22238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
Ul -lu 2223
wnere scud: one:
W 1 LJ_L/�vHS Z`S S^Z"1`I CITY OF CUPERTINOQBUILDING DIVISION (O rl I
° e%L-L Lit.No: APPLICATION /PERMIT LL l
ZI'IC Lx- BUILDINGELECTRICAler-UMBINGMWHAMCAL CATEGORY 77[EONTROL4
Archltett/En cer. Lk.Na
t74M Fi BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: 17,S(.q 5. S4APT067a.S FFPEMTISSUANCE
LICENSED CONTRACTOR'S DECLARATION 11
I hereby affirm Hut l am licensed under provisions of Chapter9(commem, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
(ngwith Section 7000)ofDlvisioe3 ofthe Busines,and ProfessionsCode,and my '
Bmnaeisinfuu andeffea. �• �
PANELS 1�. . gk0poIk,
D.t Clam M �►�> I Z.. r ``�
Dale CoC.ntractor IG f[.IdFJaJS 201IODOAMPS
ARCHITECTS DECLARATION OVER100BAMPS ,SQ 7/SQ PI.
q�q�ua ail 2 I understand my plans shag beused v public remrds. L
6e t� Licensed Professional SIGNSELECTRICAL
<< OWNER-BUILDER DECLARATION p T E R
Ina SPECIAL CIRCNT/MLSC
Iherebyadon.(hatlamexemplfmmthedProfessionsrense Law forthe
�Z following reason.(Sectian 7031.5,Buelness and Professions Code:Any city or TEMP.METER OR POLE INST. l 91
county which requires a permit to construct,alter,Improve,dennllah,or repair
any stmctune prior to its Wuance,.ba,require.the applicant for such perndtto
WE
file a signed statement the he is licensed pursuant to the provisions of the POWER DEVICES
Ou, Contractors License Law(Chapmr9(cumnnnclogwith Section 7000)ofDivi-
(�30�^ sion3ofthe Buslne,sand Pmameah is Code)orthat he b eaemptlherefurna SWIMMING POOL ELECTRIC / VqAALUATION
< the lash for the alleged exemption. Any vtolati°n of Sectlun 7BIIS by any OLEMETS-SWLTCHE--FIXTURES �t `6 OV�fV a�'
applicant fora permit m
subjects the applicant to a civil penalty a not ore than V
five hundred dollen($5M.
I,as owner of the property, NEW RESIDENTIAL ELECTR SQbT. STORIES TYPECONSTRLCTION
�n m❑ p party,or my employees with wages r thele dole
mmpec.70 n,wWBothe work and ions Code: isnot Intended oroffered Lfor
sale(Sec.7004,BuelwsaM Professions Code:The Contrattots Wcenselaw
$ does not apply to an owner of property who build,or Improved thereon,and OCC.GROUP RFS UNITS
whodce.auchworkhimselforthrough M,ownemplayea,provided thatsuch ��yy�t
Improvement,are not oak.intended oroffered for h.If,however,lhebuiWing or TOTAL: XVp
impmvement bsold within omyearefcomplctlon,lheowner-budderwillhave
ttItIjurdenofpmvingthm hedld notbuildorlmprove fwpurpmeofsakJ. qN. PLUMBING PERMIT FEE
ELOOD ZONE APN
U L as at,of the property,am exclusively contracting with Hcensed
PERMIT `LANCE
contractor.to cestruct the project(Sm 7074,Business and ProfessionsCode: ''l
The Contmomes License Law don not apply to an owner of property who ALTERDRAIN AVENTWATER Cl
Wild*or Improves thereon,and who contracts for each pkojecia - -with a FEE SUMMARY
n
unactorle limed pursuant to the Contractec. ol.License I. BACK FLAW PROTfiCT.DEVICE
LJ I am exempt under SB h P C for this mown
• Owner pale DRNNS•IIAOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION
RECEIPT a
❑I hereby affirm that I have a certificate of consent to self-insure,or a ID(TUR�PFR TRAP CL'� SQ700L TAX Y_ N_
certificate ofworkera'Cemperoation Insurance ora artrso
iUed copythef Cec. RECEIPT 4
3BOO.Iab C. s� D ,yO GAS EA.SYSTEM-1 INC4 OUTLETS PARKFEE Y_ N_
Polity M ` RECEIPT B
Cam env -• YC l�ef1 ��.w�_a��' GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
�CertCertified ropy V(Ile,withh the
fiedccopy V herebytd. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
� be city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CRIASETRAP PAID '
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA WIFE.
Date Remi tic
(This section need not be completed if the permit b forone hundred n
dolle
(SIOO)orless.) WATER HEATER w/VENT/ELFGTR ENERGY FEE Y N
I certifythat in the performance ofthe work forwhI h this Fatima I.blued,
I Ow not employ any perwn In any runner w as to become subject to the WATER SYSTEM/TREATING
Worker,'Compensation Lawaof California. Data PAID
-
0 Z ApplicantNEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
ZO NOTICE TO APPLICANT:If,after making this Centflate of Exemption,you
should become subjectto the Workers'Compensation provisions of the Labor TOTAL:
jr N Code,you Resat forthwith comply with such provlslons°rthis penNt shall be BUILDING FEE
(�
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Iherebyafftrtnthat them isaconstruction lending agency for the perfortn TOTAL l x ELECTRIC FEE QO
70 ane of the workfor which this permit b bwed(Sec.3097,Civ.C.)
Lendees Name PLUMBING FEE
LL 1= Le.dee.Addre.d QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertitythatlhavereadthisapplialbnandkatethab
attheova Information
O W
EL Itcorrect.I agree to comply withal]city and county ordinances andstmelaws I PERMIT ISSUANCE 2� FEES PAID:
>- N relating to building construction,and hereby authorlre representatives of this
H city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. -
Z (We)agree to save,indemnity an d keep harMess the City of Cupertbw Date ROeel tN
(.I egalnst liabilities,judgments,".and exp....which may Entry way accrue AIR HANDLING UNIT CTO IO,ODO CFM) SUBTOTAL' '
ag Ips►.4llrjly gpseq�e c tlM ,rtRn Ing Mthl.pertnll.
1/ 'r)I '�.kij 11-�'IY•\. AJ�],rVit of th AIR HANDllNG I1MT(OVQt 10,000CPM) CONSTRUCTION TAX
Slgru ureo ppil
nt Co tractor Date ` EXHAUST HOOD(W/DUCT) ` CONSTRUCTION TAX PAID:
XluA 'OUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) DateRecei to
material a,defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Cade Section25531(a)7 HEATING UNIT(OVER 1W,000 BTIN _ TOTAL: L
❑ Yes No
Wllltheapplicantor wmbulldingocupantuwequipmentwdevicoa VENTILATION PAN(SINGLE RESEW ISSUANCE DATE
which emit hamnious air contaminant.a.defined by the Bay Area Air
Quilty Management Distritt7 BOILER-COMP OHPOR IMOOO BTU)
PYea No
. F1ve read the haza ..materials requirements under Chapter 4.95of EOfLER-COMP(OVIR 100,000 BEI)
the California Health k Safety Code,Sections 25505,15533 and 15.534.I
understa rd that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQbT.
responsibility to notify the occupant of the requirements which moat be met
prior to issuanm of a Certificate of Occupancy.
0 Irl
Owner or authorised agent Data L ISSUED 0
TOTAL: aJ
OFFICE COPY