,000 BTU)
�i Yes Sus
4havercaHealthz&Safetmode, echos 25505, underChapter BO E2COMP(OVFRl00,0000N) 1111
the California Health&Safety Code, ociomntly have
a tenant,that
I MJ F7F -
understand thallfthe building does not currently havealenanL tlut itkmy N'EW RESIDENTIAL hfECId. SQ.FE.
rrsponsibil try to not Hy the occupy of of the mqulrements which must be met
CW
�L Ikansan#tIw14
prior to issuanm of a CedlOcatc of Ocapanry. 4�R.W�11Gt aYa{W
Owner or authorized agent DateTOTAL: ISSUEDBY, '
OFFICE COPY
--..,._.�='=,+c-=...v.7..-.-,..:.,+.raa.:.�,:��.-v:--«..z.:c.:___-�....t:.:- kv-��z..-.---�:..u..�...n.-,.=.�-, .. . . •
ADDITIONAL PERMIT FEES
V - BUILDING PROJECT IDENTIFICATION vawanory
BUILDING
ADORED '�g�>. • / i -'r + 1 (� � 11 ,'('�V�I
Ir FEE SUMMARY
ARE
f.y C41 f `7��l�
ln�/GEE EEr'F--7✓ /+�/
CONTRACTORS _ BUILDING -
NAUE G ^��E--
I'/T I NO PLAN CHECK
CONTRACTORS FEE
ADDRESS • _
SEISMIC FEE
OTY... ELECTRIC PERMIT -FEE•=
UTLETS'-SWITCHES-RECEP ELECTRIC ��,r ' -
` LIGHTINGFIXTURES, - -
• PLUMBING.'
PPLIANCES-RESIDENTIAL
PANELS - /„} , MECHANICAL
SIGNS 1
SIGNS TRANS. ,i TOTALSPECIAL CIRCUIT. •- .
_ EMP.,METER OR POLE INS. veRmlr vnuDanoN
MOTORS .- .'.SEE FEE SCH
0 SERVICE CHANGEZZ
° TO
` � N.. - r' " . ISSUANCE OATE - 1
LU > [,FIXTURES'-
PLUMBING PERMIT.;,` FEE BiDG. ELEc RLG. MECN
CL °
� Z , ALTER-DRAIN&VENT WATER IEA) 7 �' •
U O BACK FLOW PROTECT.DEVICE '-
LL' U" " DRAINS-FLOOR,ROOF,AREA COND. P_AIL�
"O vWai PER.TRAP ' p
_ F Z
GAS-EA.SYSTEM-1.INC.40UTLETS
(� GAS-EA.SYSTEM-OVER 4(EA.1' 4 -
INDUSTRIAL WASTE INTER. . ' p14y w{Pub,
LAWN SPRINKLERS-I INC5 V.B. EE6 IN
LAWN SPRINKLERS:OVER 5'(EA.1
SEWER-SANITARY-STORM EA.2001t/ -
WATER HEATER'WIVENT
WATER SYSTEM
WATER TREATING EQUIP.` -
TOTAL
QTY 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.) -
1 - HEATING UNIT(OVER 100,000B.T.U.) -
VENTILATION FAN(SINGLET
- •4 BOILER-COMP I3 H.P.o,100,000 B.T.U.)
_ -
' BOILER-COMP IOrer 100.000BTU)SEE FEE SCE.
TOTAL
•
i� '