22638APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Fra co Identification
ding A°'.,LC6
r,_33--
PERMIT NO.
22638
rcre one:SUBMITTAL
Yy�,r�-IC,
CITY OF CUPERTINQBUILDING DIVISION
APPLICATION /PERMIT
minem'e Name: ALk. No:
BUILIXNGELFi1RICALPLUMBINGMFLHAMCAL'
CATEGORY
CONTROL#
ArehBect/Engineer. Lie No
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrrse:
PERMIT ISSUANCE
SLUG numb ml�"
❑ ❑ _ ❑
LICENSED CONTRACTORS DECLARATION
Lhertby afflrmthatl.m)kmsdunderpro WmsafC pter9(commuc
IngwlthSmt n7OOD)of DINdm3ofthe Budneuand Profes msCode,and
APPLANCEr RESIDENIAL
JOB DETC N
license b fell In full foand rifer.
hcenseCla
PANES -
Lk.#
Date CordnaoT
ARCHITECTS DECLARATION
Iurdentand my plans..w u
eleali bepubBcn m
La! M 2DO AMPS
OVd> OVER 1000 AMPS
SQ. FP. FLcdR ARTA
S/FQ.FT.
SIGNS ELECTRICAL
Liensed Profenbvl
SPECIAL CIRCNr/ML9C
OWNER -BUILDER DECLARATION
1hembyaf mthat Iamexemptfromthe Comms eaLkrnu Lwfmthe
�1
TEMP. METER OR POLE INST. �C=iYd
following meson. Seelan 7a315, Bushes and Profusions Code: Any dtyor
county which requlrna permit tocorslruM niter, Improve, demolish, orrepair
anystrueum pr)or to its Lwame, a bo requlm the applicant for writ permit to
Ob a signed statement tiut he is Beena<d pursuant to the provbbna at the
Contractor's Lkeroe Law (Cleanser 9(commencing with Seebon 700M of Dlvl-
don3 of the Buebenurd PrdsbroCode) orthu he b exempt lhrrtfromaM
POWER DEVICES _
9WIMMINGPOOLPLECIRIC
VALUATION
the best far the albged uemptbn. Any vtdatbn of Section 70315 byany
applicantforapemdtsubjedetheappkc ttoadullperoltyofnm.n than
O
Ovc�¢Indred ddlan (f.SOW.
u1a
, s owner at the Property, or my employer wth wages u IN sole
�}T.
STORIES
TYPECONSPRUCIION
compensation,willdothc work. and the structure is has Imendrd or offered for
yaw/ U
ale (Sec 70K Buebeu ab Pro(mloro Code: The Coucadote Uoeme law
don not apply loan owns of property who Wilds or improves the., and
lfmlhrwghhbownemplryee., provded that soch
OCC.GROUP
RM UNITSwhodonwchworkhh
impr cv nbam Mw tendcdorofferedfm.ab.ILhowever, the building m
Is_
improvement blob withlnorcy<aro(crompletbn,lhewvnervbuBderw111luve
t rdenofprovingthatledldsotbuudorimprovefmpurpoeeofeale.).
as owner of the property, am exclu.ely oontg with licensed
[ Nractin
eantracmn to mnvlruct the pmjed(See 7DK Bueleeaa and Pre(mbrs Code:
QTy. PLUMBING PERMIT FEE
PERMIT LSSIIANCE
11,001) ZONE
APN
The Contraeofe License Law don not apply to an owner a( property who
Wilde or Improes thereon, and who wmrtes for such ptokds with a
��Tarts) Irroxd pursuant to the Contnearx Lkense Law.
U 1 am exempt under Sec B k P C for this rrmn
�� DRAIN k VENT - WATER ffN
FEE SUMMARY
BACK FLOW PImTECf. DEVICE
DRAINS FLUOR ROOFiAREA, CONTI.
SANITARY Y_ N_
RBCIDTI
Owner - Dale
WORKMAN COMPENSATION DECLARATION
I hereby afMrt that I have • mrllBote of consent to seH-#sone, or a
ocrtwole of Wark<rs'Canperwllanlrouranes ars rertEled copythemo(Sec.
MW,Ieab C)
LECTURES PER 7R,Vs
SCHOOL I" Y_ N_
RECEIPT#
GAS FA. SYSTEM -1 ING4 OUITPTS
PARK FEE Y_ N_Poi-
x
GAS FA. SYSTEM-0VER 4(EA)
Com#—
y -
Certified ropy 0hereby famished.
CertNed copy is filed with the city Impectbn divWan.
DINGS IV
BUILDING DIVISION FEES
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
not
(fhbaenbn need sat be compleM B the pemdt b /more hundred dollars
PAID -
Date Rceci fit
SEWER -SANITARY -MRM EA 20(p;P.
($1W)mlmJ
#artily thatbthe anmof the(writ forwhichfhb pemdtbbored,
WATER HFATERW/VENT/E1_DCTR
ENERGY FEE Y N_
1 shall red m
empty person
y any person in any nwner at as to become subject to the,
Warkcri Campewtbn issue of California. Date
WATER SYSTEM/TREATING
PAID
Applicant
Date Recei tit
NEW RESIDENTIAL PLMB. SQ.FT.
NOTICE 70AIsubjed tote ff, after rs'Co perhis CertBlcabofExeammq bn,yw
shouldhumussubjecttothe Warkert L.bar
TOTAL'
au&perwsinprovkebroofthe
Code, you coni forthwith comply with wit pnvNebro or this permit shill be
BUILDING
deenad rewYed.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby afOmhatthercbamumdimleWingagencyforteperfo
R= b lrID,Clv. C.)ancooftheworkforwhkhfhb
—
ELECTRIC FEE a rl
Lender. Name
Lendet'.Addrr:ae
I redlfy that I love readhis tappllcatbn ami -te thrt the above Nformatlon
Is )agree to comp) BhaOdtyand county ordWnasand elate laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT NUANCE
FEES PAID:
rtlnln t Wilding cont a ,and hereby autbo rrprmntatNn of this
ALTERORADDTOMECH.
til n repo abo sunned property for Wupetlbn purposes.
Iumltggqy�yppp� the City of Cupertino
t, v tktpp
ago Iso o a me a co�bany wayamue
laidCyeranga(t permlt.
Date Rx Cci Hi
AHt IiANOLING 11NIT ('IO to,000 CFM)
SUBTOTAL:agar
AIRHANDUNG UNIT (OVER IQ0a()CEM)
CONSTRUCTION TAX
Signa mot p1i Date
IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS
HAZARDOUS MATERIALS DISCLOSURE
HEATING IIN7T (TOIW,000 B'Hn
urcbtBo,M.Mdpantelort h)uMkhwndthe
WRlthe eppllca by the
metarialae Wythe Cupertino, Cade,Chapter9.1; and the
Date Recei tit
FiFA'MG UNIT (OVER 100,000 BTU)
TOTAL: 0, 0
SafxIy
Hralthes Safety Cod Ix$rcE1m 75532(x)2
Yes ��TQiLNo
VENTILATION FAN SINGLE RESID)
ISSUANCE DATE
FIND
Will the appOcardor opant theequipme,ruArea
which emit haanlous air contamW ms as deBred by the Bay Arca AU
Quality hlawgenem 7
4 Y.
BOILER-mhTP OFl7'OR 100,0(0 BTU)
BOILER-COMP(OVER 100,DOO BTU)
hav adthth. matedas requirements under Chapter 6.95 of
the Ca Of Ilea f Code,Seebro75505,75S33and25534.1
NEW RESIDENITAL h1ECEL SQ.FT
and that if a ildl g earrenlly have a tenant, that it is my
99H �b L�
res' to B < the Iramems which must be met
prior some t pa
Owner nut ag t Date
ISSUED BY:
TOTAL:
OFFICE COPY