22473 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification PEKMITNO.
Building Address: 2 2 4 7 3
Ru3oo S-Fent veCI�PK GG 3
ante: one. SUBM11-FAL DATE
I Vey-7— - CITY OF CUPERTINO-BUILDING DIVISION
Creno-r eo aNam<: yl �/ 7 u,.No: APPLICATION I PERMIT 7- 15—q/
/\r
K. G1 rte/ e t C `/1a BUILDING-ELECTWCALPLUMBINC-MECHAMCAL CATEGORY CONTROL#
Archil,et/Engorec _ Lie.N.
AJoAv G- - BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Add.. - PERMIT ISSUANCE 2a—CV But, 1�1�1 PLUMB M�ft
❑ y ❑ ❑
by LICthat Ia CONTE under provisions
RATION
the Sectio irmthatiamlicensed 3ofthe ur ne and Pr(Chains 9(rommen APPLIANCES-RESIDENTIAL JOB DESCRB'TTON
Ingwhh SeafulltoAnddieon3ottheguslnessandProlnelonaCode,and my
license bins force And died. PANELS UP TO 200AMPS ' A /
License Clam CID � Llc.a y7/a90 t��"
Dale Y=0/ 7f7f contractor — r.e
ARCHITECTS DECLARATION 201-IODOAMPS 5"". 1, -
9OZ l understand my plans shall be used as public records. OVER1000AMPS " S/SQ.FL
qqq ❑O SIGNS ELECTRICAL
(� Llceneetl Professional
�6GL'i
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Z f., .Za .Wong r a me.( MI..7 exempt fromBusiness
a d Prol Contractor's License law forth,
Q followinhichre uireafonrmit S,Bustrue"t t,impr improve,
Code:Anytltyor
�� uR countywhich requlmsa perrNttororutruct,alter,impmve,demolish,orrepalr T�P'MCff7R ORPOLE INSr.
7 anyatrucwre pdormlts issuance,also requlreslheappllcent(orsuch permit to
r file s signed statement that he Is licensed pursuant to the providers of the POWER DEVICES
3 4D y Contractor's License Law(Chapter 9(commenclog with Section 7000)of Divi. SWIMMING IDOL ELECTRIC
slon3o11he Business and Profenlons Code)orthis
et he exempt therefmmand VALUATION
Q the basis for the alleged exemption. Any violation of Section 7TI1S by any OUTLETSSWITCHESFIXTIIRE4
applicant fora permit subjects the applicant to a evil penalty of not more than
five hundred dollars Mail). �,�,.
NEW RESIDENTIAL ELECTR
LLL...111 (^n pI,as owner of the property,or my employees with wages thele sole STORIES 7Y1'E CON57RI1CTIOK
C 6 cont(Sec.70K WlEdoBudesthe tand Prandtheao-oaurebn d intendedContactor or License
Lar Vtw I-T w t
D sale(Sec.apply
matr owner of property
Co buildsThe Contreols License Law
$
does not applytoan ownerofpropertywhobuildslo Improvethereon,And
whodoessuchwork himselforlhrough hisownemplayeea,providedthatach OCC GROUT' RFS.UNITS
Improvements are not Intended oroftemd forsale.If,however,the budlddngor TOTAL:'R
Improvement Issold withlnoneyoarofcompIdioNtheovner-Bullderwillbave
tj!R rdenofpmvingthSt he did not build or Improve for purpose ofade.). QTy. PLUMBING PERMIT ,i:.,FEE FLOOD ZONE APN
L�I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to'caomrue the project(Sec.7044 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
builds or improvea thereon, and who contracts for such pkajects with a
cgiBfaator(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec B k P C (or this reasonOUTSIDE PUS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION
Owner Date RRCEIPFM
FIXTURES PER TRAP SCHOOL fAX Y_ N
❑I hereby afRrm that I have• le docate of consent to self-Ineure,(S . RECEPT M
certlflLab a(Workers'Compevatlonlrourancearacertified mpythereof(Sec, GAS FA.SYSTEM-1 INCA OUTLETS 380),Lab CJ PAItI(FFF. Y_ N
Pollry b GAS.EA.SYSTEM-OVER 4(EA) DING DI N
Cam any BUILDING DI VISION FEES
❑Certified copy is hereby filed
the city - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b filed with the tlty W pection division.
CERTIFICATE OF"EMPTION FROM WORKERS' GREASCTRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT. Date ReceI I#
(this section need not bemmpleled tithe permit b(Drone hundred dollars
(SlW)oriess.) WATER HEATER W/VENT/EL[CTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is Booed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREAHNG
Worker'Compensation Lawsof California.Date PAID
OZ Applicant
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMS. SQ.1T. Date Recei t#
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
fA Code,you must forthwith comply with such provision or this permit shall be
> deemed revoked. UUILDING FEE
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafRrmthat there b a construction lending agency for the perform ELECTRIC FEEI SQ
Z ane,of the work for which this permit b laved(Eec.3097,Civ.C.) TOTAL;
u O I<ndcr'e Name PLUMBING FEE
U. F LanderBAddrcsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certify that l have readthb.pplicatio...datalethattheabovelnformation
IL Lacorrea.I agree to comply with all city and county ordinances and nate lawn PFRMITISSUANCE FEES PAID:
ID relating to building construction,and hereby authorize representatives ofthle
H Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Rm[CI t#
— (We)a to save,Ind emnlfy an d keep harnder the City of Cu ped loo
agoustll tles,pdgmen sandeapenseswhdch mayln anywayacaue AIRHANDLINGUMT(TO10,ODOCFM) SUBTOTAL:
City in con of the Ranting of thh permit AIRHANDLINGUNIT(OVERIQOOOCITO CONSTRUCTION TAX
p e, / 01 actor Date FXHAUSrHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
JJIAZARDOUS MATERIALS DISCLOSURE
Will a pGcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Iiealth and SafetyCode Seaton 25532(.)7 HEATING UNIT(OVER 100,00)BTI) TOTAL: 7'56'a"
❑ YeaNo
Wiillheapplicant or uture building occupant use equipment or devices VENILAIION FAN(SINGLE RESID) IrjSUAll�h�ppgE
which emit hazard...air ecourre..ts as defleed by the Bay Area Air r'/■1CyiM'lll�y
Quality MawgcmArt D❑istrict? BOILER-COMP OFI'OR 100,0(10 BTU)
4
Yen M No INTO)havereadthe Raza fuy C.de,S ri..255M,25S Sar d255m. 95 of BOILER-COMP(OVFR 100,000 BTU) JUL 1 $
the erstand t Health building Safety Code,SMlone 25505,ve a t and 25534.1
usdertandthat ifthe ntifytheoccupant of the oultly mments which
that it is my NEW RESIDENTIAL MECH. SQ.Ff
prior toibe a cenotify the occupant of the requlrementa which must be met �of cvaa�
prior to Lssuance ofaCertl(kate of Occupanry. � TT- ANI r\(\q'
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY