22427 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buudln Project Idemlficatlon PERMIT NO.
Budding Address: n f1 A f�
o �� 224G
weer` .cors: '\ / one;
CITY OF CUPERTINO-BUILDING DIVISION//
c Rar. a U
APPLICATION / PERMIT
BUILDINGELECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL N
A Engl er. Llc.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add ot FERhETISSUANCE 2s dV � ❑
LICENSED C NTRA OR'S DECLARATION
I hereby lonlO Mt l am licensedll eller prov andP f Chapter ode and c AI'PLIANCFSRESIDENTIAL eZ.O )FSCRIT70N_�
ingI hereby
affi m that I am nsunder
perssand s of C a pten g donsommy
limrar Is
11( rndLlc.N died.�23 �Z.�3 PANES /
Date Contratlar L JUP TO 2DOAhU
ARCHITECTS DECLARATION 201-IODO AMPS
X I understand my plan shag be used as public records. OVERlODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
gyp±! CO
E () Licensed Professional SIGNS ELECTRICAL /�
<� OWNER-BUILDER DECLARATION 3 SPECIAL CIRCUIT/MISC /_` �' I N
zF, I herebyafilrrnthat lam exempt from the Contractors License Law for the {r L
ppp following rearm.(Section 70315,Business and Profession.Code:My city or
Kqsy muntywhlchrequlrnaper ttomns c"ter,bnpmve,dem iLshormpair TEMP.METER OR POLE INSE. ak
B - C
Bel
prior tops bsuance,alaorequireslheappliant fensuch perm Ito G
isle a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
3w Contractor.License Law(Chapter 9fer.odngwith Section 7000)ofDIA.
�OS ston3ofthe BusinessmdPmfemiomCode)orthatheisemmptthemfromand SWIMMING POOL ELECTRICI DATE oN
<S the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETS-SWITCHES-FIXTURES
applicant fora perMt objects the applicant to a civil pemlty of not morethan
five hundred dollars($50Q, NEW RESIDENTIAL ELECT'R SQYr. STORIES TYPECONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work mb and the stature net Intended or offered for
O site(Sec.7054,Busir e,.and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilda or Improve thereon,and OCC.GROUP RES.UNITS
who does such work hlmselforthrough Nsownemploym,provided thatsuch
ImprovementsarenMN tendedaraHeredforuic.If,however,thebL:uildingw TOTA .
Improvement/sold within omyearofcomplelion,the ownenbugderwill have
t"rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE - APN
LJ L as owner of the property,am exclusively....a Ing with I4 _ PE ULH ISSUANCE ^ j
contractors to ronatruct the project(Sec.7044,Business and Professions Code: q,U
The Contractor'.License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EN
Wilda or Improves thereon,and who comrecta for such p(ajeds with a
Aactor(s)uansed pursuant to the Contractor.License Law. FEE SUMMARY
Lec I i am exempt under SB k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FI(7VRES,PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o lmuwe of comm to o"thnre,ora d RECEIPT N
3900,abo(Workan'Campewtlanlwuranceora certBled copy themnf(Sec. GAS F.A.SYSTEM-1 INC.4OUTLETS PARK FEE Y N
Polk # C.)
Policy N DING
X
CAS F.A.SYSIIM-0VER 4(FA)
Com any � BUILDING DI VISION Fr.ES
IC liedmpylshembyfurnlshed. GREASE/INDUSfRL WASTE INTERCEPTOR PI.ANGHEGIC FEE
ertified copy b filed with the city Inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANHARY-STORM EA 200F1• Date Recei t#
(I'hlesectian need not be completed if the permit b forone hundred dollars
(SI00)or len..) WATER HEATER W/VENT/D FCTR ENERGY FEE Y N
I certify that in the performance of the work for which:this permit is issued, —
I shall not employ any person In any manner an as to beceme subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of C.Bfomla.Date PAID
Zplicant
0 NO77CETO APPLICANT.It,after making this Certiltate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Recel t#
F should become subpct to the Workers'Compensation provMlom of the Labor TOTAL:
CC N Code,you at Forthwith comply with such peovlelora orthls permit shall be BUILDING W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby ef0mnthat therelea constmction lending agency for the perform- -ELECTRIC FEE
Z anceaftheworkforwhichthbper t6ls d;:., 09 cw.CO TOTAL: / , VO 3Z rA
O O Lender.Name PLUMBING FEE
U. F Lendce.Addre.s QrY: MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icerllfythatl have read thisappumHon and stmethattheabove information
L+on 0.Iagreeto comply wlthalltltyand countyardlnancea end state laws PERMITISSUANCE FEES PAID:
CL relating tobuilding construction,and hereby authorlu representatives ofthb
(_ N city en
to enter upon the above-mentioned property for bapection purposes. ALTERORADDTOMECH.
Zagree to save,isdormyy an d tarp harmless the City of Cupertino Date Receipt#
V about biuties,jud rats, a d pe which muyinany aya a AIR HANDLING UNIT(TO to,"CFM) SUBTOTAL:
icon a CO In c vary. ce a I of this permit.
6 AR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
171�Igm Applicant on ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA
ZARDOU ERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(M 100,W)BTI) Date Reeei t#
material as defined by the C nlno Municipa l Code,Chapter 9.12,and the
Health and Safety Cod a Ion 25532(aIt HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant or core but ding occupant use equipment ordevlces VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
which emelt hacardous air cont ..is.,defined by the Bay Area Air PAIDQuality Management Distri BOILER-COMP(3HP OR 100,00)BTU)
Ye. o
1 havered the hazy ons materials requimments under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTL)) ��� 0 11
the Ifornla Health k Sof ode,Sections 25505,25533.ed 25534.1 Q
rs edthatifthebulldl g n currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
r me Illtyton Ify the m e m h requirementshich stbemet �
fart. u.,Vcd Certlf ate of n
U
mer thoriveda e t t TOTAL: ISSUED BY:Q
OFFICE COPY /