24229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'eet Identification - PERMIT NO.
Building Address:
o3B a LE R •
wne Phone: APPLICA LION scamr[AL DAM
CITY OF CUPERTINO-BUILDING DIVISION
Co tmeber'aName: Ic APPLICATION / PERMIT
• BUILDINC-ELECTRICALPLUMBINC-MECI IAMCAL CATEGORY CONTROL p
Archlt
t t E48CTRICPERjo11T' t 41 T.AEE t. `.i;BUI RWPIPERMIT,INFOPLUMB MELH
'
A PERMITISSUANCE El El
v ElLICF.NSEDCONTRA OR'S DEC6AR IO �J
Ihereby affirm that Iam Been"under provisions of Chapter9(coWnsec. APPLIANCESRESIDENTTAL JOB DESCRIPTIONIngwith5ection7000)ofDivlsion3 ofthe uImssana ProfessionsCode,and my PANELS
lice.ae le in tailf and diedic.# - t �JL V)��le
Lken I •Gc.p
Dat Conha
201-1800 AMPS
AOEC 1,
CZ I understand my ple.A.B usedu Ierer6Ns. OVER IWO AMPS �x SQ.Fr.FLOORe Alt $/SQ.FT.
QU Licensed Professional - SIGNSELECTRICAL �'� Ii , -•, f
Q w OWNER-BUILDER DECLARATION
SPECIAL cmc nTiM sc a i
F„�m owing asormthat lam31.5,Business
from
ossa Contractors Oade:Law for the _ UT �'
vF� foilowingmason.imsa(Section 7QtW Buel dandy, (pm ns Code:Any tlpor s-i '..
� rountywhich requlreea permltmmratruct,alter,Mprove,dertolish,Orrepalr 'TEMP.
METER ORPOLE[NST.
g .a any structure prior wits Issuance,also requires the applicant for such permit to POWER DEVICES TE (
L5 -file a signed statement that he ls licensed pursuant to the provisions of the
3w� Contractor's License Law(Chapter 9(commencing with Section 700f)of Divi- SWIMMING POOL ELECTRIC
F, sion3 ofthe Business and Profeesiea Code)orthat he is exempttherefromand ,. ,VALUATION
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESI]XTURES
applicant for a permit subjects the applicant to civil penalty of not more than
five hundred delta.(SSO%.
I,as owner of ro NEW RESIDENTIAL ELECIR__SQ.Fr. STORIES TYPE CONSTRUCTION
..�n ❑ p perty,or my employees with wages as their sole
compensation,will do the work,and the structure isnot intended or offered for
0 sale(Sec.70K Business and Professions Code:The Contactors License Law
j$$ does not apply to an owner of properly who Wilda or improves thereon,and OCC.GROUT' RFS.UMTS
who does suchwork himself orthrough his awn employees,provided that such
lmprovernenh are not intended proffered for sale.If,however,thebuilding or - TOTAL: '
Improvement issold Mthinoneyearofmmplellomtheowner-Wederwlll have * ,
tFflZurden of proving that he did not build or improve for purpose ofsak) QTY: GU1vIEING.PERMIT,' „';`FEfiz,`•,' - FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with Ilronsed PERMITISSUANCE
contractors to constmet the project(Sec.7044,Business and Professions Code: "
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojece with a
cgR[pc[oKs)Ilreneed Punu tttothe Contractor's Llmnae Law. 't:fir, `F ESUMMAIIY,' '•;i�
LJ I am exempt ugder pec. B k P C for this reawn BACKFLOW PROTECT.DEVICE t"" "' OUTSIDE FhLb
—.
Owner Date DRAINS FLOOR A,ROOF,ARECOND. SANITARY Y N-
COMPENSATION DECLRECEIPT
WO KM p
FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm t t I have a certiBate of consent to self-Insure,ora RFGEB'C p
certificate ofWorkers'Cbmpe adlon Insurance or a certified copy thereof(Bar. GAS EA.SYSTFM-1 INCA OUTLET& PARK FEE - Y N_
3500,Labe 2
Po11ryN J /O GAS EA.SYSTEM-0VER4(EA) BUILDINGRECDIVISIONFEES
Gram Pia— a�• y .
ort p is e t cols a GREASE)INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rt18ed copy ls(fled with the city Inspection division. -
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE S-�D
(This section need not be completed Bthe permit ls forom hundred dollars SEWER-SANITARY-STORM EA.2DOPr. Date Recei t#
($100)or less) WATER HEATER W/VENT/ELECTR ENERGYFEE Y. N
I certify that in the performance of the work forwhich this permit is issued,
I shall not employ any person In any manner was m become subject to the WATER SYSTEM/TREATING s
Worker'Compensation� o(F.W9arnla. Date - PAID'
PP moat NEW RESIDENTIAL PI.MB. SQFf.
Applicant
Z O N'OITCETOAPPLICA :If,afiEr�ra gthis Certificate of Exemption,you Date Recei t#
'F should become subject to the Workeri Compernatlon provisions of the Labor-7—
,1 TOTAL:
N Coae,you must forthwith amply with such provisions A orthis permit shallbe t` BUILDING -
deemed revoked. '
W
G - CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaf8renthat there is a construction lending agencyfor the perform- n ELECTRIC FEE
Z anceofthevimkforwluehth aper dtlslssued(So..3097,Cle.CO TOTAL Y/� t
C1 Q Lender"Name PLUMBING FEE O
LL - Lenaaraaaareea QTY' '{: •.:MEGHANICAL��PER'MITt `FEE :'. MECHANICAL FEE
OW. Icertifythat]hav re h pllcationandstatethattheabovelnformatimn
S Is cnmuct.Iagree to spin y with all city and county ordinances and state laws PERMTTISSUANCE FEES PAID:
W relating to building mmtructlon,andhembyauthorize representatives of this
F— Z city to enter upon the above-mentioned property for impeRlon purposes. ALTER ORADDTOMECH. Date -•RfCel t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino p
against liabilities,judgments,msaand expenses which may In anywayaccree AIR HANDLING UMr ITO lo,000 CFM) - SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data E%HAus r HOOD(W/DUCT) • CONSTRUCTION TAX PAID:,
HAZARDOUS MATERIALS DISCLOSURE - -
Willtheappllantorfuture building occupant store or handle hazardous HEATING UNIT(TO 100,080 BTU) 'Date ROeei t#
material as defined bytheC entino Municipal Code,Chapter 9.12,and the -
ITeaunanasaretycoaese on 2ss3zta)r - ' HEATING UNIT(OVER 100,000 gnu) TOTAL:
❑Yee 0
Willtheapplicantor rebuildingocmpantuseequipmentordevices VENTTLATION FAN(SINGLE RE5ID) 4ISSUANCE DATE:
which emit hazardous a m taMwnts as defined by the Bay Area Air - -
Qu lily Mansge orb Ist 7 - BOMER-COMP AFB'OR 100,IXq BTU)„ p '
4 Yea No A
have read the haza terials requirements under Chapter 6.95 of " BOILER-COMP(GVQf lOD,000 BTU)
the California Health Ssfoy Code,Sections 25505,25533 and 2:534.I �j •I(�.(yry.
understand that if the tiding does not currently have a tenant,that it is my NEWRESIDFNTIALMECH. SQ.Ff . 00T 1-'Ix7s7(�
responsibility to notify the occupant of a uirements which must be nest
prior to Lss on of a Certifies f cy.
CI`f.Y I (;U crirl
Ow r a o zed t I Data 'TOTAL: - ISSUED BY:
OFFICE COPY