24264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Pngect Identification - PERMIT NlQ/]
Building Address: („f 4 2 6,4
er Name9 Ai,�srri� l l�
Phone: AVVUr IIONSUBMI I"1 AL UA I
CITY OF CUPERTINO-BUILDING DIVISION -
c aN Lie.N o-
1 APPLICATION If PERMIT I asec�z,
BUtLDINC-ELFGTRi l I'LUMBING-MFGHAMCAL CATEGORY CONTROL a
m i ect/Engineer: cLlc.No: I ' L
t ' , '' ;BUILDING PERMIT INFO ; •'•
ELECTRICPERMITi • FEE, _
Address: L1FGT'—PLLmo nuw.n
I'Q4MITISSUANCE �❑ jam' ❑
LICENSED CONTR under rU[onsofCION I L�kJ
firm[hth Sb OA7DOhafD,mik 3.fthnderpro..nd mfnaws9(mmmenyI APPLIANCES-RESIDENTIAL JOB DESCRIPTION
horrech Sefiell i00)otDwblon3 ortheBminmsand ProfaslonsCotle,end my
license is in full lorcc en erred./1� PANELS /'
License Cla s - LIL# X/oI 5 k'J 1 � 1
Date - Conractors$INAUify/�✓N7.✓Yiia I1P T0200AMPF r 1y
ARCHITECTS DECLARATION 201-1000AMPS 10
gq�q+mO Zp lundersnnd my plainshagbe used as publicremrds. OVER1000AMPS j b 1 sQ k'T.RLbOR/�il� $/SQ.Fr.
Licensed Professoriat SIGNSELECIRICAL ^,,
6 OWNER-BUILDER DECLARATION ;�
L, IhcmbyafBrm that am exempt from the Contract or a License Law far a BE UC]AL CB{CIRT/MLSC I I'
following reawn.(Section 7031.5,Buslncm and Profeisbne Code:An d or
09 u9 county ichr kesa permit to ronstruct,aiter,ire c city TEMP.METER OR POLE INST. DATE 7
Fv� tto equ pe provgdemolbh prnotto
,[ anystrociure ptriscitshahe Is lice sed pursuant to het(erwions of the ROWER DEVICES �r to tG floe a algned statement that he k licensed pursuant to the provisions of the
3"'•� Con3ofths Business Law(Chapter 9(mmmorthat with xSection
mptthe00)emandI SWIMMING IDOL ELECTRIC
slon3ofihe Business and Pro(esslonsCodc)orthat hebewmptthere(romand I VALUATION
�n�'•, the basis for the alleged exemption. Any violation of Section 70115 by any h
applUantfor a permit subjects the applicant to a civil penalty ofnet more than OUTLETSSWITCHIN-FIX17URES �1/a
five hundred dollars MS00). NEW RPSID (/
�n ❑I,asowner,ef/he property,ormy employees with wages PNDAL ELFO7R SQ.FT.
astheirsole I I STORIES IYPECONSTRUCTION
compensation,will do the work and the structum Is not Intended or offered for I+
p In(See.7044,Business and Prolessloes Code:The Contractor's License Lar
Ly$$ does not apply to an owner of pmperty who builds or improve theme,and CC:: who does such work himself or thigh his own employees,provided that wch OCC.GROI/ts RFS[MI75
Improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement is sold within one yearof completion,the owner-bullderwlll Its,._ _
tjk u,den of proving that he did not build or improve for purpose ofsale). QTY. '( . �' PLUMBING PERMIT '1 " 'FEE ' I F1pp1)ZONE Al'N
LJ L
contraction owner of the property,moct am exclusively Business ess and with licensed de: / PERMIT ISSUANCE; r• .1�
The Cdorso romicense L w it (Sec.apps to an invee tell prop Cade: J U
The Contndor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT
bonds or Improves thereon, and who contracts for such ptojece,with a _ wnTlx(FA) I y
c tador(s)Ilmmad pursuant to the Contractor's License Law. FEE SUrs7MARY
LfI am exempt under Sec B &P C for this reawn BAIX FLOWI'ROTCCT.DEVICE + 'r PI Ircl(tn.-Pro
DRAINS.FLOOR ROOF,AREA,COND. I (SANITARY; Y • N
�3 Owner date RUCITPIE '
,�.( WORKMAN COMPENSATION DECLARATION FIX'RIRES PUR.[RAP I SCHOOL TAX Y— N
f'idol hereby affirm that I have a mrtiflrate of consent to eel(-Insure,or a RECEIPT N
-mot' rt irate of Workers'Co�mApensation Insurance ora certified ropythereef(See. GAS FA.SYSTEMd INC.40[TD.UTS I �PAW(FEE' Y N
38M Lab CJ,� �.�A,�).i _
I'ollcyM -10 q,2s. RECEPTp
Core any= IJII CAS-EA SYSTEMAVER4(El) I j BUILDING DIVISION FEES j
OCertlfied copy Es harclry furnished.
city (GREASE/INDUSTRL WASTE INTERCEPTOR I IPLANCHECK FEE
IGY�crUfied copy lsriled with the city inspection division.
1� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP __I (PAID
COMPENSATION INSURANCE SEWFRSANTTARYSTORM EA 200FT Date Rece
tlhlswctlenneed ridMENSATI NINSURANC for one hundred dollars 1. Dip
($100)or ten.) WATER HEATER W/VENT/ELECTR I ENERCYFEE Y N
I certify that In the performance of the work for which this permit is noun— —
I shall not employ any person In any manner so as to become subject to the
Workers Compensation Laws or California.Dat• (WATER SYSTEM/TREATING PAID
O Z Applicant
ZO NOTICE TO APPLICANT:If,after making this Certificate of Exemption,You
(NEW RESIDENTIAL PLMe. SQFT. Date Recdptfl
FN should bemmesubject to the Workers'Compemation provisions ofthe Labor I TOTAL:
Code,you must forthwith comply with each provisions orthls pemdt shall be i BUILDING FEE I
LU> deemed revoked. I SEISMIC FEE li
Q. G CONSTRUCTION LENDING ACINCY
T hereby of irmthat there Is a constmdoon lending agency for the pskorm-I TOTAL: I LLECTRIC FEE
M ZO ance o(the workfor which this permit is LUued(Sec.3097,C1v.C.) ^-�
O — Lender.Name V.,�PLUMBING FEB 6 D
LL F LenderSAddre•• PP QTY. MECHANICAL PERMIT . ',� ' FCC ;MECHANICAL FE FEE
U Itertl that l have read then Bcationand sntethattheabove information
O W bmriect.I agree to comply with all city and countyo dinanasand&ate laws[ PERMRISSUANCE FEES PAID:
U) is to building romtrudlon,and hereby authodae representatives ofthis '
f. 2 city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MUCH. I .
(W4)agree to save,Indemnify and keep harmless the City or Cupertino Date Receipt#
U
gximth.bilitlestidgmentsconigand expenses which may in anywayaceran AIRIiANDLINCUMT(I'O10,000CfM) I I SUBTOTAL: .Z,a,Lrfi7) j
ag u a1 City in consx; lithe II of thlepermit.
/� AIR HANDLING UNIT(OVER l eeeBCr•M) I. I CONSTRUCTION TAX
Sig' reef nppu /Con 'a or Cd�b Date /. f IXl-IAUS'T HOOD(W/DUCT) I CONSTRUCTION TAX PAID:
ZARDO S MATERIALS DISCLOSURE
Will the spell ntor futumbuoldingoccupantstoreor Fandlehaeardous HEATING UNIT 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code Chapter 9.IZ and the — I I
(fealty. S' Code Sectors 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) GI I TOTAL: ya(cv�l
Yes �No
Wlllthe apphnnt or cure building occupant use equlpment or devices I VENTILAHON FAN(SINGLE BESIDE I ISSUANCE DATE '
which emit harardous.1,mnLaminantsas defi end by the Bay Area Air _
Quality ManagementDisMct2 BOILFR-COMPPIIPOR100,OMBTU) PAID
I0 Yes - ❑No � Q
I have mad the haaardous materials requirements under Chapter 695 of I BORER.COMP(OVER 100,000 BTU) NOV s/
1.The C-lifomla Health&Safety Code,Sediom 25505,25533 and 25534.I 1092
undmtand that tithe building does not romently have atenanp that of is my It NEW RESIDENTIAL MECI I. SQ.Fr. S77v7
rapomlblhty to really the occupant of the requirements wh kh must be met
prio to LSUance ofa CertlOcate (Opan , CITY Ur QUer rli limo
Owner or authorized agent - Date I I TOTAL: �J
(ISSUED Ny�`�~Qlef/�i'•Sp'/A
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OFFICE COPY