22823 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Proed ldetffWtlunO PDLWT NO,
bowing Add=�s� - � - 22823
ooe:
-� CITYOFCUPERTIN0. UILDRJG DIVISION
APPLICATION / PERMIT
EMA)qNGQ.EC7RICALII.UMBINGKECHANICAL CATFL'ARY CONTROL I
rchltect/Englruer. Llc.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PMMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
Ihercbyefirm that l am llcean!under provisions of Chapter9(mrrunenc APPLIANCES-RESIDEM7AL BD
IngMth Sedlon7000)of DMvi .3oftheq ..dProfe .Code,and p�
Ibms h In iou f d d(eR S! PANELS
a/`f
Lkewc Clan_ eLio.Y e/
Dale oNrador TO 2DU ANTS
1 �
ITECTSIARATION
ZT. ]understand myplanashallbeuedepubllcrtmrda OVER IWO AMPS �SQ.Fr.FLOOR I AREA� f/SQ-Fr
�nn .
Led PrdmbrW SIGNS ELECTRICAL ,
OWNER-BUILDER DECLARATION SPfICLALC1R_=/MISC
Fp, 7, IherebyafBrmtlutlameaemptfromthe Comr ori Ldcenslawfmthe UT
R
0 cl following reason. 70715,Bu1neseaM Profenbru Code:Mydtyor TEdP,MEOIRORPOLEINST. t
ntywhkhmqulruapens+tomrut malter,Improve,de ti5h,ormpatr
an
a`�
couyeh mmprbrtotUl ame,alaorequlrestheappllmntfmauchpemdtto p�,FR DEVICES l^f
L O file a signed statement that he b licensed purauant to the provisions of the ll
(-,
Coot.aloe.ldcenselaw(Chapter9(mmmencing with Section 7000)of D(vi- SWNMNC POOL ELECTRIC, VALUATION
sion3 ofthe Buslnesaand ProfembnsCode)orthe he Is eaempt therefromand
the basis for the alleged e..roption. Any violation of Section 70315 by anyO[rTLE1SSWITCFQSHXfURES
applicant for a permit wcm
bjthe civil applicant to a l penalty da nmorethan a
,-. five hundred dolhn($50P). NEW RESIDENTIAL ELECCR SQJT.
mmSTORIES; TYPE CON'SIRUCTpN
C P<
F-1 1,as owner of the property,or my employees with wages as their sole
copeadoe,will do the work ctat and the struure not intended or offered for
❑ elle(Sec 70K Businessand Professions Code:The Contractors License,law
5 S3 dm not apply to an owner of property who builds or Improves I r,and OCC.GROUP RES.UNITS
www who doessuchwork hlmslforthrnsgh wownemploym,provided that such
Iomprovemcrda are,not Inte led proffered for set,.It however,thebullding or TOTAL
Impmvemea bead wkon
hineyearof letbn,theovner-bullderwW have
tele¢nionofprovingthathedldrot�orlmprove(orpurposedeaM.). QTY. PLUMBING PERMIT FEE
LI I,ae owner of the pmperty,am exclusively mntrading with Licensed FT.ODD ZONE APN
mes tme,toto mnsmId,the project(See 70K Bushes and Protestations,Code: ' PERMIT ISSUANCE
The Coanctors 11,m Law does not apply to an owner of property who
builds or Improve thereon, and who mrnnds for ad ptvjeaa with s ALTER-DRAIN&VETT-WATER(EA)
o91111actorW Brerued putnuant to the Contractor.Lleerue Law. FEE SUMMARY
LJ I am exempt order Sec B&P C for that nawn BACK FLOW PROTECT.DEVICE
Avner Dat DRAINS-FLOOR, A,ROOF,ARECOND. SANITARY Y_ N_
RECEIPT s
WORKMAN COMPENSATION DECI.IRATION FIX.IVRES PER TRAP SCd30IX.TAX Y_ N_
F-11 hereby affirm the 1 have a certificated muem to sB lneun,m a RECEIPT e
,(0,Lateo(Workers Cmnperuxionlnsursnmmamrtifled ropythereo(LSee GAS Fit.5YSTEM-1 ANCA OUTLETS PARK FFR Y N
3B00,II CJ RECEIPT
C. a GAS EA.SYSPE]N-OVER!(FA) BUILDWC DIVISION FEES
Com ray
I�ccrtufed copy la hereby with
thenea. CREASE/INDUSTRL WASTE INTERCErroR PLANCHECK FEE
�'CertNed ropy at filed with the city Wpedbn divisioe.
CERTIFICATE OF IXFMPIION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 20OF-f Date Reeel t#
(row sdio.need not be cmnplded if the permit bfor arc hundred dollars
(SIM)ccle"J WATER HEATER W/VINP/£TECTA ENERGY FEE Y N
I certify that In the orrvnm o(thc won rwNchtw pemaatlsstud,
1.hau not empty y con io n r u to to the WATER SYSTEM/TREATIIvY;
wnsker�cmnpe Taw.pr p e PAID
O Z Appuont NEW RESIDENTIAL PLMB. SQFr. Date - Repel t#
Z O NOTICE TO :Q,after ngt Ce flute of ption.you
should bemire subjct to the Worker Compensation prowl. of the labor TOTAL:
cr N Code,you stforthwith comply,with such provbbns or this pemJt"I be UUILQING
FEE
W > deemed revoked.
a c CONSTRUCTIONtthem6 LEADING AGENCY SEISMIC FEE'
I hercbytfthe af0rm1hatlhereatammtrolesardrding 097,CN.Cj Perform, TOTAL ELECTRIC FEE
D aendte.ewoeforwMchtw pertNtbbeued Crec-3097,Civ.CJ
U O 1<Mere Name PLUMBING FEE
IL I— Leben Add . QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l mrtlfytheti have sadtw appuatbnard.tatathattheshoweinformatton
(1 bcomM.lagreetocomplywlthall cKyaM countyonllnancesand statelaws PERMIT ISSUANCE FEES PAID:
N relatingtobuilding mnstrudion,and Mroby.whorlu roproentaeves.ftw
city toenter the abov otb property for Wpe cm purposes. ALTERORADDTOMECFL
Z (V • t save,tndezfy keep hsrmlu the City d Cupertino, Date Recei [#
V against Wt ,Ndgme, expen.eswhknmaylneywayamue AQt HANDLING UNIT fro 10.000 CT+h:) SUBTOTAL:
ago Id In t grantingedth permit AIR HANDLING UNIT(OVER I0,W0CF1fI CONSTRUCTION TAX
51 o Appllant Date IXFIAUSr HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI OSURE
Wditheappl .ntcrfuturebuBdI.S.pant oreorhardlchaaedous DATING UMTOO 100,000 BTU) Date Recei t#
materbla.deflnedbytheCupertinoMurddpsl ode,Chapter9.12edthc
I liahh and Safety CodQ_Vdion 25532(.)? FIFATLNG UNIT(OVER IW,"BTU) TOTAL: tI
Yea Np
Ill the appllaio mbullding oaupant usequlpmem odevkes VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emu heardou ab mntam3ruaa as deflned by the Bay Area Air v
Quality hlavgemea i BOILER-COMP QHP OR 100,000 FM
Ym KLNO
r have read the hav snutcrfahmquirementsunderChapter6.95of BOR.QLCOMP(OVER IM,000M)
the Glif iealth&SafetyC ,Sedlons]55f6,75533 and 25534. I �NNF
u Menta t tRthe lou ding rapt dsrtenlly have a/enanG thatltb my NEW RmDENT1AL MECH. SQFI' OCTrespov' 1 to dthi:7 mem.whkh mrd be net `e / aH 1()�
prior
I. a Oce panty. I
0 �Cityy ... 1 ua
roe authorlreda est Data df*rn
TOTAL: ISSUED BY: �]p
OFFICE COPY