21446 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Eulldi Pm'ed IdendfkaHon PR.WT NO.
Building Address,
Z I ZQ
21446
Qw,wr• ane —tee APPLICATION SUBMITTAL
B CITY OF CUPERTTNO-BUILDING DIVISION
c.nHadda Name: Lk.No: APPLICATION / PERMIT
BUILDINC- LECTRICALPI.UMBIN MECHANICAL CATFLORY CON]ROL I
Ardikeei/Enginrer. Lk.No:
QTY ELECIRICPERMIT FEE BUILDING PERMIT INFO
PLUMB Address: co — PERMITISSUANCE
N ® Ela
LICENSED CONTRACTORS DE URA ION
Iherebyafore Hut lamllremeduneerpmvWoneof CTapler9(mnvrven APPLIANCES-RESIDENTIAL JOBDESKRIPI70
f.limnseh5edbn formanDlvfret. (the BuareeandlhofmlonaCode,and
1 g" t V In .force and died. PANELS
License Class Lk.0
Date C.M.d.r UP TO NOAMPS
ARCHITECT'S DECLARATION AMPS
MG% I urderaard my plaroshall be used as (3
public remote. OVER 10 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
V
Lbemed Professional SIGNSELECTRrat
OWNER-BUILDER DECLARATION SPECIALCIRCUTT/MISC
71.,� that am exempt frwn the Contractor's Liere.Law for the
qppqq fallowing reason.(Section 7(315,Buelness aM Proredoru Code:Any dty or TQ{p M OR POLE INSf.
F�43 c ntywhlchrnryMapermlltowvmc,alter,Impm ,de to hormpalr
q a nystm=mprbrtoit wake,aborequ Lheappt.tfineuchpermltto R II Ile � /t p
PJ Ne a signed saatemitnt that he h ucensed pursuant to the pmWlom or the I' 1 1 \ II
g3u,� Contractors Lkeme Law(Chapter9(mromeneing with Section 7000)of Dld- SWEdMING ELECTRIC ,• ._m u
1� O elon3 of the BuWeasnd lideeebro Cade)orthw hebo.rr tthemmmand - n VALUATION
y.'S the bail for the alleged exemd.nSection7031
piten. Any dolaof Section 5 b/any IXIfLE1SSW1 ( ) 1 S
p� PPlkant for a permitsubjnfa theapplkant to a dull penalty of not mom than I9
fiviQmirdreddolles(35DT.
ba I,as owner of the property,or my employees with wages a their sok NEW R DEN]L�I :�'IR <I STORIES TYPE CONSTRUCTION
rtution,will do the work and the.tmcturt is wt Wended or offered for
k�O vie isle 70N,Bu.iros and Pro(mbm Code:The Contnd.re Wcense IAw
�js>3 don rot apply to an owner a property who builds.,improve thereon,and
C• who does surh work himself or through his own employee,provided that such OCC.GROUP RES.UNITS
Impro nearrm arc rot Intended proffered for ask.If,however,theWidleg or TOTAL:
improvement is sed within oneyearofcompletlon,the o vner-lou W erwou have
t rden.f pmdng that he dm not wild or Improve for purpose or axle.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the Property,am exrhoowly mnteuting with lfttn.ed FLOOD7DNE APN
rontractaa to oarWrud the projeet(See 7DK Busbenard I'mfeaebm Code: PERMIT PSUANCE
The Contractor's Llcerue!Aw doe not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or tmprwe thereon,and who rontncts for such plpjMs with
c9rIT+da(a)bcenaed pursuant to the Cmrseme.Lbeme lay. BAOC FLOW PROTECT DEVICE FEE SUMMARY
LJ I am exempt wider Sec B k P C for this reasonOUTSIDEFEES
Owner Dae
DRAINS A,CONTI.FLOOR,ROOF,ARESANITARY Y N
RECEIPT I
WOR1mthan I haw a COMPENSATION DECLARATION FTXTIIRES PER TRAP SCI{OOLTAX Y N
❑1 hereby affirm than 1 have•redfliete of cauent to self-Wort,ora RECmrI'e
3800,,IAb
rertlWorkeri CompemaHonlmuraamacertlfkd ayythertof 6ec. GAEA.SYSf.Flf-t INC./OUY iLE15 PARK FEE N
I.&bC CJ S
Pd1ry s GAS EA.SYSTEM(OVER/(EA) RECEIPT a
� ^Y BUILDING DIVISION FEES
CC ropybhereby furnished, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CeHlfled ropy b(fled with the dy impectbn dlvlaon.
CERTIHCATE OF EXWPFION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSUSEWEISAN71'ARYSFORM EA.IIXTFF Date Reeel t#
(Fede lection need not he cromplded Irthe permh mlt is,b Were hundred dollara
(5f00ytiss IJ
IcerrifrtBy hWATER HEATER W/VENT/ELELTR ENERGYFEE Y N
In the pe����sora¢ofthe work f.rwMch this permit Issued,
I.lull not employ any Person In any menne,so as to berorrc subject to the
Worerr m
CopemaHonl,aw.of Calimmia. Date wnrtse sySlTa{/TRFAnNc PAID
O Z NOTICEApplioa
NEW RESIDENTIAL PLMB. SQP Date Recei t#
Z O NOTICE ld been.
APPLICANT.dtot ll, mie.'k mperCenlfhte.r Exemption,you
shw,,you.e wrthwit cor Workeit Comp re taim,mvislomr itsthe Labbe - TOTAL:
~ N Code,You.9 forthwith rompy with avis proWbm.,thio pemdl.hall be
W ] deemed rewk d.
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
BUILDING FEE
CL iaaromtmdsued(S gagenri,.C.) ped.mv ELECTRIC FEE
7 Z an of the work!or whkhthi.permHbhwed(Sec 30YI,CIv.CJ TOTAL:
U O lZer.Name PLUMBING FEE
Ly F Ieniee.Addmse QTY. MECHANICAL PERMIT FEEMECHANICAL FEE
O W Irenlfythalhave reed thLe appllotbnard datetha the above lnlormrtlm
Ismneed.Iagmetoc plywlth.RdtyardmuntyordinanmandMtelaws PEtMITL4UANCE FEES PAID:
n' rtlalr,gl.wlding romtmdlon,and hereby uthortu represntative of this
F = rgytoenWupe,t6.above-mentbrcd property for inspection purpose. ALTE{ORADDIOMECH. Date Rxel t#
— (We)agree to rove,Wemmly an d keep hu e+e the Cly of Cupertlro P
xgaWtllabWtks,}udgerents, Mexpeiffmevah meybanyway• AIR HANDLING UNIT(JO 10,0DO CFM) SUBTOTAL_
a i Id Cly in a ing of spemdt. e
Q AIR HANDLING UNIT(OVER 10,000CFW CONSTRUCTION TAX
hurt of Appllent/Con odor to — IXHAUST HOOD(W/DILM CONSTRUCTION TAX PAID:
HAIARDOUSMATERIAL SCLOSURE
Wllltheapplicnnt or(uturebuildingnecu taoreorhandle hazardous HEATING UNIT FCO 100,000 BTU) Date Revel t#
materiel as deRned by the Cupertino Mu Ncipe Code,Chapter 9.11,and the
Heath and SafetyCode Sedi.n 25531p)7 DATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ye ri Na
WBltheappl"mda wu bulldNg.,ntu.e q.1p.mN devim VENTILATION PAN(SINGLE RESID) ISSUMaMTE
whkheMthaurdousairmntam ntsadeRrudbyted Bay Area Ab rT (n']oo
Quality Mamgemea DfarNo BOILER-COMP OT-0'OR IW,"BM
Y ❑No
hove read the h uardoua materials requirement.under Chapter 6.95 of gOILFR ODMP(OVE{IW,OW BTU)
the Ulllmnh Health k SafetyCode,Sectlom 25505,25533 and 25534.I
uMestandthatifthe WUdtngdoenotarrentlyhuveatenan4twtlthmy NEWRFSIDFN11ALh1ECH. SQFT.
rexponsdel ty to notify the oavpard of the requirements whkh mow.t be met dace(yrS�3e'F{1rn
prior to fsuarcc ofa Certiftee&of Omrpency.
Owner or authorlud agent Date TOTAL: ISSUED BY:
OFFICE COPY