22398 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmjsct Identification _ PERMIT NO.
Building Address; - 22398
10557 unj j'
sere ante: one: AL DA IE
4 SC lcsfy CITY OF CUPERTINO-BUW.DING DIVISION
C adw'sName:^ Lie.N. APPLICATION / PERMIT U `J
`g T 7 UI
BLDINGELECTRICAT PLUMBING.MECIIAMCAL CATEGORY CONTROL 4
IM ArcrlEngines,. EMP
(' a-Y BUILDING PERMIT INFO
¢atp QTY ELECTRIC PERMIT FEE - I
U
Address: 01M PERMITISSUANCE
LICENSED CONTRALTO SDECLARATION FAY
Ihereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL ESC ON
Ingwith Sedion7000)of[XviYon3 ofthe Buslnessand ProfessionsC.dGand my
licence I,in(uI and effect. PANEL �{�q ,` ��y��{� {
Lin n Li, 7 # 1/M) 4, G`"1�"�'6&
Date Contractor
AACHITECI'S 'CLARA ON
201.1000 AMPS
QZ I understand my plane slag be used ss public records. OVER 1000 AMPS SQ.Fr.FLOOR AR S/SQ.FT.
COC
U Licensed Professional SIGNS ELECTRICAL
`kv
OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/MISC
7F ]hereby a(flrm that l am exempt from the Contractors Limnos Law for the
O qfollowingreason.(Section7031S,BusinessandProfnal...Code;Anytltyor
0Z)"ry TFAIP.METER ORI'OLE]NSI.
o.untywhlch requires a permit to construct,alter,Improve,demolish,orrepair ev
anystruclure priorm its houtance,als,requlrestheappRcant for such permitto
]'OWER DEVICES
f1leCo a signed statement that he t r9(colicensed pursuant it the tion 70M)of the
3w Contractor'. .gLicense andPhfpter9( dm).rtingwlth Sedion7f00)of .. _
Ye basis fo the alleged Pro(esion, Any orlation f exempt 7MLS bman — ,VALUATION
0 S the bash for the alleged exemption. Any violation of Section 703L5 by.any ��►
applicant fora permit subjects the applicant toe dull penalty of sat moretlu
five hundred dollars($500).
�n 'o❑L as owner of the property,or my employees with wages as their sok p 'hT' STORIES TYPE CONSTRUCTION
5.90
c mpensatlon,willdo the work and thestrudure is not Intended or offered for
5' 0 sala&c.7044,Business and Pmlenimu Code:The Contraaols Licerr�Ys�p Lw
� does not apply to an owner of property who builds or Improves thercaand --- OCC.CROUP RES.UM1'S
G who does suchwork himself orthrough his own employees,provided that such
Improvements are not intended orofferedforsale.If,however,thebuildinilar r'• TOTA
Improvement issold MthinoneyearolcompletoMtheawner-builderwill have
tFIR,(I.udeo ofpmving that he did notbulld orlmprove,for purposeofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with Iireneed
contractors to construct the pro)ect(Sec.70K Business and Professions Code: PERMITISSUANCE
The Contractor's License Lw does not apply to an owner of property who 1 pL7Eg-DRAIN&VENT-WATER(EA)
Wllds or Improves thereon,and who contrcds for such ptojects with a
qwactor(.)kcenscd pursuant to the C.ntradors License Law. BAIX FLOW PROTECT.DEVICE
FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N'
rnru
Avner Date RECEIPT'#
WORKMAN COMPENSATION DECLARATION p�.NRES PER RECEIPT
SCHOOL FAX Y N
❑I hereby affirm that I have a cenlRate.f consent to self-Insure,m a RECEIPT#
certificate of Workers Comperaatlonlneucane or a cerUlled copythemof(Sec.
3800,Lb C.) GAS EA.SYSTEM-1INCA OUTLETS PARK 1°EE Y N
m RECEIPT#
an GAS EA.SYSTEM-OVER Y BUILDING DIV]
SIONFEES
Co
Certified copy 6 hereby filed
the cid. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
F1 Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAIr PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.hOFC Date RCCeI tN -/0.
(this section need sat b completed](the Permit V f.rone hundred dollars
(St00).filyth (f WATER HEATER W/VENT/ELEFCTR ENERGY FEE Y
]certify thato the person In ofthework for which thio permit Is issued, A,
I shall not employ eery penton In any manner m ne/o bjo'me X06 jed to the WATER SYSTEM/TREATING PAID Q'!J� t
Workers Come do sus of I sats Data j
Z Applicant /L NEW RESIDENTIAL PLMB. Date t tW
Z O NOTICE TCr1lPPLIC AVYF.If,after king this Certificate of Exemption,yosi —SQ'IT"
should become subject to the Workers'Compeneation provisions of the Labor T TAL:
W
Code,you,roust forthwith comply wlthsuch provisions.,this perml ,luth be B I NG s
W j deemed revoked. r
W g CONSTRUCTION LENDING AGENCY SEISMIC FEE #
Iherebyaffirmlhat there is a ecogrudion lending agency for the perform TOT ��� ELECTRIC FEE �w
D Z .noes!theworkforwhlchthlspe,Mtlsleaued(Sec.3097,Civ,Cd
U O Lenders Name PLUMBING FEE
ly — Landee.Addm.. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW ladlfythat]havemadthls eppliatlon and Yatethat the above information
(1 i.cormd.lagreetocomplywlthaBdtyand countyordleancesand Yate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize reprexntatives of tole
Zcity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL - /e
(We)agree to save,Indemnify an d keep harmless the City of Cu ped In. Date Receipt#
V againetl bllitles,pdgmenta,cogs and expenses which troy In enywa accrue AIR HANDLING❑M7CTO 10,000 CFM) SUBTOTAL:
gains Id Clty�p.conemryence of the an ting ofth,.;:.Y t. /y
a AIRHANDLINGUNR(OVEAIO,000CFM) CONSTRUCTION TAX
SftTalmre_oof A•ppppHant/C tractor 'bill EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldingoccvpantsmre orhandle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined bythe Cupertino Municipal Code,Chapter 9.17,and the Date Recel tN
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER IDg000 BTU) TOTA
EDYes No
Wilitheappllunl or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which eMt ha ement air District? ants as defined by the gay Area Air
Qu Ifty nagement District? BO LF.R-GDMP 31 IFDR 100,00 BTU
4h.Ycs n No PAID D
va..dthehaz. ...terialsrequtmmenhunderChapter6.95of BOILER-COMP(OVER r ^ '
the CGIIloinla I lealth&Safety Code,Sections 75505,25533 and 25534. I
understand that lithe building does not currently have a tenant,that It le my NEW RESIDENTIAL MECH. SQ.FI. �OV
responsibill Condifythemcvpantofthomquiremants It Iftmutbamet 199,
priortoles nceofa Affiatco(0 ��� // - yy
n ll��/L�- C�
Ownel or aothorlmd agent at �' ISSUED BY.
IOTA
OFFICE COPY
ADDITIONAL PERMIT FEES
BUILDING PROJECT I OENTIFICATION VALUATION
BIIILOING
ADDRESS I�S
OWNEflf L/
"AME FEE SUMMARY
CONTRALTCRS BUILDING
Kiss r=E UC.N -S /✓! PLAN CHECK
f,ONTflPCiOR'6
FEE
SEISMIC FEE
CITY. ELECTRIC PERMIT FEE
OUTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES _ PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS U
SIGNS TRANS. 1 )l.J TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. JUN4T VALIDATION
MOTORS " SEE FEE SCH. !� fI 10
O SERVICE CHAN E _ �. O
ZZ U �� Y 198'
I— ° TOTA /Y Ur �4,
Lu T
> CITY. PLUMBING PERMIT FEE
' Wa O BLDG. ELECT. L NEC..
2 ALTER-DRAIN&VENT-WATER(EM_ ❑ 0' ❑
V O BACK FLOW PROTECT.DEVICE
LL
0 0 U DRAWS-FLODR,ROOF,AREA,COND.
y FIXTURES-PER TRAP "
F- ? GAS-EA.SYSTEM-l1NC.4OUTLETS
() GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC S V.B, ^
LAWN SPRINKLERS-OVER 5 IEA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT
WATER SYSTEM 2��q4
WATER TREATING EQUIP. Zq
TOTAL
CITY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10)000C.F.M.)
AIR HANDLING UNIT(OVER 10)=C.FM.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT ITO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COMPO H.P.or 100,000 B.T.U.)
BOILER-COMP oo—100.000 BTU)SEE FEE SCH.
TOTAL