22715 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PE14 ONLY
Building Proed Identification PERMIT NO.
BaBd in d a_ " 1 - - 22715 '
ti�mg, cx�sa- A
CITY OF NPERTINO-BUILDING DIVISION
Co O'eNaair L[ `IGra � APPLICATION / PERMIT
( BI DINGELECIMCAI PLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lk.Na.
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: bLOU LL�l PLUMB MELEE
PO MITISSUANCE El 11 1:1LICENS BD CONTRACTOR'S DECLARATION
IhthSadifirmthat l ivlm3ofheBusirovklonPmfCsipter9(mmnd my APPLIANCES-RESIDENTIAL r JOB 0C 11.1'RON.
IngwBh Sectlan f.meaf Dlvfect. ftheguelntsadndlsrofesiansCode,end my -
liann le In fuq force and d(ect. '1 PANELS
LD�nre bss V C rat_ �Ir
UP TO 2DOAMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
QO iunderntand my ph re,shall be used as public records. OVER IOW AMPS SQ.Fr.FLOOR AREA 5
�zz Ltcenvd Professional- SIGNS ELECTRICAL I1t, ® 1p�1g1
6 OWNER-BUILDER DECLARATION s� l'an �I v
�n SPECIAL CIRCUIT/MLSC
F owing raf@mlWtram exempt from the Conlredo/e License law fm the
following rearm.(Eectlon 78715,Business and Professions Cade:Any or TEMP.METER OR POLE INST. \{J 1
K tn@county which requlrre a permittomrutruct alter,Improve,demolish,or repair V YY
OO �N�
any stmciam prior to its bauance,also requires the applicant for such permit to POWER DEVICES a7 /C �-7
file a enced statement that he t r9(cont pursuant it the proWbre of the UP r•--
3p� Contncttha usirLw em.nd PledramraC.,10 nciat Imis xemptthere of DWI- SVMAMING POOL ELECTRIC vas
tkn3sie fa the
exemption. Ary orthrthob exempt therefrom and VALUATION
6 the basis far the alleged exemption. My violation of Section 70715 by any .
applicant fora permit subjects the applicant to a civil penalty of not comethan OIITLETSSWITCI{ESFIXTURES
five 1,as
dor ars of
pro NEW RESIDENTIAL ELECTR SJ.FT. STORIES TYPE CONSTRUCTION
I,as owner I the property,or my employee with wages r there dole
k <
compensation,willdotheworl:feamerad the etrude:TheCure is intended Licamses Law
O d for
vie(Sec 7064,to=oBu.ionsand f Property
Code The C Improv fd herem Law
$
dean cluesuch loan owner or ofp rough when emporees,grated that each
OCC.GROUP RFS.UMTS
EE whodoements an not mselfedcoofghhbow le.If, oe,er,thedildingh
improvements an notintendedprofferedforeio th caner-g flder ldingoe TOTAL:
Improvementbsold withlnoncyearo(compldiogtheowner-bullderwillhave
ttiLlfunden of pmving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj 1,as owner of the Property,am exclusively contracting with licensed
contredon to construct the projed(See 7016,Business and Professions Code: PFRMITISSUANCE
The Contractor's Limese law does rads apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(E V
Wor Improve
thereon,and who contracts for such p\o)ects with a FEE SUMMARY
cgp((e&or(.)Imused pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LII am exempt under Sec. B A P C far this mason
Owner
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION F1X. FS PER TRAP SCHOOL TAX Y N
I hereby Affirm that f have o certificate of sent ci opythe of or . RECEIPT N
3800,.AlflabofWorkers Compersatlonlaurencemacertlfled mpythereo((Sec. GAS F.A.SYSIEM-1 INCA OUTLETS PARKFEE Y N_
3800, ab CJ
Policy M W (��c�— 1 RECEIPT M
Pl L GAS FA.SYSTFhf-0VERd(FA)
Com antUY7Pf\ BUILDING DIVISION FEES
CertlBed mpyTi hereby(urN'shed. CREABE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE -
CertiflM copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID -
COMPENSATION INSURANCE SEWEIPSANITARY-STORM EA 200FT Date Remi tM
(This motion
ancient be mmplded tithe permit Is foram hundred dollars
($100)ort..) WATER HFATERw/vENTIELECfR ENERGY FEE Y N
I eartilythat In the pedarmaneraf the work forwhich this pemdt la Issued,
I shall not employ any person In any manner an as to brooms subject to the WATER SYSCEM/TREATING
Workers Compensation Laws of California. Date PAID
Z Z AppIleaNOTICE
NEW RESIDENTIAL PLMB. SQFr. Date Recel t#
NOTICETO esubjCANT:e after making this Certificate ofExemption,oft the
I" Com,y.ld ecome subject itto the ply Mth.ohpwdonprrtha pmo/the Lobar TOTAL:
W >N Coda You coked. thwith comply with such provisions orthb pertNt shallbe BUILDING
seemed revoked.
CONSTRUCTION
commuLENDING AGENCY SEISMIC FEE
MZ a.fthyaffirm that themcukfrwhtcht bemmtIs ion Issud(Secgagency for 7,Civ. .) perform TOTAL ELECTRIC FEE
deader s c work lorwhkh this permit b owed(&c.3097,CIv.C.)
LL O Lender's Name PLUMBING FEE
LL F Lender's Add.thatl QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW coma,'hatlha comid'hbappliati n and Yatethat theabovelnfornalon
IL bmrmct.Iagrceta comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
I- Z city to enter upon the abovnmentiomd property,for Inspection purposes. ALTERORADDTOMECH. Dale Receipttl
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino
against liabilities,judgments,mete and expenses which may In any wayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga Wt said City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contrador Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCei
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the
Ilealth and Safety Cade Section 25532(a)7' HEATING UNIT(OVER IM,"BTU) TOTA .
F1 Yee fnNo
Will the applicant ortutum building occupant use equipment or devices VWIILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hamrdous air contaminants as defined by the Say Area Air
Quality Management Dbtr NO BOILER-COMP(3Ifl'DR 100,000 REM
Yen ❑No
have mad the hazardous materials requirements;under Chapter 695 of BOILER-COMP(OVER 100,000 BTU) ''A p P
the California Health A SafetyCode,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT
reaponsibility to notify the occupant of therequirements which most be met FEB 13
prior to Issuance of a Certificate of Occupancy. 119,
av— /J;!sd c ' z-i a-5 'I 791?
Owneror authmi dagent Data 5&11 vu
ISSUED BY:
OFFICE COPY