22377 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—'USE BALL POINT PEN ONLY
Building Project Idendfkrtlon PUMIT NO.
Bu Od Ing Add nv: 1
pe G 22377
mer sonsrecast
CITY OF CUPERTINO-BU ILDING DIVISION -
• Contnchar'.Name: LheN. APPLICATION / PERMIT
BUII.DING-E.ECIRICALPLUMBINC-MECL CAL CATEGORY CONTROL Y
ArdWect/Engbeem Lle.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PIXhOTISSUANCE ❑ � •X I PLUMB a
IT
LICENSED CONTRACTORS DECLARATION I/—i1
I herebysdlrm that l am Ecensed.ruler probstoroaChapter9(sono. APPLIANCES-RESIDENTIAL IOBD N
Ingwlth Seaton N00)of Di m3ofthe BuNrc and ProfudwCode,and Pe)( .m
license b In faro for¢ deffect. PANELS
Duple)(
.eye
X' LbYUP TO 200AWS I vmbt
Date Coritrart j 6I�t -
ARCHITECII' DECLARATION 201-1 PS
µQS
Ob Iunderatard.;7pleu.1hallbeusedupub1ic.coeds OVER1000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
& (� LI¢ruMProf®Iona] SIGNS ELECTRICAL I?eplates
OWNER-BUILDER DECLARATION SPECIAL CIRCUrr/MISC �/s yy� 1�
ZI,I77� Ila,ebyafflrm that am exempt from the Contrenar's License law for the 1 e.11aI
pp U�U.a /olbwing mason.(SeCIm 70315,Business and Professions Code:My city or
li F7..F. IEMP.MEI'FRORPOLEINST.
HEppp muntywhkh rtquWapermktomrutvct,alter,bnpmve,demolhRorrcpalr
Nystmma¢prlortolui aM,aleom)ubn appBantf¢euchpem to POWER DEVICES �OO�
9 0.V Ole a dined atatement that he b licensed pru.t to the provaaoro of the L/
Lk.Lklaw(Chapter 9(mmeentlng whh Section 7000)of DIvI-
{{E�� �� ebn3ofthe Budnmand Pm(embro Code)orthrt he beumpt lherefrom.rd SWD4MING POOL ELECTRIC VALUATION
lbe heals for the alleged exemption. Any violation of Stolon 70715 by any
<` appdantfor.permit subjects theapplkant lo.civil penalty dna morcthan OUTLLfsu'TVTPCFl4Fl)CIlIRES
m O five hundred dawn(1;500).
R I]1,as come,of the property,or my employ.with w.gn u their sok NEW RESIDENTIAL E[ECIR TYT'E CONS7RIICT]ON
mmpcnubon,wBldothe worl;amdthestruclure In not Intended or offered for
Osale 0,,706{,Buanmand Prof®bv Cade:The Contractors U.law
Pjr$$ donrotapplyto.n nwrerapropertywho buildsorlmpm,eataerea,and .UNRS
whodo mchworkh4 gmthmughhbownemplay a pr idedthatwch DA
Improvenew are mat Intended oro(fered f-sale.IL however,thebuaHing ar TOTAL
Improvement fiscal wNhlnoneyneofemopletbn,the awner-0udderwal have
tl(�,Lurden./posing thrt he aid wtbuua mrlmprove f¢paryoeof sale.>. QTY. PLUMBING PERMIT FEE
LI L as owner a the property,am exchulveay mntracfIng with ifee reef FLOOD ZONE AIRJ
contract.m mrotroa the project(Sec 70K Buenessand Pdealoro Code: PERMIT ISSUANCE
The Contractors License law dos not apply to an owner a property who ALTER-DRAIN 6 VENT-WATER TEA)
WIWI or Improves thence, and who contra. f¢such p�o)eas wkh• FEE SUMMARY
�Wox(.)B¢rsed pursuant to the Comtranor'.Gam Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for" reason
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Owner Dale RECEIPT Y
WORKMAN COMPENSATION DECLARATION EIX'IURErr PER TRAP SCI100L TA% Y_ N_
F-T.1 heRby a(fUm!hrt I have a¢Nfi¢te of consent to self-bwR,or a
d�i^mrrt RECEipT Y
sof W0 tE C-npemtimimunn¢¢a¢rtB copythertof Gm GASEA.SYSTEM-1 INCE OUTLETS - PARKFEE Y N
Pale N C) �J- p / z
Pd�kyyY Z— / L GAS FA.SYSTEM-OVER RFICEIPI'M
ny S BUILDING DIVISION HES
ertNed copy Is hereby famished.. GREASE/INDIISIRL WASTE NTERCEPIOR PLANCHECK FEE
lip Certified!copy b pled with the tllylropeabn dfvWon.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARYSTORMFA.20 em91
Date Ri t
(Thissculon need na h completed lithe SURA b fa one hundred dollen
(9100)¢IceJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I¢nor that employ
persrtun¢ofChannel:fir to bthiomemsbluued,
I shag ns empen any Levy f any manner at u to benne subject to the WATER SYSTEM/TREATING.
w-ke�eaenpersatbnlawaar California.Dae PAID -
O Z Applicant NEW pFnDFM]AL•I,I.Mg. SQFT. Date Reoel til
Z 2 NOTICETO APPLICANT.If,ager maingthb Certdkateof Exemption,you .
should become subject to the Werten'Compemtlon provlslom of the Labor TOTAL:
~ N Code,you m a forthwith comply Mth such provisions orthb permit shat be
> deemed¢caked. -
CONSTRUCTION LFNDINc AGENCY SEISMIC
a herebyafBmthathrcbamnsWeionledbgageny(orthepAomm ELECTRIC U�
_ Lenders
forwh7ch thio permNbbwed(Sec 307/,Cfv.CJ TOTAL J
LL O leader'•Name PLUMBING FEE J
LL H ]seders Alarm QTY. MECHANICAL PERMIT FEE _ MECHANICAL FEE
O W I¢rtlfythe l have read thbappll¢tbn ant statethrtm the above lnformetl -
Ill. baorma.Iagrcetocomplyw aUckyaMm ntyordbunmandl teaaws PFRMRIAUANCE FEES PAID:
>- rclatingto WlWingmnswNon,ant herebyauthoAurcvatNn
prentofthb
F N city to enter upon the.bove-mentbrcd property for has? (We)agon Purposes. ALTER OR ADD'fO MBCFL
rtr to saw, Ixeep harmless the City of Cupertlro Date Recei tp
V agalrot Bablllt4a,}ndgmenb,mstaaM expevn which mey ln.nywayamue AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL:
against Id C1 v e f the granting of this peon t.
� AIRL-rANDGNc UNIT(OVER 10,l)()()clmf) CONSTRUCTION TAX
Stns to of p / e EXHAUSTfioa3(W/DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MATERULS DISCI A U
Will the pliant-futon budding occupant atom or handle havedous HEATING UNIT(TO 100,000 BLU) Date Recd [M �
materials,defired by the,,,CCC pertin Municipal Code,Chapter 9.IZ and the
i kethant Saety Cal ion 255320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
FT�'r'Yu No
Olthe.ppli. or nebuddamgom5pantussequipment¢dcvices VENTILATION FAN ISINGLE Ri ISSUANCE DATE
whkh emit haxardou.er contambama as defined by ted Bay Area Ab
Quality Management IX f,iC7 BOILER-COMP QF[P OR 100,OM BTI!)
YnNo
have read the ha ,materia.requirements under Chapter 695 of BOILER-COW(OVER100,00037V)
ted CaW.o ll,"h A Safety Code,Sectbro 25505,25533 and 25536. I
understand that lithe budding dm not currently have a tenant,that it la my NEW RESIDENTIAL MEC1-L SQ.FT _
res lty int a the requlrementa which.cast be met
prior f ua a I foceupaxy.
Owner or ea agent � D.� TOTAL,- ISSUED
OFFICE COPY