22728 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Prn'ed Identification PERMIT NO.
Building Address: 22728
10 j/
wners amt: G one: A 7�2J' CITY OF CUPERTT6
N6UILDINGDIV]SION �7
nH+aero aces: Lie./Na: APPLICATION / PERMIT
aC 297 BUILDINGELECTRICALPLUMBINGM=G NnCAL CATEGORY CONTROL
Itect/En
Lk.No: - ._ .
r- BUILDING PERMITINFO,-.}
jg, ;ELECTRIC PERMiGv. _ "'FSE'-
Add. PERMITIS5UANCE 159 El El [ILICENSED CONTRACTOR'S DECLARATION
I hereby-affrm that l am licensed under provisions of Chapter 9(commen APPfIANCESRE57DENfUL JOB DESCRBTPON
hearse Seafon me'e' f d effecn3olthe BumnessandProlesmaneCade,and my �/ f
Bmnse b in fu ores d effect.
) PANELS
Llcenn = !Z LIr.N O� -e Y �
Date Cozumt —UP TO 2DOANTS
ARCHITECPS DECLARATI 201-IODDAMPS
1WZO Iunderstand my plana shall be used as public records. OVERIODDAMPS SQ.FT.FLOOR AAEA $/SQ.FT.
j Z Licensed Professional SIGNSELECTRICAL I N A L E D
<a OWNER-BUILDER DECLARATION SI'ECIALCIRCU[T/M15C O M P}11 T R
I hercbyalfirm that7ameaemptfrom the DECLARATION
License Law fee the
following reason.(Section 7MI5,Business and Professions Code:Any city or
cwntywhich requiresa permit tomruHuct,alter,Improve.demolbh,orrepair TEMP.METER ORPOLE INST.
a nyrtmaunprlermlfalnuancSaisorequWtheappBuntforsuhpermltto 7C :0 G
a file a elped matemmt that he Is licensed pursuant to the provisions of the POWER DEVICE^+ Ri ri
Conennoes Licerou,Law(Chapter 9(commencing with Seaton 70D0)of Divi.'O Swpd),gNGIWLEI.ECfRIC LyA sion3 ofthe Business and Prafessioes Code)orthat he beaerept therefromand W
the basis for the alleged exemption. Any violation of Section 70315 by any
+ppU..t fora permit subjects the applicant to a civil penalty of not more than OUTLETS SWI3CHFSFIXfURFS 0
fiv�undred dollen(ESOP). NEW RESIDENTIAL ELECTR SQFT. RIES TYPEtbNBIRIK:TION'
Z�n I,as owner of the Property,or my employees with wages as their sole
compenuHon,willdothe work,and thestvcture Is not Intended or offered for
i C<O sale(Set-70K Business and ProfessionsCode:The Contractors Lignse Law
,"R does me apply to an owner a property who Wilda or Improves thence,and OCC.GROUP RES.UNITS
who does such work himself orthrough Msown employees,provided that such
improvements are not Intended proffered foraale.If,however,thebuilding or TOTAL:
improvement bsold within oneyearofcomple Ntheewner-bullderwUI have _
t men of proving that he did cwt hugd or Improve for -� ' ..-J s
ALJ P B P purpose Qjy; , ,PLUMBING PERMIT'.',-;> 'i"'FEE,.,' FLOOD ZONE APN
LJ L as owner of the property,am exclusivelyB.si ess contracting Pro with a Codd
contnaonto cons Licenseruct law doe nice apply to a n.and Pro!®ions who
ISSUANCE
The Contractors License Paw don req apply ct, f owner of Property who ALS-DRAIN k VENT-WATER(FA)
builds t of Improves thereoM and who mntram !m such plojeae with a
oLJI am exempt
dnder S pursuant to theConmaam:License Law. "x,"v
v.
LJI am exempt under See B 4 P C for this Halon BACK FLOW PROTECT.DEVICE - - - '
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WOR KMAN COM PENSATION DECLARATION FI%TURES PER TRAP SCt-POOL TAX Y_ N_
❑P hereby aff em that I have a certificate of consent to self inure,or• R_ NN
'-" cenf0cate of Workers Campenomi, aura ma cealflgA mpythereof(Sec. GAS PA.SYSfFM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.I e Q r(I yq/,s
PoliryN lri�'Gii4 /+f'GA-N1..0( c t
aRECEIPT If
CCCny GAS EA. BUILDING DIV
ISION FEES
edified
copy is heed with the
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b(Bed with the sty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANq.1.ARY-STORM EA X)mT Date Re i t#
CENa creation need req ba completed Hthe pemat b(Drone hundred dollen
($100)orless.) WATER HEATER W/VENT/ELFGTR ENERGY FEE Y N
I certifythat In the performance of thework forwhich this permit is issued,
I aha0 n ploy any p/-Iq,any manner n u m become aubjett to the WATER SYSTEM/,T.RFA.DNC
Wgken' pen tion ova Bf7 Date PAID
Z APPBca^t ((Lt NEW RESIDENTIAL I'I.MB. $Q.FI. Date Recei t#
O NOTICET ICANT-.I�Jmaking Ihis Ifl cof Eaereption,you
should subject to the Workers Compmudim,prmblmuofthe Labor TOTAL:
% Cade,you at forthwith comply with such provisions or this permit shall be G p
> deemed revoked.
f7 CONSTRUCTION LENDING AGENCY SEISMIC FEE (Y
I bereby affirm that there b a construction lending agency for the pemomv ELECTRIC FEE
Z ancaof the wmkf.r which this pemmt Is Issued f5ee.3097,Civ.C.) TOTAL: ELECTRIC EEE
) O (ander:Neme
1- Lender,Address Q'IY " a",IVIECHANICAL'PERMIT FEE`.. MECHANICAL FEE
O I roes t(y that l have read this application and mate that the above Information
bcoingtobgres to comply with all ndByand byauthchbo,ordinances andmatelawa PERMIT ISSUANCE FE PAID-./
LU
. Z1 relating toe nob building abvNagandherebyrty feelureprese po ivmrpm of this yp
ciryt OAgrter upontheabovo-nedlyaned propertyfeeWpe Cit purposes. ALTER OR ADD TO MECH. Date Re el t#
— (We)agrees jade,bd costs an d keep harmless the ins of ymyaCupertino
agaWtltsbNtin,pdgments,coatund espenaes which may In anywayacaue AIR HANDLING UNIT(TO l0,g10 CFM) SUBTOTAL: N I
.gal Id Cityln of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER IgMO CFM)
Slgnsv sof Applicant/Comraaor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER LSDISCLOSURE
Wil the applicant or future bu1dingoccupantetoreor handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCei !#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(,)7 HPA77NG UNIT(OVER 100,00)BTU) TOTAL:
❑Yea r�No
Will the applicant or future building occupant u,eequipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which treat hazardous airmnumlnanteas defined by the Bay Area Air
QualityManagementDistria) BOILER-COMP OHP OR100,ONBTU)
PAID
ban ❑No
4_ haveread the haze do us material.requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
iH(omla Health k Safety Code,Sections 25505,25533 and 255131. I lJ' CLL..f!C T 1 G �(�!)v7�
ttandthatlfthe butldggdoesnet codently hawatenant,that Runny NEWRESIDENTULMECH. SQ.Fr. 7
uibBity to ngl(y the amapant of the requirements which must he rrel
alssuanceofa nif of Ocvpanry.
ity OF Gun inn
u oHred agent Date ISSUED
TOTAL:
OFFICE COPY