22891 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prole"IdentificationPERMIT NO.
BWWing Address: r � 22891
C�9�GU GdR(yl/gG a '11VOFCUPERTIN6BUILDINGDIVISION
d Lie.Na: APPLICATION / PERMIT
BUILDINGELECnUCA PLUMBINGMECI LAICAL CA BY CONTROL 9
JhUact/Engineer. Lie.N.
77
96 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
LICENSED CONTRACTOR'S DECLARATION PERMIT ISSUANCE 1:1 El 1:1I hereby affirmtlut lam licensed under provWonsof Chapter 9(commerm APPLIANCFSRESIDENML ]00 DESCRD'TION
1 ng with Section 7000)o!Di W don 3 of the B usi neva and Pmfesdans Cod e,andrny
license lain luE farce ddfed. PANELS /M�r..I' [� 1^_`
Llmnae G 1� 7J � UP TO 2DOAWS ' L d 1,L� tJ 4 V v Ce
Dat GARCH1T1E or 2011000AMPS
re0 O I understand my plans shall eused as public reoordw OVER I IX)0 AMPS I ; SQ. .FLOOR AREA S/SQ.FT.
SIGNSELECTRI AL 1
Licensed ProfemWvl — -
< OWNER-BUILDER DECLARATION
G SPECIALCIRC T/MISC
e,�F Iherebyaffirmthatlamexempn frmnthe Contract.e.Llmnselawfmthe _ - ilp1
ZO fall-wing reason.aedlon 70313,Bu.ie...d Profmxi.r a Code:Any dty or I
K I"'8 rountywhichrequlmaper twmmtrod,altenlmpmv,de=il h,ormpalr TFb1P.METER OR POLE INSf. 1
ggqin 3Q anystmd mpr rtoltsl wancgalwmquimatheapplimntf.,.0 hper Wtt. POWER D&VICEB DAI S
V file a signed statement that he V nt licensed pursuava the proimans of the J
3w Contractors License Law(Chapter 9(commanding SOwithSection 7000)o!Divi. SWIMMING POOL ELECTRIC VALUATION �0 S don3oneu so
fthe Busld Pmfemlons Code)orthat he is exempt lherefromand /
Qthe basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHESFIRTURES
appll.nt fora pemdt.bjed.the.pph..t to a dull penally of not..than
flue}undmd dollars($500). NEWRESIDENTIALELECTR_SQ. . SIO FS TYPE CONSTRUCTION
7< �f I,as owner of the property,or my employees with wages as their sole .
compensatlan,wllldothe work andthe structure is not Intended or offend for
O
.In(Sec.7044,Business and Professions Cade:The Contractors Llceve Law
$$ does nal apply to an owner of property who Wilds or Improves thereon.and OCC.GROIRa RFS.UNITS
who dmsauchwork himself arthrough his own employees,provided that such
Improvements re anot Intended oraffered for sale.If,however,the bulWingm - TOTAL:
Improvement lawld within om rarofcompletlon,theowner-bullderwgI have
t en of proving that be dm not Wild or Improve for purpose orale.). QTY, PLUMBING PERMIT FEE FLOODTONE APN
LI,as owner of the property,am exclusively contracting with licensed pppp LSSUANCE
.at.&..to corelrud the project(Sec.7014,Business and Profs®Ions Code:
The Contractor's License Law does not apply to an owner of propertywho ALTER-DRAIN&VENT-WATER(RA)
Wilds or Improves thereoM and who contracts for such ptojects wth a FEE SUMMARY
cop((actor(s)licensed pursuant to the Contradoe,Litems Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec. B &P C for this reason
OUTSIDFITES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
01 hereby affirm that I have a certificate of consent to self-Insure,or a RECEIPT Y
mri(IrateofWorkers-Comperoatlonlr mnmmamdlf4 mpythereof(Sec. GAS EA.SYSTEM-11NC.d OUTLETS PARK FEE Y N
3#lcy0 RECEIVE#CJ
Policy M
Com any � GAS EA.SYSTPM-0VERd(El). BUILDING DIVISION FEES
CF
Certl(Ied copy is hereby furnished. CREASE/INDUSTRL WASTE INTTRCEPTOR PLANCHECK FEE
MCerlBied ropy b filed with the city Ivpedlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID /D--�?�_�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Revel l#�s n
(Thbaedlon need rad be completed Blhe pemdl isfm om hundred dollars
(5700)mfy that
WATER HRAT11t W/VENT/ELECTR ENERGYFEE Y N
1certify that.the person I.nce of
numner so as towhich
se hi le to
I shall not employ any person In any runner so u to become subject ro the WATER SYSTEM/TREATTNG
Worked Compeneatlon Laws of California. Date PAID
-
0 Z ApplicaNOUCnt NEW RESIDENTIAL PLMB. SQFT. Date ReCel t#
Z Q NOTICEco APPLICANT.B,aNdr rs'Co pe atio pmt bExemption,you
should become subject to the Workeni Compensation provlslons of the Labor TOTAL:
CC W Code,you most forthwith comply with such provisions or this permit shall be BUILDINGFEE / Ilk 410
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL ]hereby film,that orkfowlherebaronst6 tionIssued
leading agency Cly. .) perform ELECTRIC FEE
7O ance of Lard.ehe woRforwhich lhbpdmdtb Weed(Sec.3097,Cly.C.I TOTAL:
Lender.Name PLUMBING FEE
V LL F Lenders Address QTY. MECHANICAL PERMIT FEE
W? 1 cart that I mad thbappllcitstate above gmu
MECHANIC
AL FEE
OIeormo.bagree
tgcathall dyand
county
orefinancesand gate PERMIT ISSUANCE FEES PAID.
>. S relating
tbuilding ronstmetnrepresentatives afthisN city
oenter
upon the abne-moriedproperty
for
h purpoee. ALTERORADDTOMECH.
(WE)aimato save,Indemnify and keep harmless the City
of Cupertino Date Receipt#
V against liabilities,Hdgerents,metsand expenses which may In anywayaccrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
.galrad.aid CityN nsdquenceoft Mittn flhle permit CONSTRUCTION TAX
/ AIR HANDLING UNIT(OVER 10,000CFM)
5 0' pplimn on4a ate 'D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
1RD0 S MATERIALS DISCLOSURE
WillthcappBmnlmfuturebuilding occvpannstore or handle hazard... HEATING UNIT(70 100,000 BTU) DRM RLYeI t#
letlal as defircd rlino Mu
Ncipal Code,Chapter 9.12,and the —.—
calthandSafdyCgd. o25532W77 HEATING UNIT(OVER 10a"BTU) TOTAL:
Yea No
Wilitheapplica orfumm Wlldingo pantumquip=ntmdevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemithazard us air contaminants as defined by the Bay Area Air
Quality Manage at W BOILER-COMPE1HPOR100,000BTU) A
?Yes 0 D
M
have read the ous materials requirement,under Chapter 6.95 of BOILELCOMP(OVER 100,000 BTU)
I the California Flcalt &Saf&y Cod,Sections25505,25533and25534.1
"t. understand that lit building does not currently have a tenant,that it b my NEW RESIDENTIAL MECFI. SQ.FT
responsibility Condi th..pant ofnhe reqs' ..is which most be mat
pto of a rt[ at.. pansr Ur
ner.raul ud age /ate ISSUED �r d
TOTAL:
OFFICE COPY