22376 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B"Wins FroIdentification ITNO.
Bullln Address:
5 a� i e J 22376
• arse. CITY OFCUPERTfNO-BUILDING DIVISION /7
. Cmncte .Name:_ Lk.Na APPLICATION It PERMIT / ^
BUILDING-ELECTRICA1 PMUMBING-MECHANICAL CATEGORY CONTROL.
Architect/Fagtrieer. Lk.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERkU171SSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affrmthat l am Bcmaed underpmvbiuruof Chapter9(cvmmmc AFFLIANCES-RESIDEM3AL
tngwlth5Mbn70RpofDTWMon3oftheBuM...dProfe .Codc,andmy �alV�9eDF Vp�'e.�(
license b In WEjjjRRpp��eyyy���deffect. � PANELS 1
Lk,
Lkennc_Cbpl A C11N AiECLA -1 AMT'S l�rn b�n
Date 77//��JJ/! •' Corenrtor ^C
A..hall be CT'S
DECLARATION
q�+�7QQ IuMentand my plaveluBbe used sspubec rtm.da OVER 1000 Ah1P5 ✓Q.FT.FLOOR AREA S/SQ.FT.
pc w�wwwj LlonadlWeslonal SIGNS ELECTRICAL ReIQces . .
<Fa OWNER-BUILDER DECLARATION 1
z I hereaffirm arm that Iamexempt fmm ve the Contractor'•LkxLaw for the SPECIALCIRCUTI'lMIST Perm,I /�y�
ale+
FE'u(
QQ following reason.(FCalm 70015,Business and Pmfesbru Cade:My city or r
' hich I • rmRtocoruhv TFMP.MEIT72ORI'OLE WST. U
F� mnntyw rtqu res pe Rdter,bnpmve,demoWh,orrepsir � coo 19
m Q anyatrucwretxtem,lb bon he 6 lioeoxed pursuant
t the fresuchpemdte POWER DEVICES
file a signed mtement that he b Ilcorued pursuant b the proWloro of the
Q r` Contractor.LWemelaw(Chaper9(..ro gwith Se .7000)of DIW- SWU9UNG POOL ELECTRIC
F O alon3 of the Business and Prorewlom Code) he b exempt therefrom and V LON
Qthe bub for the alleged exemption. My WoL den of Section 70315 by any OUITETSSWIICEfESIIXTIJRFS
app0ont forapmNtsubjeaatheapplc tto.dvllperuhydnm.m then
A' flvchundredddluv($.500j. NEW RESIDIN73ALELFLTR
�a ❑1,as owKr of the propMy,or my employers with wage P TP 92
as theo-sole TYPE CONSTRUCTION
I. compensation,wdldotheworkandtheetructu Ubro eMe oroffemd for
10 sale(Sec 71100,Buelnna and lardesbro Code:The Cantnctore Dame I�w !/
@ don not apply to an oweer of bonroes property who ds or Impvthereon and
0. who doeeuch work Iirmall or through hb own employees,provided that such
impmvemew art oat intended oroffered for ole.1(hcwevegthe building o TOTAL
Improv MbaodwltMnomrarofcanplet ,thewvner-b.MerwW ve -
tIlc�rdenofpmWngthathedm na bnua.rR„prwer.r pnrp..e.re,leJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE A`N
LJ I,as owner of the pmpnty,am exeWelvely omha tIng with lianxd
contractor to conatmtt the project Foe 70K Rushes and PNmWns Code: PERMIT ISSUANCE
The Contractor.Lice.Lw does not apply to an owner d property who AI,Tpt-DRAW A VENT-WATER ff.0
builds or Improves thereon, and who contracts fee such pPjem with• DEVICE -
c .r(s)lkenied pursuant to the Cunmader'.License Law, . FEE SUMMARY
m exempt loci r Sec B mk P C for this rcuon enac FLOW PROTECT
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
OUTSIDE FEES
Owner Date RELI=#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCllOOLTAX .Y_ N_
�I he. affirm that I have a cenlBute of eawent to.elf-loon,or a
rT ffode of Wor4en Compemcbon Insurance oat certificd copy thereof Fee. RECEII'C a
3&10, bCJ GAS EA.SYSTEM-1 WGg OUTLETS PAWFER Y_ N
P.I; .If �J9Q�rE17 RD=
Can v y4n�a�a{L.f!lp._—�f51? GA'' 'S �'0���) - BUILDING DIVISION FEES
�a CIII ropy t(RCrtby fumi.hed.
F51cT rtwed copy b filed with the City impection divlslon. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIRCATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STCAM EA.]fXIFI D Date Recei t#
ffM section need net be completed B the pend[b fooanhundred dollar
F10"Ally that
WATER HFATE2 W/VENT/ELECTR ENERGYFEE Y N
Teen emp in the peAomummoyt nnerwuweek for nich thbpe bjet boli;
I dull not employ any person f any canner at ate to become aubje.Y to the WATER SYSTEM/TREATING
O AWalke�compenuatlon lawn ofaurenl,.Date PAID
Z = PP NRW RESIDENTIAL PLMB. SQFf. Date. Recei t#
O NOTICE TO APPLICANT:If,after making this Ccrtdlote of Faempllon,yw
should become subject to the Workers'Compruation pmvblons of the Labor TOTAL
-
cc N Code,you.9forthwith Comply with such pemnslov orthb permn shall be L
Q > deemed revoked. _
dCONS.RUCTION LENDING AGENCY - SEISMI FEE
Ih...byafflrm that there b a construction kMingageruy for he perform TOTAL: ELECTRIC FEE' '
= arses celthe work(or whWhthio pcmJt Blwed Fee 3097,CW CJ
U O la'Md.Name PLUMBING FEE
LL F Lewers Aaalees QTY. MECHANICAL PERMIT FEE MECHAhIICAL FEE
O O lUJIadlfythatlluvemMthbappbotlonanasiatethattheabovein(ort tim
11 is res lagre wconplywhhaUdtyaMco tyordbunm•vd Yatelaws PERMIT ISSUANCE FEES PAID:
nelrting tobulldingconnsuctlon,and her l y•uthorfu representatives of thio
F_ sty to enter.pon the abovrmentbrsd property for inalmien purpo•ea. ALTS CIRADDTOMECH.
V Z (WO agree to save,Indemnify an d keep lundem the City d Cupertino Date R rpt
igalrwliabwtln,}nagmew,co b•rd expmrs which may In any wayamue AIR HANDUNG UNIT CFO I0,EU0 CFM) SUBTOTAL:
ago is id lty} Qct. of thegraMirB of d ie perm)
// AIR HANDLING UNIT(OVER 1Q000CFM) CONSTRUCHONTAX
ore of Ap est/ est DCRADSIIIOOD(W/DLcn CONSTRUCTION TAX PAID:
=111OUSMATERIALSDISC 5 RE
Will theapplkant or future building oavpart core or handle hazardous HEATING UNIT ID3,0D0 BM Dale ReCCI t#
material a.defined by the Cupertino Municipal Code,Chapter 9.IZ and the -
Hiahhand Safety Ccde Ion 2S532(a)7 FIEATING UNIT(OVER 100,000 BTU) TOTAL:
RYes
I enutll the apardou rtbuliding as upjnt by equipments Air a VENTILATION FAN(SINGLE REM) ISSUANCE DATE
whWh eM_ ren sus air conlamW nt.ss defined by the Bay Area Air
. QF-1 YexfarugemeM 7 BOILER-COMP OI-R'OR 100,000 BTU)
4Yn No
hwere;a"a naedab qulremenbunaereuperG9sar BOR ERCbMProvx100,000BT
the Cai fomlo Health k Sat rty Code,Senlotu 25505,25S33 and 25530.I _
uMe ndthatiftheb UdingdonnMtc nllytuveatenanLtMtltbmy NEW RESIDENTIAL MECH. SQFI.
neaponx Ritytonot thew pLaMdtherequiremew which utboat
at
prior t�ksuanc nl -teofO panuy.
neraauth en
/Dtd ISSUE
TOTAL: —
OFFICE COPY