22391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldentlflaadon PERMITNO.
Ba11a1 1Add_resL j .�GkAlQE� 22391
{ R hone. A A. A
VK" CITY OP CUPERTINO-BUILDING DIVISION ^u d
ContradOr'.Nanxe: Lie. o: APPLICATION / PERMIT Vr L
BUILDINGELECTRICAL,PLUMBINC-MECHAN'ICAL CATEGORY COMROUA i/�'�
A itect/1a p k.No: (p O L
l Qry ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
LICENSED
IIDCONTRACTOR'S ARATION
PERh4TISSUANCE
Ihb mthxtlamlkensedlunderAwWmaC9( c APPLIANCES-RESIDENTIAL ENTIAL I (� JOB DESCRIPTION
DfSCRO}I'C�7Y10N
IngthIGA70W)ofDlvtlon3oftheBusies.andPmleuionsCe,aAdmy
lice.sel.in
yIQtL]-
�
full forty and effect. PANELS
License Claa Lk.I
Date Contractor
ARCHITECT`S DECLARATION MI-1070 AM13S
ggqqqq0ad7 I understand my plans shall be used As publicre es. OVER IODO AMPS SQ.Fr.FLOOR AREA f/SQA.Fr.
�00 Licensed Professional SIGNS ELECTRICAL
<w OWNER-BUILDER DECLARATION •�n v �ay��
Ir'i F7 SPFLULC]RCUIT/MISC
following reason.(Section 7mL5,Businamd Prafasn.Cone An atyor
w
for 23 -2-0, affirm that l nm exemptM Contractor's License the
OZcwhich rcqulreaa perocoralter, elTQ.P.METPR OR POLE INST.
Fm�, Marm Ir
anystmatem,pdorto Its bsoance,alsomquim theappllunt forsuc pe R PEVICa
C e file a signed statement that he Is licensed pursuant to the pro m. t s
8�m Contractor's License Law(Chapter 9(mendtgI v, Sedlon )of vl-
F�O� .ion3a(lhe mmBuslnes.and l'rofesiom Cade)orthat hets emmpt th the, a VALUATION
Q .•5at the basis for the alleged exemption. Any violation of SeRba 7 .5 kZ / .. (� /} q e a,y s
appllantfora perMt sobjects theapp0canttoa dvii penalty ofa rrorethan I �IXJ D "/L Y1 t l..i0
m�5EC.. five hundred dollars(SM.ollars(SM.
I,as owner of the property,or heyemploy.wi wagess 1
lawd
A YT. STORIES YMECONSIRUCTION
t=] comPenzation,willclothe
work,and the isnat
Ind aedor
sale
(Sce.74k Bmut....
dPrmos Code:
The
Ccuaracwes Gae
whoa not apply to an ownerof property who orimproves 1Maen an
whod«asuchwarkFimscl/wthrough hlsownemplogm,provided
that such T OCGGROIII' RFS UNITS
improvements are not Intended oroffered far sale.It hawemr,thebuileiing or TOTAL:t> •Iv
Improvement bsold withinoneyearofcompletbq theawner-bullderwlll have
rdcn o/proving that M did not build or Improve far purpose ofsale.). QTY. PLUMBING PERMIT FEE
e Las owner of the property,am exclusively..trading with licensed Fl.ODD ZONE APN
ant dors to mnstmat the project(See 7DK Bei.InesaM Professions Code: PERMIT L561JANCE
The Contactor'•License law does not apply to an owner of property who ��-DRAIN k VENT-WATER�V
Wilds or Improves thereon, and whocontrada for such pkojeds with a s
yyttrrador(s)Ilcenxd pursuanuothe Cont •License Law. BACK FIAW PROTECT.DEVICE FEE SUMMARY
LJ I ce 4 un Sec. B"Tle C for 1his mason __ss....
I. DRAINS FLOOR,ROOF,AREA,CC,ND, ew SANITARY Y_ N—
n r Date RECEIPTN
A fPA Ain ��11 f ...a 10 FIXTURES PER TRAP SCHOOL TAX Y_ N
❑t
firm ,ver.sorties tgpr can.em to.dr-mare,w a I a RECER'I'
ccdlflcam ofworkeK Compo tion Insurance ova ceaified copy themof&x: GAS FA.SYSTFA]-1 INCA OUTLETS PARK= Y N
Is
3800,lab C.)
Polity. GAS EA. L RCCEIPI'N
CIt . any H UILDING DI VISI ON FE IS
�Cedifled copy at hereby furnished.
❑Certified copy Is filed with the city Inspection dlvidon.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID_�{S<(I ro29l-N-F e�
COMPENSATION INSURANCE SEWERSANHARYSTCR.M F.A.700Ff Date Remi ted 2� 4
(rhlasectbn need not M completed the permit b fw ane hundred dollars
(St00)or les.) !'� ENERGY FEE Y N
I oertifythat In the perforrrunm ofthe work forwhlch this permit is issued, WATER HEATER W/VENT/F],ECTA ``� —
I shall not employ any person in any manner m as to become subject to the WATFRSYSTIN/TREATING
Wwken,'Compenastlon LA a of California.Date PAID
0Z NOTICE
NEW RESIDENTIAL PI.MB, SQ.FT. Date Recei ted
_Z O NOTICE TO APPLICANT.If,after making this certificate of Exemption'you
should become subject to the Worken'Compensation prevision of the Labor TOTAL'
H
Crain,you=at forthwith comply with ach provisions orthis'nout shall he BUILDING 1
W j seemed rcwked. FEE
CEi L CONSTRUCTION LENDING AGENCY SEISMIC
Ihembyaf(Irmthat there ba coruwttlon lendingagenq forth perform O
Z once of the work for which this permit b law097
ed(Sec.3 ,Civ.C.) TOTAL:
U O I<.derbName cCp ELECTRIC FE
PLUM BINGF.
V 3L
LL I— Lcader.Addsv QTY. MECHANICAL PERMIT FEE MECI{ANICAL .
O W Iartlfythatl Mve read thbappllatlon and aatethat thcaboveinfortvtlon ��..aa�s) L
Il ucorscd.I.greet.complywlthalldtyandcountyordinancesanddatet.ws PERMIT ISSUANCE 2c LY FEES PAI¢
} rclatingtobulldingmvtructlon,and hcrtIXAuthoeim,mprewnutivm of thin
Zcity to enter upon the abose-mentioned profor inspection purposes. ALTERORADDTOMECH. u� Date Recei t
agrae ta.a.e emnity an d lam ha ex tee city of Cupertino P
m t Iabi00cq' d rro ts,cortundexpen a hicha,ayln.nywayaarve AIR HANDLING UNIT Ro 10,000 CFM) SUBTOTA
a sin t 1 n venae ofthe gr ani this pe it.
AIR HANDLING IATT(OVER]0,000CFM) CONSTRUCTION TAX
I 11A
gn.t ircof est Coi a r ate ExHAuSTHOOD(W/DUCT) CONSTRUCTION TAX 'AID:
S 11 EMALS DISCLOSURE aasshY�
cappliant."Ci ding occupant store or handle hazardous HEATING UNIT 100,000 BTU) tw Date RCC t#
rruted.l as defined by tM CupcAlno Munkip.I Code,Chapter 9.lZ and the _
Health.ad Safety Code Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
F1Yes �]No
Willtheappllcant orfuturebuildingomupantmeequipment ordevu,cs VFNfILATIONFAN(SINGLERESID) (� I$ .(
whichemus
it hazardoairmntamli.a.defined by the Bay Ain.All Ljj -,DATE
Quality Management De,trld7 BOILER-COMP OHP OR 100,OD0 BTU) -.
Yea FF��No �
Th,lveye.read thehuars7ousrrutedala requimmentsunder Chapter6.95of BOILER-COMP(OVEN 100,000 BTU) .ry
the CalifwnlahealthkSafety Code,Sa Wo 7550.5,25M3and75534. I b
understared that lfthe building does not currently have a tenant,that it is my NEWRESIDFNITALMECH. SQ.Fr.
mpomibility,to notify the occupant of the requirements which rust be met aa..��//a.,���,�sr..��k.a
prior to laauance of a Certificate of Occupancy. Co.W,cuplelYIIB
Owner or authorized agent - Date ISSUEDBY.*Z .
TOTAL:
OFFICE COPY