21955 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm M Identification 7 IIFJMT NO.
Building AaanesO-L6O to 21955
tJw.1.Name, Ph..
CITYOFCUPERT'INO-BUILDING DIVISION
,. C & Name: Lk.N. APPLICATION I PERMIT l
BUfLDING-E ECTRICA PLUMBINGMBCHAMCAL CATEGORY CONTROL Y
XM gireer. IJc.No:
- QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.l�; .Q C�'KQ,I C' f>acwn�DaN� 0 1:1 -
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam lkrnsed under provisions of Chapter9(commen APPLIANCES—RESIDENTIAL D
Ingwlth Section70D0)of DivMlcel3 ofthe Budnessand ProfeslonaCnde,and my
Have b In full force and effect. PANELS
Llanac Chs Llc Y L}+I 1 J
Date Cowvctor IM TO 200 Ahfl�S
ARCHITECTS DECLARATIONZg-JON AMPS
aZ I undemtand my plana shall be used a public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
❑❑❑O
() Licenacd Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SlICIALCIRCUIT/ML'S
Ihenebyarfirm the im exempt from the Contractor's License Law for the
Q folbwing re+son.(Section 6 70315,Buainm and Protractors Code:Any city or Z TFL4a.ME"1"p20R I'OI,E ANSI.
r 4�� manly which nqulrssapemJttumruwcl,almr,Improve,aemoLLahorrtpalr
anystructurt pAmto lhlesrarKe,also requbeetheappBantfeead penNt to
POWER DEVICES
g a 5 file.signed statement the be b licensee pursuant to the provisions of the
OwI- Contractor's Liceme Law(Chapter 9(comonmeing with Section 7000)of Dld- SWIMMING POOL 30 ELECTRIC VALUATION
"J don 3 of the Rosin. dProf.lo.Code)or that he is exempt therefrom and
a.••�]]] the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWrICtES-FLXTURES
Applicant fora permit sobjects the appBant to.ci l prealy dnot mon than
tli"11,as edl comer of
lXAN. NEW RE�ENTLV.ELECRt SQ.FT. STORIES TYPE CONSTRUCTION
p^fin �L+aom,will ochehe wceny,orhe employees with wages rofebsoh
cont IS,,70 ,willdotbe wmk+ndtoo,C durthrot ntended oro(rertdfor
O rah(Sec 7OµBueneasand Rdmbns Cd,:The Contractor's License,Law
r$ doo notdoes
ch torn owner of propertymthmogh who colds or improv tlenaR and
S'-
who damsuchwork him.eReethmsgh his own errWlgrss,Provided that such OCC.CROUIa RFS[NITS
Impmvertknnt arenotIntendedprofferedfor Bale.ILhowever,thebulldingor TOTAL
Impmvem mhw w hlnorcyearofcompldl MtMo ner- Werwi0 have
enofprodngtheledd ootmlldorimpmvefmpurpoaeofaale.). QTY, PLUMBING PERMIT FEE FLOOD TONE ApNr
owneras or the property,am exclusively connacfing with licensed t PERMIT ISSUANCE
etnctms to construct the project(Sec.70W,Bue�and Pmfessbns Code:
Contractor:License Law dm not apply to an owner of property who ALIFR-DRAIN ak VENT-WATER(FA)
muds or Improves thereon,and who contracts la such pWj-m wish a _ FEE SUMMARY
cQW�acimW Baud pursuant to Ne Contractor's Llan law. BACK FLOW PROTECT.DEVICE
ETI am exempt under Sec B t P C /or this reason
Avner OUTSI DF HES
Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. WORKMAN COMPENSATION DECLARATION
RECEIPT a
❑1 heaby affirm that I have.cerdfiate of consent to self.W ,or• FD(TURE$���P SCHOOL TAX Y_ N
anNate o/Wor4rn'CamperoaHon Ivurana as artRled mpythereo(Sec. RECFBT a
380,lab C.) T LAS_UA. INC{OUTIElS PARK FEE Y_ N_ .
RECEIPT'e
1 dky a GAS PA.SYSTFTI-0VFR 4(EA)
Com ray BUILDING DIVISION FEES❑CMlfiel copy b hereby furnished, GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Cera led copy Is filed with the city inspection dlvblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FT. Date Recei t#
(Thheectbn need not be completed Bthe permit is forone hundred dollar
(9100)mles.) COATER HEATER w/vFxr/EI.FLIn ENERGY FEE Y N
I anify that In the performance of the week for which this Permit le issued,
1 shag not employ any penin In any manner so a to become subject to the WATIR SYSTEM/TRFiATING
Woken'Compensation LA.of CalOmnh. Date PAID
PP Date Recei t#
Z O ABorst NOTICE TO APPLICANT:If,aker mating this Certificate of Faemptbn,you NEW RF_9DkT DAL PLMB' 9QF7'
H N should become sub)M i to the WorixerCompenselon provisions of the Labor TOTAL:
code,you most rathwkh comap)y with such prokions or this Permit stall be
W > deemed revoked. BUILDING '
EL
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
P hereby+fl thattherebwctlon kndNgagenq forthe perform ELECTRIC FEE
7 Z anaof the workfor which this=b lsand(See 3097,CN.C.) TOTAIs
V O Lerdrr.Narm PLUMBING FEE
F LxMcr:Add�. QTY. MECHANICAL PERMIT FEE
LL U Icenifythelhaveaadthbapplicatbnardwatethdtheabwelnfommtlon MECHANICAL FEE
O W bcorsM.lagnetocomplywkh aB city•nd county ordwnae and steela.ve PFRMITLSSUANCE FEES PAID:
r a rtleing to raiding mvvuctlon,and henbyauthcAerepresenteNeso!this
I.. Z city to enter upon the abavo-mentbred popertyfm Inspection purpm ALTERORADDIOMECH. Date Recei t#
_ (We)agree to save,tdemnify an d kkeeeep hammes the City of Cupertiinno
against ,pd me costs and ops which may ln.nywaya a AIR HANDLING UNIT R010,OW CFM) SUBTOTAL:
age By in consequenao 1 of I •�m'JNL / AIRHANDUNG UNIT(OVER IQODOCFM) CONSTRUCTION TAX
Ig App oral/C tractor Date EKHAUSC HOOD(W/DLCO CONSTRUCTION TAX PAID:
HA7ARDOUSMATERIAL SURE
I theappliamorfutuam0dingoau nteoreorhardbhavrdmts HEATING UNIT IM,000 BIT1) Date Receit#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
I fealth and Safety Code Section 75537(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yo No
Will the eppltomm tun,building ocoupant sae equipment or devkv VENTILATION FAN SINGLE RE-12D) �i. aiS6i'J7ANICE DA'Z'E
which emit hanrdov ab contamlra a as deRned by the Bay Area Air d'"'6�9�d
Quality h3arugemen District? BOILER-COMP QHP OR 100,O(q BTII)
M YeamadNo ➢�A R � �
havetheh as materiimm.2menteunder Chapte4.1 o! BOILER-COMP(OVQt 100,000BM �r11 -
un eras ndt Health&Safety Code,SMbrmntlyh 7.riatand2that 1
undestanityi.titfy the cngdon of to rntuiremr.t.wh.ntthat itbct NEW RESIDENTIAL A(ECH. SQFT .s�
rapovlbRhyto n fa theeatrof dthertquimmenh which mast be met rjLTLp'�'ptA
prior to Lewance daCenll)ute of Occupamy. "�� ]
Ownerorauthor .gent Date ISSUED BY:
'TOTAL
OFFICE COPY