24174 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT,PEN ONLY
Building project Identification PERMITNQ.
Build Ing Add res.: s)
10Z �g2I3 a,eA LAn�L GG
ante. one: 4174
A
nee. 4 CITY OF CUPERTINO-BUILDING DIVISION
Such=��aName: Lic•N.: APPLICATION /PERMIT � 2
F' s BUILDING[LECTR CALPLUMBINGMECHAMCAL CATFLORY CONTROL M
t-. ' Architect/Engineer. Lie Nm
BUILDING PERMIT INFO
,QTY ELECTRIC PERMIT FEET:`;.
Address: PFRMITISSUANCE F-1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I affiren'hat lam Bcm3oftheunder ugp saionsol Chapter9(rommm APPLfANCESRESIDENML ]OB DFSCRII'TION
licur.h di..fall force and efelon3o(Ihe BuAnessand ProleaslonsCode,and my
LI..c Isinfull force and effect t rpNE7.5
_t D.tr Class ..M
Date Conlnctar —UP TO 200AM25
ARCHITECTS DECLARATION 201.1000 AMPS
gyp+± qO I understand my plane shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E (/ Licensed Profealonsl - SIGNS ELDCTRICAL
<�6 OWNER-BUILDER DECLARATION SPECIALCIiCUIT/MISC
X ,�4 Ihercbyaffirmthallameaemptfromlh.Conlraaoes LimnwUwlorthe
oo following reason.(Section 7MIS,Buainea and Professions Code:Any city or
CFz u9 rountywhichmqutmsapermittommt d,alteplmprovgdemalbh,orrepair TEMP.METER ORPOLE INST,
q� anystm=mprortoibrauance,ahorequimatheappBcentrorauchpermitto
file a signed statement ihm he I.Ilaneed Pursuant to the provisions or the POWER DEVICES
3 tt� Cantraaoes License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
SOS slon3ofthe HuaNeea and ProfaalonsCode)orthal hebexempttherefromand V_AL�UkATI IDLj -
Q S the basis for the alleged exemption. Any violation of Section 70715 by any OUILETSSWITCF@SH%TlR2E5 O �'
applicant for a permit aubjectsthe appllcant to a civil panslly a not marc than than
five hundred delta.($500). '.
�n ❑I,as owner of the NEW RE9DFNMLEI'ECTRSQ'FT. STORIES TYPE CONSTRUCTION
property, employees r theirsets
compensation,on,Businesswill do andwork,and the structure The C ntractIntenr Licamse,Law
O sale(See.apply to Business and Professions Code:The Contractors ves hereat Law
doesna,such torn owner ofproor pertyhisonemporimproovidedreoryand OCC,GROUP RES.UNITS
0.0. whodoe.entsw notInteBedmutgh hleowne.If,lmea,provldedilding that such
Improvementiarcnotintendedprofferedfoe Male.If,h er-g rider ilI have TOTAL:
Improvement bsold within oneyearo(complctlorytheowner-budderwlll have
thLtiurdenofprovingthat he did net build or improve for purpose of sale.). Q'jy, 'j;(:PLUMBING PERMIT-, FEE,-t [TpO mNNE APN
u L as owner of the property,am exclusively mnlraning with Ikenxd PERMIT ISSUANCE
contractor.to construct the project(Sec.7044,Business and Profesems Cade: '
The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
Wilds or Improves,thereon,and who contracts for such p4o - -
jecis with M -
cgptractor(s)licensed pursuant to the Contractor's License Law, -„�,. FEESUMMARY
I_J I am exempt under&c B&P C for this rcawn BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,IND. SANITARY Y N
OU
Owner Date RECEIPT -
WORKMANCOMPEI.ISATION DECLARATION
E31bV(711RES PER TRAP SCHOOL TA% Y_ N_
I hereby affirm that 1 have a certificate of consent to self4esure,ora RECEIVE X.
artafacateofWorken'Compemationlmumncearamrtarkdmpythemof(Sec. GAS EA.SYSTEM-1 INC.40ITILEIS PARK FEE Y N
3800,
Pakyp GAS EA,SYSTEM-OOVER RECER'TM
On
anv Sp„ _Lklr� �— BUILDING DIVISION FEES
Certified copy he d with n e city GREASE/INDUSML WASTE INTERCEPTOR PLANCHECIC FEE
' fi7Certified copy Is filed with the sty inspection division.
Y� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP I
PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei tN
(This section need not be completed if the permit lsfor one hundred dollars
($100)or leas.), WATER HEATER W/VENT/ELECTR ENERGYFEE Y _ N_
I certify that in the performance ofthe work for which this permit is Issued,
I.hall not employ any person in any manner so as to become subject to the WATER SYS-TQd/.I.RFA.DNC
Workers Compeoutlonhwsof Caliromia.Dale PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei tM
O, NOTICE TO API'LICANT:IL after nuking this Certificate o(Exemptlon,you
_ F should become subject to the Workers'Compensation provisions of the Labor TOTAL:
f�7 Code,you most forthwith comply with such provisions or this permit shall be BUIL D[N
LU 7 deemed revoked. - '
EE
3, CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL
Ihereby affirm that there b a construction lending agency for the perform- TOTAL ELECTRIC FEE
7 Z ance of the work for which this permit he Issued(Sec.3097,Civ,C.)
U O ,rder'e Name - - PLUMBING FEE
IL Lenaer.Ada aaM QTv. '`MECHANICAL PERMIT' FEE
OW I certitythall havereadthisapplicatlonand statethattheabeve lnforenation MECHANICAL FEB
IL le correct.I agree to comply with all city and county ordinances and&ale laws PERMIT ISSUANCE FEES PAID:
} N relating rebuilding construction,and hereby authorize representatives or that ,
(— Z city to enterupon the abZ=ndoned pmpe rlrupeRlon purpaua. ALTER OR ADD TO MECH. Date RCCCI tM
(We)agree to uv,indemnify an d kee rhea the City or Cupertino -
agalmtllabWOn' gmenb,amisando see which may In anywayaccrue AIR HANDLING IIMT(I'010,000 CFM) SUBTOTAL:
agalnstsaidC in consequen oft anon of this permit. p1R HANDLING UMT(OVFR]O,000CFM) CONSTRUCTION TAX
gmture ofAppii.Pfi1/CBipB5r Date EXHAUST HOOD(W/DUCT) CONSTRUCT ION TAX PAID:
HAZARD US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle huardous HEATING UNIT OD 100,000 BTU).
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date' Recei tN
Health and SafetyCode�Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL.
F-1YeaYe. No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harandous air roniarenumn ami defined by the Bay Area Alr
/
Quality Management Dhe istrict? - - BOILER-CAMP(3HP OR IMOM BTU)
I Yea rJ No
havcreaa Health
sus mode,Se t..25Senlsundea Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) R
the ersta cob Health A Safety Cods not cu ns 2550.5,have
t and 75534.I 6J
andeniandthat i(the tify the ing doesoccupant not currently require encs tenancy that it met NEW READENTIAL MECH. SQ.IT. (((���iin” �
responsibiu Issuance
net Rytheocte of oftherequlrenenis which most be met SEP . 19T75L
prior to Lasuance ofd Certificate olOavpanry. � t TicY
Owner or authorud agent - Dale CM
TOTAL: ISSUT:D BY:nzry
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OFFICE COPY