22883 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN-ONLY
Building Project Identification PERMIT NO.
Building Address: ' Lij_
22883
• eo
2 2 ^8 3
r : �fCsCITY OFCUPERTIN66UILDING DIVISION
ota
Jr APPLICATION /PERMIT O
leg UBUILDING-ELECTRICAL PLUMBING MECHANICAL CATEGORY CONTROL
hltect Enol ea lie/ , Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmas PERMIT ISSUANCE ❑ N ❑ ❑
i.LICENSED CONTRACTOR'S DECLARATION
I Mrebyaftl7000).DivJxi I am 3.fth.derleassannsof Cssioni9(commac APPLIANCESRFSTDENTIAL JOB DESCRIPTION
Ingwlth Sed1on7000)of Dlvislon3olthe Buslnesea dProfesslonsCode,and my
license is In fuB(li¢e and d(eaT. r� ax �) PANELS
License Cla® �7 Crmt r`/I� U
Date Contractor 1�'/Lt^Irfji'/e711`
ARCHITECTS DECLARATION 811-IOW AMPS
Oa Oq I understand my plam ehall be used as public records. OVER]000 AMPS / £Q.�F r.BOOR AREA $/9Q-FT.
U Licensed Professional SIGNS ELECTRICAL L .;'
�6 g
OWNER-BUILDER DECLARATION - \ t
zp,�7y IhercfR
byarmthatlannm examexemptfromlhe ContnctL
or'e License wfo SPECIAL CIRCUIT/MISC
the
OR— following reason.(Section 7031.5,Business and Professions Code:Any city or
p4Zconatruct,alter, pair TEMP.METEROR POLE
anystm mph oriresaperanct alomquimsth apbmntfmolbh,orrctt
any etrudure prlorta Wlsaance,alw requlrcstheappBcant for such perMtt0 POWER DEVICES DAT
file a signed statement that he is licensed pursuant to the provisions of the
O wI� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
307 alon 3ot the Bustnessanl Pmfrsn,ma Code)orthat he lsexempttheretramand SWIMMING POOL ELECTRIC VALUATION
k5 •77 the basis for the alleged exemption. Any violation of Section 70315 by any
pis applicant for a permit subjecta the applicant to a civil penalty of not momthan OUTLETS-SIVITCIiESFIXTURES
a$ five hundred dollars($500). NEWRESIDENTALELECIR
�n I,as owner of the property,or my employees with wages as their sok SQFT' STORIES TYPE CONSTRUCTION
compensatfon,will dothe work and the strocture Is cant Intended or offered for
sale(Sec.7044,Business and Profeselow Code:The Contractor's License Law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GRON' RES.UNITS
who done suchwork hlmselforthraugh hisownemployces,provided that each
improvem¢nts are not Intended orotfered forsale.If,however,thebullding or TOTp
Improvement Issold withlnoneyearofcomplanum,the owner-builderwlll have
til, Man of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT ',FEE pIgOD WNE --Al—'N
U 4 as owner of the property,am exclusively contracting with licensed
contactors to cotutruct the Project(Sm 7044,Business and Professions Code: PERMIT ISSUANCE
The Contactors License Law does not apply to an owner of property who ALTAR-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pRajects with a
ol5actorp)licensed pureuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
l_l l am exempt under Sec. B k P C for this reason
DRAINS FLOG ROOF, SANITARY Y N
OUTSI UP HTS
Owner Date - R AREA, RECEITTM
WORK MAN I have COMPENSATION DECLARATION FLY�ps PER TRAP SCI 1001,TAX Y— N
❑I hereby affirm that I have a certu ate of consent to copy
thereof
ora RECEIPT.M
certifiateolWorkera ComperoaHon lruurana ma certlfhd espy thereo((See. GAS EA.SYSTEM-11NC.40UILm PARK FEE Y N_
3300,Iab CJ
Policy N GAS EA.SYSTEM-OVER 4(EA) RECEIPT
rfid ropy V hereby tdBUILDING
VISION FEES
Certified copy V filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
—
not
Rewi
Rhis eedlon need net nt complded If the permit V SEWER-SANITARY-STORM FA.IOOFT. Date(Drone hundred dollars pt#
($l I unify
h WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]ll cut that In the performance I anof y
m userweean as to become,h this
subject
Ito thessaudi, —
I dull not employ any person In any manner m ss to Wrome eabkct to the WATER SYSTEM/TREATING
Workers'Compensellnn laws of Celi(ornla.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. Date Recei t#
Z 0 NOTICE TOAPPLICANT:If,after making thisCertiflateofExemption,you SQ'FT•
Hshould bemmesubj:ct to the W¢rkers'Comperustion provisions of the Labor TOTAL:
V3
Code,you=at forthwith comply with such provisions or this permit shall be
LU j deemed revoked. WILDINC FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
lhercbyatFlrm that there S a contraction kndingagency for the perform - TOTAL: ELECTRIC FEE
7 Z anc¢of the work for which this permit Is forced(Sec.3097,Civ.C.)
V O Lender's Name PLUMBING FEE
Ir, Lander.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertilythatlhavereadthlsappliationandookuihatthogsweloformatlon
0 W Iscurnect.I agree to comply with all city and countyordinancesand state laws PERMIT ISSUANCE FEES PAID:
} IL relating to building conotaction,and hereby authorize representatives of
F.U) city to enter upon theaWve-mentioned property for inspection purposes. ALTFRORADDTOMECH. DRfC RCCei t#
— (W save,lndm
erdly and humilisP
keep the City of Cupertino
ag thabll i s,jodgments,rostsand expenses which may In anyway accrue AIR HANDLING UNITED 10,OW CFM) SUBTOTAL:
1 C of the granting of this pe It. AP —
AIR HANDLING UNIT'(OVER 10,000CFM) CONSTRUCTION TAX
Signature o! p unmet., at -I EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
RDOUS ATERIALSDISCLOSURE
Will the applicant or future Ilding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
matedalasdef)nedbytha Cu rtlno Munidpal Code,Chapter9.13,and the -
Health and Safety Code Sectln75537(a)? HEATING UNIT(OVER 100,000 BTU)• TOT O`er
❑ Yea M No
Will the applicant or future building occupant use equlprrsnt or devices VENTILATION FAN(SINGLE RESID) I$$U�JfiFn TE
which coot hazardous air contaminants as defined by the Bay Area Air 'W�' Yr
Quality Management District? BOILER-COMP OFT'OR 100,030 BTU)
4 Yes I—I N9
hav¢r¢atlink zar fet mode,ls Sections
ection 255ntsundernd 25534. 1 of BOILER-COMP(OVER 100,IXDBN) rj I
the Callan dcalth&building
Cade, out currently
u rentlyh have
a tenntl,that I /
send and that thehfy the ingdoes not errcnllyursuds which
that It is my NEW RESIDENTIAL MECH. SQ.Pf. Quy
o nntity the occupant of the requirements which must be met RW (s
W
cc rtlfkateofOmpanry.or agent V t¢
' TOTAL: ISSUED BY:
OFFICE COPY