22591 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
B.Bdl.,Pru'eut Identification . PERMITN'O.
Building Address: - - 22591
S n G r Y
A
n l/O CITY OF CUPERTIN0.BUILDENG DIVISION
co o-a .r.Narn: Lie.No: APPLICATION /PERMIT -9
BUILDING-ELECTRICAL-PLUMBIING-MEC.HAMCAL ,};, CATEGORY % CONTROL
Architect/Engineer. Lk.Nre - '
u , +,'1'•`� I'.BUILDING PERMIT INFO
.QTv 1 ELECTRIC PERMIT t' FEE• '-^Yat - �a-Lu
- Address • PERMITISSUANCE ❑ �'ly ❑
LICENSED CONTRACTOR'S DECLARATION f'—J
I hereby affirm that l am licensed under provisions of Chapter 9(comment. APPLIANCES-RFSIDENITAL JOB DFSCRE'TION
limn.hSection 7000)to.afdoffeon3o(the Buslnasand Pro(ealonsCode,and my n _�
Ing with
b I.Section
fun force and Mfe t. PANELS 11-\�.-•-\� Vl DY
License Class Lir.0-
Datti Contractor LIR IQ 2DO ANTS ..- + • �
ARCHITECT'S DECLARATION 201-IODOAMPS
97 '1 understand my plans eh.B be used as public rucom.. OVER 1000 AMPS SQ.Fr.FLOOR AREA L,k`' S/I•Q.FT,
Licensed Professional - i SIGNS ELECTRICAL J •.. LED D I Y y
6 OWNER-BUILDER DECLARATION u ) ` TI P
rd C, SPECIAL CII2CUIT/MISC YA 1[�� ,'••(l
owing rasormthatlam31.5,B fromthe Contractor's Wceae Caw d the
pO following reason.(Section 7031.5,Business and Professions Code:Any city or
F Z runty TEMP.METER OR POLE INST.
cnygmeture requires.fiopermuu,.I..requiresit to construct, th..pmvgt feesuch,armit ir
to
gg any swdvretatemepoor to ltahathefi,alsoregWressuanttothepmbdomch ofte POWER DEVICES DATE
file a signed statement that he b licensed pursuit it the tion 7000) of the _
qqpq Contractor'i Lkerse Law(Chapterg(commends withSectlon7000)ofDiol.
�OS slon3 ofthe Business and ProfaaoaCode)orthat hebexempttherefromand SWAIMINCIWLELECTRIC VALUA.'RON '
<� the baits for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHE&FIXTVRES
applicant fora permit subjects theapplicant to a civil penalty of net more than
cireddollars($500). - NEW RESIDENTIAL ELECTR SQFC. RIES TYPE CONSTRUCTION�n I,a owner of the property,or my employees with wages as their sok
m neatlon,wBldo the workandthe structure E not intended or offered for
Osale(Sec.7044,Business and Professions Code:The Contractors License Law
Sg does not apply to an owner of property who builds or Improves thereon,and OCC.GROUI' RFS.UNITS
whodoessuch work himselforthrough his own employee.,provided that such
Improvements are not intended retracted for sale.l(howevegthebuilding or TOTAL:
improvetoerit b sold within ane year ofcompietlon,the owner-bullderwlll have
t � rdenofpmvingthat he did not build orlmprove for purpose ofsakJ. QTY, W,, PLUMBING PERMITp 1',r EE, FLOOD TONE ATN
tyL as owner of the property,am exclusively contracting with licensed pp(h{IT ISSUANCE
cato construct,the project(Ser.7044,Business and Pmf nsiaa Code: Q.(,�
The Contractor's L Law d.no apply to an owner of property who ALTER-DRAIN kVENT-WATER(G)
Wilds or Imp atom, and who contracts fm such p5ojem -
with a 77 FEE SUMMARY +1•''t
"Nacter t)It and ursuantt Contractor's Llcenae Law. BACK FLOW PROTECT.DEVICE
I;-J I a ex pt oder Sc B k P C for that reason -
Owns rate Date —
07 1 DRAINSFLOORROOEAREA,COND. SANITARY Y_ N_
OR AN 'ENBATION DECLARATION RFOFIPI'N
❑1 hereby affirm that 1 have a certificate of concent to self-Inwm ora � r / •o0. �'I�LTA% Y N
RECEIPT X
read,Laeo(W.rkers'Compewatlonlmu ora rertl(Ied copythereof(Sec. GAS G.SYSTEM-1 INCA OUTLETS PARK FEE Y 'N_
Polis Lab C)
RECEIPT N
Policy Y GAS G.SYSTEM-0VER 4(G)
" - Com any _ BUILDING DIVISION FF.ES _
ffm'fed copy is hereby famished.
,-❑CedBkd copy It filed with the city inspection division. CARCASE/INDUSIRL WASTE INTERCEPTOR PLANGHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP PAID
COMPENSATION INSURANCESEWF34 SANITARY STORM EA200FT DatC Recel t#
TTh6 aedioa need not be completed lithe permit k fm one hundred dollars
0 that
(8100) fyt 'or In
'I hat In the perfomre unof thework farwmdthlch this pela kwaed, WATER HEATER W/VENT/ELECTR ENERGY FEE YN—
I shall not employ any person In any manner ro as to become subject to the WATERSYSTEM/TRGTING
Workers!Compensation Laws of CaRfomis,Date PAID
Z ZNO]ICETOAPPLICANT:If,after makingthb Certificate of Exemption,you NEW RESIDENTIAL PLMR. SQFI'. Date Recei t#
P0 should become subject to the Workev
rs'Compeatlon provisions ofthe Labor TOTAL:
N Code,you must forthwith comply with such provisions orthb permit shall be G V�
Wj deemed revoked. 6UI G PE l
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them Is a construction lending agency for the perform ELECTRIC FEE
TOTAL:
7 Z ance Lardee Nitersfor which thbpertNtVIssued(Sec.3097,C1v.C.) .oD
LL O Lenders Name - PLUMBING FEE .0
LL F Lenaert waarea QTY. ",MECHANICAL PERMIT'• ' FEE MECHANICAL FEE
OW Icertifythatl havereadthliapplicationand gatethat theaboveinformation
fL arorect.I agree to comply wdhaR cityand county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} W misting tobtildingcomlructlon,and herebyauthmize representativesofthts '
f. citWI
he above-mentioned property for Inspection purposes. ALTER OR ADDTO MUCH.
? ve,Indefy andkeephe'roo the City of CupertinoDate Receipt#d n its and expect whichmaylnanywayaceme AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL"
n ence of the gra ntl of this permit. —
AIR HANDLING UMT(OVER IO,OWCFM) CONSTRUCTIONTAX
-
/
Sigw of App HContra or Date IX}IAO57 HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAA
' AZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous HGTINGUMT(TO 100,(001ITU) Date Recei t#
materlalasdefrani by the Cupertino Municipal Code,Chapter 9.17,andthe
Iie❑alt i6ed SafetyCode Scodoon25532(07 HEATING UNIT(OVER 100,000 BTU) TOTAL:
WlllthY.e a ppllcantorotom building occupant use equipment ordevkcas VENTILATION PAN(SINGLE RESID) ISSUANCE DATE '
which emit hazardous at,contaminants as defined by the Bay Area Air
Wp. �'
tiny Managrmem Dl. ct7 IiOILER.COMP(3}R'DR 1010,000 BTU) Pp��
Yea ❑No
have read the rdous materials requirements under Chapter 6.95 of _ BOILER-COMP(OV[R 100,000 BTT)) �p
the California He Safety Code,Sections 25505,25533 and 75534. I ^ �I i 1
understan tha fth belch gd Wati entl haveatrr.m,thatitbmy NEW RESIDENTIAL MECH. SQ.IT p1'f 4
resp. Iblllty the.. lithe to which most be met
priort mu nee of ncy.
Ownrr thorize ens -L1131Sa `
TOTAL: ISSUED BY..
OFFICE COPY " '
ADDITIONAL PERMIT FEES
-++ BUILDIN G PROJECT IDE NTI FICATION VALUATION
.. BUI rvc - F _ n . f
m
'!5 e
DIINIIs
' - .rE 'V 1••7�I t�! m FEE 6UMMARV � �I
CON A c o s - , 'BUILDING
ppp
._PLANCHECK 't. ..
CONTn c o s
.{ FEE
SEISMIC FEE
E
- , - QTV ' ELECTRIC PERMIT J' FEE- -
f x. '•.
UTLETS-SWITCHES-RECEP �, 1C-, -ELECTRIC, -
`" LIGHTING FIXTURES' '., ,-. - jc'.' - PLUMBING -
- PPLIANCES-RESIDENTIAL
PANELS ?: - , MECHANICAL
+a.. ;. SIGNS"; :. ., ;•-. .. u
- TOTAL . .
SIGNS-TRANS. - t
SPECIAL CIRCUIT -
EMP.METER OWPOLE INS.' " . PEHMIT VALIDATION.
MOTORS': ; SEE FEE SCH I
SERVICE CHANGE -
b
ISSOANCE DATE
W > - GTV PLUMBING PERMIT y FEE-' BLDG. LECT PLG, NECK T
'r Z, .ALTER DRAIN&VENT-WATER(EA.) a' ❑ Q i
BACK FLOW PROTECT.DEVICE
+ - - LL Uj DRAINS-FLOOR,ROOF,AREA,COND
a FIXTURES-PER TRAP J. ,
F'.. Z -GAS.EA.SYSTEM-I INC.4 OUTLETS
a..
-V GAS' EA:SYSTEM-OVER-4(EA.) -
INDUSTRIAL WASTE'INTER.
LAWN SPRINKLERS-1'INC 5VB .: 1
LAWN SPRINKLERS-OVER 5(EA.)
WA ER-SANITARYEA 20011/
WA
- TER�HEATER W/VENT W/VENT '
WATER SYSTEM -
{" ;;..�. WATER TREATING EQUIP
QTV MECHANICAL PER MI T FEE - r
ALTER OR ADD,TO.MECH
' 1 - APPLIANCE
AIR HANDLING UNIT.(TO 10=CF.M.) s ~ t
"t t'� F ,
AIR HANDLING UNIT(OVER 10=Cl M.I - O /
))/
-,.
EXHAUST HOODIWITH DUCT),"' E4/ :9`9!a(
HEATINGUNIT(TO 100,000 B.TU,I'
HEATING UNIT(OVER 100,000 B.T.U.1
y r VENTILATION FAN(SINGLE) -
sJ . . ,Tr hlt BOILER001 100,000 B.T.U.P -
, ' BOILER-COMP 10vm IB0.000BTUI SEE FEE SCH.
1
TOTAL
s � n• •