22036APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
9simin Pram IaentBwtlon -
BuiWlng Add.: L L(QO t) 6__ .T)9
PERMIT NO.
22036
.phone/b
C. q l /'d 4p c,
'C17 OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALfLUMBINMFCHACAL
GM
L
Cmtnctels Name: Lk. Nm
CATEGORY
CONTROL
ArCitlM/Englnser. Llc N.
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
IRFMITISSUANCE
1:1 El ElLICENSED
CONTRACTOR'S DECLARATION
I hereby aHkmthat ofaa =30fthnderprovf dPm Chepter9( ,and
Ingwomy
1heBwinavandl'roleatl«u Code, and
Danse l la s force and effect.
Becoseh5eabn 70=force of DIW effect.
DateLloeCls nor
Dae Contusion
ARCHITECTS DECLARATION
I understand my plans. hal be oxd as pubic oeneda
Llcensd Por4esbnsl
OWNER-8WILDER DECLARATION
I hereby affirm that I am exempt from the Connmra License Taw for the
following rtesvan. Onction 7m15, Boanes and Prefevbm Code: Any city or
muntywhkhrequireapert tomnst malter,improve,demollh,orrepair
anystouauoa prior to its lmarcG also requirestheapplant t«suds perms to
a signed statement that he l Ikenwd pursuant to the provisions of the
Contre,im'sL ieense lrw(Chapter 9(co..eing with Stolon 7000) d Dw{
sloe 3 ofthe Business and Prdesbna Code) mtha he l esempt the efromand
the baW for the alleged ezemptbn. Any Wolatlon of Scab. 70315 by any
applant fora permit subjects the appl .t to a adl penaltyd na come than
Ove hundred dollars (fM.
❑ e I, as owner of the property, or my employewith wages as their sole
rompers rtIM wW Bothe work. and thestmctom b not intended or offend for
sale (Sec. 7DK Bua4ru and Pod®bra Code: The Conraam's License Taw
doe not apply to an owner d property who kids or improve thereon,and
who doessuch work hkwelmthrmugh Ms own empley., provded that such
Improvemew are not Intended uroHcred fmsale. If, however, thebuikhog m
Improvement lssald wflldnawyarolconplabn,thewvner-bulloerwlll have
aljLtpedendpmvingthahedd not bund or improve f«purposed We.).
as owner of the Property, en elusive y contracting with ll C aed
tracton hocons the Project (Sec 70M, Business and Prdesbns Code:
The Contractori License Taw don not apply b an owner of property who
or Improve thereon, and who mama for such pAojeaa with a
limned pursuant to the Cantna«: Lkemoc a .
1_11i am exempt under Sec this re
B k P C for thisOUTSIDEFEES
AleT'LIANCESRESIDFNI7AL
JOB DESCRIPTION
G�1 l �� � ,
` yl
PA1vF3s
UP TO 200AMP55
201 -1000 AMPS
OVER IODO AMPS
SQ. FT. FLOOR AREA
5/SQ.17.
SIGNS ELECTRICAL
SPECIAL CRCUIT/IMLgC
TEMP. METER OR POLE INST.
POWER DEVICESfile
SWAIMENG IDOL ELECTRIC
VALUATION
(50BOO
OUTLETS-SWITCHESFIXTIIRES
NEW RESIDENTIAL Fr LY�f4 e��'T'
iiTORIE5
✓
M'E ODNSIRLCTION
TOTAL
QTY, PLUMBING PERMIT FEE
OCCGRO(IP
RFS. UNITS
pFRMIT 1S5UANCE
ALTER -DRAIN A VENT WATER (EA)builds
FOOD ZONE
APN
FEE SUMMARY
BAC]( FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FD(TURES PER TRAP
SANITARY Y N
REOEIPTs
Owner Dae
WORKMAN COMPENSATION DECLARATION
' ❑1 hereby aHlrm the I have a certlfkate d consent to sen -Insure, a a
39W, Lab CJ e afWarkens'CompeosaHm lnmunnce«acertBied ropy thromf
3.00, I
Paltry a
SdiOOLTAX Y_ N
RECEIPT T
GAS FA. SYSTEM-11NG4OUTLETS
PARK FTE Y N
RECEIPT
S
GAFA. SYSTEM -OVER l (EA)
C
DINGDray
BUILDING DIVISION FEES
LTenined copy filed th the cis.
CenNed ropy b filed with the city Inspection dfvllm.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(fhb salon need not he completed Hthe pemdt b f«ane hundreddo0sn
(f14()ar hem')WATERT
Icertlfythe In the perforrtunadthewvkforwNch this pemW bowed,
I anal not employ any person in any manner so as to become subject to the
W«otikeCompenvunn Laws of CeJfomla. Date
Applicant
NOTICE nc APPLICANT: e o k r,'Co ter CcrtHlate of Exemption,yw
Code,sboolbemus forthwitthe Waken'Compensatlanamviabvofthe Labor
Cede, yrs overt fothwtlh o>mply with each pmvLslons orthb permN shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyafnrm that them Is, a constrodlen lending agency for the perform
ance of the work for which this permit is booedbee 3097, Clv. C.)
Lender. Name
l,r,der.Addnaa
IaMifytha IlavereadthbappBeek, andstatethathe abovelfomutl«i
lcomed.Iagreetocomplywithalcilyand muntycodiwncesandstsebws
oclating to building construction, and hereby authorise mpresentalves of this
Clay to enter upon the above-mentbrcG property f« inspection purpose.
(We) .gree to save, I demntfy an d keep hem. the City of Cupertim
ag.Ine lbbWties,0dgmeons,ones. nd e. pews which may in any wayaccrue
against said City in quence d m
m�sthe grant Ing d this peat.
GREASE/INDUSRL WASIE WTERCrroR
PLANCHECK FEE
PAID
Date ROCCI t#
GREASE TRAP
SEWER -SANITARY -STORM E1. XK)PT
TER W/VETT/FSECTR
ENERGYFEE Y N
PAID
Date Recel t#
WATER SYsmt/TRFATING
Nh5VRE90ENTTALPIMB. SQFT.
TOTAL:
B
5EISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID.
ALTFRORADDTOMECK
Date Recti t#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER IIt= CFM)
CONSTRUCTION TAX
Slgiuturt sir Appl t/Ca,b.a« Date
7AR DOU5 MATERIALS DISCLOSURE
Will the applicant or futon bulftng a pant store or handle haraodous
material as defined by the Cupenti. Municipal Cade, Chapter 9.1 Z and the
lle.hh and Safety Code Sectlun 25532(W7
E Ye N No
TV ll the appilant« lowre building arvpant use equipment or devkn
which emit havodous air centaMrunt. as defined by the Bay Area Air
Quality Mansgomrd Dtvtrk[7
es j�1 No
ha vereadtheh.Tar�oua material oegalamenb under Chapter 6.95 of
the Callonb Heatlh k Safety Cade, Sections 75505, 8533 and 75534. I
understand that ifthebuilding does not comently have a tenant, that it is my
oQponsblity to notify the o pant d the requirements which most be met
prior to baron c of. Cartiflateofoccupancy.
EXFIAUST HOOD(W/DUCT)
CONSIRUCTION TAX PAID:
HEATING UNIT (M 100,0)0 BTU)
Date Recti t#
HEATINGUMT(OVERiWWBTU)
TO L•
VENTILATION FAN (SINGLE RESID)
ISSUXKEWRTE
saoD 7 �e7��
p1-„ d 9
a of DPW!
ISSUED BY:
BOIEF OOMP OI B'OR IW,IX9 BTU)
BOILER -COMP (OVER 1050 TU)
NEWRESID211TIALMECH. SQ.FT.
Owner«mthorlud agent Date
TOTAL:
OFFICE COPY