22276 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Budding
160_/°s! HR,+ UNN R) • GUP£,<-nNU 22276
_r`s aFSQ ICLAL 2 ^ � one: L.(
�]'L� CITY OF CUPERTIN6BUILDING DIVISION /
Contrador.Name: L—I=.N/°. APPLICATION /PERMIT (o
u 'v BLnDINGF➢,EC7RICALl--UMBINC-MECFIAMCAL CATEGORY CONTROL#
Architect/Engineer. Llc.No:
QTYELECTRICPERMIT FEE BUILDING PERMITINFO
Address: - POWTISSUANCE _� ❑ ;K ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hthSedlon700ba Tam Bcen3 oftheerprwblonsof Cssions9de,and c- APIsLIANCESRESIDENTIAL JOB DESCRII'ITON
ingwe 1 In hodl 70W)of d Affeon3 afthe Budneuaand ProfeWone Code,and my'
liana b in!uB Torre and Affect, PANELS
Licensee Lk.M s 906
Dale / Contractor V C"e,
ARCHITECTS DECLARATION 701-1000AMPS
^EEO I understand my plans shall be used as public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA E/SQ.FT.
GoLicensed professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
In U7 - SPECIALCIRCLRT/MISC
7 f.; a owingrhere .. lhatlam31,5,Bfromthe ContrasAl..Censelawforthe
following reason.(SMlon 70315,Businessand Pro pmoee Code:My city or
O TEMP.METER OR POLE INST.
•
r� countywhlch requires.pemNtrocoruwc5 altenimpoove,dennlbh,orrcpalr
a any structure prior to its Juana Ace,also requires the applicant fonuch permit to POWER DEVICES
U lite a signed statement that he Is Bmnsed pursuant to the provblom of the
Ow Contradors License Law(Chapter9(commencing with Section 7000)ofDivt-
sion 3 ofthe Business and Profession Code)orthat he bexempt thsoefromand SWLMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation o!Section 7011.5 by any
05 OUTLETS-SWITCHES FIXTURES
Applicant for.permit subjects!heapphcant to a civil penalty dna more than
five hundred ascarecrofthe pro NEW RLSIDENTIAL ELECTR SQ.FT, STOIUIS TYPE CONSTRUCTION
�n ❑ as owner of the property,or my employees with wages a their sale
compensation,widdothe work,and the structure b next intended or offered for
q sale(Sec.70"Business and Professions Code:The Contractors License law
does not apply to an owner of property who builds or Improves thereon,and -
EE who doessuch work himself carthrough hlsownemployee;provided that such OCG CROUP RFS UMTS
Improvements are not Intended orofferedforsale.If,however,thebuilding or TOTAL:
Improvement b sold within ons yearofcompleioq the owner-builderwlll have
tFt,JTtrden of proving thin he did net bu0d or improve for purpose of sale.). QTY. PLUMBING PERMIT' FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PFRMCC ISSUANCE
to construd the Footed(Sec.7014,Buainess and Professions Code: nn
The Contrsctor'e License law does not apply to an owner of property who FLYER-DRAIN -W I`T
Wilds or Improves thereon, and who contracts for such projects with a FEE SUMMARY
Cc➢t�ador(s)liconaed pursuant to the Contraaorb License Law. BACK FLOW PR FGT.DEVICE _
LJ I am exempt under Sec B k P C for this reason /l I' f
FEES
Owner at.
DRAINS FLOORaRIOOF,AREA,CONS � A ARY Y N
DI
WORKMANBE=COMPENSATION DECLARATION
❑ FIXTURHS PER TRAB rT(5 L,AX Y N
I hereby affirm that I have m
e a rtlBratn o!consent to sal(-insure,or RECEIPT N
mdiOot-ofWorkai Compensation Insurance ora certified copy thereof(Sec. CAS EA. -1 MC.00UTLETS PARK FEE Y N
3800,Lab CJ
Coliry Y GAS F.A.SYSTM OVER d(EA) DING DI#
Cm any - BUILDING OI VISION Fr.ES
[�Cerdfled copy is herebyfurnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
E�yCeriNed copy b filled with the city Inspection division.
`Ian CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP pAlp
COMPENSATION INSURANCE SEM -SANRARY-STORM EA>((qF7. Date Recei ted
(d cr ledlon need not becampided lithe permit b(Drone hundred dollars
($1I(andlcss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify thatoi othe person In any
an As tohcopemdtis tuned,
I shall not employ any person In any manner n as to Femme subject to the WATER SYSTEM/TREATING
Workers Compensation Law.o(Gb.lirornDate PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFf. Date Recei [#
N
Z O NOTICE 70 MI'LICAM:IL ager making this Certificate of Evemptlon,you
Pshould Wcomesubpetto the W°rkem'Compematlon pmvbiom ofthe Labor TOTAL:
cc Codeyou most forthwith comply with such provisions orthls permit shallbe
deemed revoked. DING FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirrnthat there is a construction lending agency for the b perform- ELECTRIC FEE •
Z anusof the work for which this permit Issued(Sec.3097,Civ.C.) TOTAL: 2-0
02 Lender's Na me - PLUMBING FEE
ISH LendereAddmas QTY. MECHANICALPERMIT FEE MECHANICAL FEE
O W Icerti(ythat l have read thbappBcatlonand--And the above Information
a dmrmd.I'greeto comply with all city and county ordinancesand state laws PCRMD'ISSUANCE FEES PAID:
} relating to building construction,and hereby authorlu representative.of this
F city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against habildles,' gments,cosh.and expenses which may in any y..A AIR HANDLING UNIT(170 ledge CFM) SUBTOTAL:
against.i,4 ty co �uenc f he granting of this permit.
6 17--q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signets Appl nt/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS TE RIALS DI SCLOSURE
Will the apphesm or future bu ding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI [#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
HeallhandsaletyCod ctlon 25537(.)7 HEATING UNIT(OVER 100,000 BTLA TOTAL:
Yes No
Ill the Applicant or future Wilding occopantuseequipmentordevices VENTILATION FAN(SINGLE RESIU) ISSUANCE DATE
Which emit hazardou,air contaminants as defined by the Bay Area Air Y r aewc
Illy Maragemcnt Dis�ld7 BOILER-COMP p)IP OR 100,000 BTU( _ •�
. Yes iy(I No JUN
� •� 1�1
havereadth.Ith& fmyC e,S requlrerrenb5533.Chapter.I of, BOILER-C'OMP(OVIR 100,000 BTU) 47V1[ a
the Califomla Health A Safety Code,$ectiore 75505,25533 and 25530.I
understagd that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. p�y
responsibility to notify the occupant of the mquiremenls which most be met V�V at
f4wM1a
prkHt.. ane ,.Certs' teof Ocmpanry. V1y Wt IOU
%7 7 `t
Ow er ran orixedagc Date TOTAL:. ISSUEDBY: �• D �\ V
OFFICE COPY