22378APPLICANT TO FILL IN INFORMATION WITHIN FEED LINES —USE BALL POINT PEN ONLY
a
.
Building Project Id—lifk.tion
f
C
PERMIT NO.
Ballabig nddnaee: F In v-22378
nee ams: oue.
CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION / PERMIT
/
7— 2--9
Contractor. Name: Lk. N.
gU1LDIN -ELECTNCA4I'UIMBING-MECHANICAL
CATEGORY
CONTROL Y
ArchBect/Engineers Lee, No:
QTY ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Add.
PERNUTISSUANCE
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
lhmbyaHirmthatlamlkmeeduMerpro Wb of Clupter9(mmrmtc
Ingwilh S, n7000)of DivW=3ofthe BuN and Profml Code,mdfny
Mxn
Iec b In full d effect .�
I.Im C ssXt Lk. N
Date Carrtractor )[yf[
APPLIANCES-RFSIDENI7AL
JOB 'LION
L-.
/ Q e
,ate I I '
PANELS
-
5
'RAC Hanes s DECLAMTIoN
I understand my plum shall be used upublic records,
ILJ
v
OVER00Ah
OVER 11)(K) AMPS
Fi. FLOOR AREA
f/SQ. F7:
SIGNSEIECTRICAL
Lkamed Professional
ESQ.
''�e-p)ac�`
SPECULCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cantndor'a Lkseee law for the
following resson.(SeNon MIS, Busbm and lhafmleas Code: Any city or
muntywhkhrryuL aper tommtmMWter,impmve,de Lolb ormpalr
enyrtrodanprlmtolNbwarcgalsunqubntheappaantforwdipermitto
ilk a signed statement that he is limned pursuant to the provbiors of the
J
I 1 ^m I
e
,f �OQ�I41
-�`
TFAIP.MEIFR OR
pOWERDE'VICFSIses,
NG POOLQ
Contnanari license Law (Chapter9 (mmmencing with Section 7000) of Divi -
Nona of the Business and Pn(esslow Code) orlhrt heir exempt themfromaMVALUATION
the baab for the alleged exemption. Any violation of Section 70315 by any
appaunt fora permit subjects the applicant to a cavil penalty d stat more than
OVD.EISSWITCREs
NEW RESIDEaNTI'V- �"•��
Ove hundred della. ($5001.
❑ I, as owner of the property, or my employee, with wages Is their sole
ES
TYPE CONSIRUC ION
compensation, walaothe work, wdthertsuctum is not Intended or offered for
/
sale (sec. 7061, Business and Profession Code: The Contractor. Limve Law
don not apply to an owner ofpmpmy who bull" or improves thomn,and
who doe such work himself orthrough Macaw. employees, provided that such
OCC.G IN
RE5.UMI5
Improvements are not Intended oroffered foreale. If, however, the building our
bnprewmemosold within omywrafcompletion,tb esu buaderwW have
TOTAL
"
t"mien ofpmving that he dui not bead or impown for punposeofeale.).
L j L as owner of the property, am a rh, b,cy contracting with licensed
mntractm to mnatmct the project (Sec 7094, Business and Prefe soca Code:
QTY, PLUMBING PERMIT FEE
plOpp TONE
ApN
PF ISSUANCE
The Contractor's License Law does nU apply to an owner of property who
builds or Imprwe themem, and who eoninN ler such p\o)em with a
c9Ltraner(p licensed pursuant to the Contractor'•License Law.,
U I am exempt under Sec B & P C for this rtmn
ALTER -DRAIN &VENT - WATE7(fFiV
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, MND.
SANITARY Y_ N_
RFCm'[
Owner Dare
WORKA
MAN COMPENSATION DECLARTION
p�JT
nrt0tatleof Worfit.
krni that
Compevatlm inru . ma nndled mpythereef(Sec.
3800, Lab C)
yL YJ eu/( �'f�3
Ca��pp+a v copy
.KIOeriflM copys�"byth the Fed-�J'— 1 1
�U�4LG��' nBled copy b filed with the nifty lsspeelon dlWNon.
FIXTURES. PER TRAP
SCHOOL TAX Y_ N_
RF�FIP
GAS E.A. SYSTEM -1 WC40UTLF
PARK FEE Y_ N_
RECEIPT ;1
_
GA,S G'SYSFEM VF-R4(FA)
BUILDING DIVISION FF.F.f
GRFASEANDUSR, WASTE PrrpRCEPMR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E'XEhf PTION FROM WORKERS
PAID
SEWER -SANITARY STORM FA 2TOFr
COMPENSATION INSURANCE
(rhbsectbn need not be completed If the permit leforone hundred dollars
Da[C ReOCI [#
WATER HEATER W/VENT/ELFJM
ENE RGY FEE Y N—
I..) (SIM) orm.)
I nor at b the performnm of the work for which this bsu
permit la sd,
WATER SYSIflN/TRFA7INO
I shall stat employ any person In any manner n as to became subject to the
Wurkers'Compevatlon Lawsof California. Date
PAID
Applicant
Date Reeel [#
, NFSIDENTIALP1M8. SQ.FT
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
TOTAL:
Cade, you must fanthwhh comply with such provlelonu orthb permit shall be
deemed nevmked.
I III IN
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihembyadtrmtluttheneba conatmctbnlend Ngagcncyforthepedom,
anon of the work for whichthis permit fe bsucd (Sec- 3097, Cl, C)
TOTAL:
ELECTRIC FEE 1
-
QTY. MECHANICAL PERMIT FEE
PERMITL%UANCE
PLUMBING FEE
[amiss Name
1<ndeea Address
I nniythrt I love read thio applkatbnand datethn lheabove Information
Isco ect.I.gnectocamplywithaadtyaMmuntyoNWnma dsatelawe
relrting to build Ng mnmtwctlan, ami hereby authonae representatives of this
dtytoenterupoothe abovs-menOvned propertyfor Wpection purposes
• (We) agree to save, i demdy an d keep harmless the Ctty of Cupen W
MECHANICALFEE
FEES PAID I-',G.l
✓1
ALTERORADDTO METH.
.Date Revel t#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
aga Wal baltln, yd mende,co hard expense, whkh nay In an wayaawe
agar a BY n. of the gninningofthis pemdt
AIRHANIXlNGUNTT(OVa I0,000CFM)
CONSTRUCTION TAX
stun of p t/ ontnactar /"-71C,Pte/—
EXHAUST HOOD(W/DUCD
CONSTRUCTION TAX PAID:
ASAROOUS MATERIALS UISC UR
HEATING UNITITO 100,0(10 BTU)
Will thsappllant m loran building occupant stone 'undIchargdou,
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I leah an Sdety Code 2S53z(a)r -
yca
sun
Date _ Recet t#
HEATING UNIT 100,000 BIT)
TOTAL:
VENTILATION FAN(SWGLE RESID)
ISSUANCE DATE
Wit] the appBay building occupant use equipment or devires
which emit hazaraoea air contaminants as defied by the Bay Area Air
BOILER -MMP OHP OR 100,000 BTU)
Qu ]by Management 7
ye, VJ No
BOILER -COMP (ova 1 W,000 BTT)
I avc nad thenuterlab nquimmenb under Chu pier &95 of
the California Health & Safety Cod, Sections 25505,2&W and 75534. I
NEW RESIDENTIAL MECH. SQFr.
understand that lithe building does rot arrtnty have a tenant, that it b my
nspomuib By to nil ly he asp, t of the requirements which nbennet
prfort rtl tc avpamuy.
ISSDF
Owner or aumorl int to
TOTAL:
OFFICE COPY V