24311 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '
Building Protect Identification PERMIT NO
Budd ing Address:
IO ZZZ 2.i4#_a�jj+&4 ^ ^ 24311 .
3 V a.
Pre nte:eahone: 1 11 A
a CITY OF CUPERTINO-BUILDING DIVISION / n
Contimet"a Name: Lie.No: O!
; -APPLICATION / PERMIT ( L
It'06c C. BUILDINGELECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL#
A... Engineer. Lie.Na
t(�'Xi�', 1 X X BL6TR[C PfRMYT X ' 4 l X ;FE) " i `,?-j ,BUILDING PERMITINFO --
Addrcec .. PERMITISSUANCE .� ..�. .•• .
LICENSED CONTRACEOR'S DECLARATION -
Ihereby afflrenthat l am Bcrosed under provisions of Chapter 9(mmmenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Se on7DW)of DiWam3oftheBusimmand Profee msCode,and my. /PTI
license tains force and effect . PANELS ice` I \^ I r^
License Class Llffc .a
Date Contractor
ARCHITECTS DECLARATION 201-1000AMPS '
ceZI understand my plats shall he u
0uI O and as public records. - OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FC.
VZ�j Licensed Professional
SIGNS ELECTRICAL ,5 A
6 OWNER-BUILDER DECLARATION SPECIALCIRCUT/Mk:� ° -� N
>Ho s owing rasormehatlamexempt(ro Business
Professions
Law for the � �
O following reasonui mint e7 m Bushes and Profealons e=le h, city ^
pzt-'a countywhich regrto its emdtrocorsreciinitenlmprove,derroVah permit
TEMP.METER OR POLE INST OAS(■
� .a. PU
any structure prior lswnance,aieo requlreetheappVwnt(onuch perNtto
g (OWER DEVICES
file a signed statement that he le licensed pursuant to the provislom of the
6Q3O� Cootrador's Licence Law(Chapter I(commenclag with Section 700(d of Divi- SWIMMING POOL ELECTRIC
don3 ofthe Businessand Pmfewimu Code)orthat he leexempt therefromand ONJ
the basis for the alleged exemption. Any violation of Section 7031S by any
G appllcant(ora permit aubjedsthe appilcant taadvll penalty of not more than OUTLETSSWITCHES-R (TURES
five hundred as
dder ars ofth Pru e - NEW RESIDENTIAL ELECTR SQk7, STORIES TYPE CONSTRUCTION
❑I,as owner of the properly,or my employees with wages m there sok
compensation,will do the Business and k and the rofeadom Code:Thhare Contnot actor or offered for
Idoes n(Sec.apply
to Business owner
f pmpar a who
builds or Improves
Licheeme Law
'$ whodot applylomownel olprough whonempoyees,pouded thatand such — OCC.GROUP RES.UMTS
who am khimse dee oroughed own employees,hcxw,erothe building
or-
Improvements ithindneyearfcomoreale.theo vepthebulldingor TOTAL: -
ImprovemcnHeaoldwithinoneyearo(complelion,theowner-bu0derw1lih e -
trt*rden of proving that he did na build or improve for purpose of sale.). QTY; t:,:, t,PLUrVl$(NC+. EKMI'I' t" =,FEE'""t' pL000 ZONEAPN -
u L as owner of the property,am exclusively contracting with Licensed
contractors to construct the project(Sec.7044,Business and Professions Cade: ' PERMIT ISSUANCE „.
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER O+NN
builds or improves thereon,and who contracts for auch-pro)ectx with a
Cg0t(actor(s)licensed pursuant to the Contractors License Law. Y. `tt;XF,EE'SUMMARY^.`
LJ I am exempt under Sec. B
B&P C for this reason ACK FLOW PROTECT.DEVICE
OUTSIDE FEES
Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner - RECEIPT p
WORKMAN COMPENSATION DECLARATION
FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that I have o lmuR a of consent to al;tnemof or a - /• _ RECEEq,# ,
certificate o(Worken'Compersatlonlaurmceora certl(kd copytherem((Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3KQ Lab CJ
Policy# - .. RECEIPT#
Com a GAS F.A.SYSTEM-OVERd(EA)
T - BUILDING DIVISION FEES
❑p Certified copy 6 fiercbyth the ed.city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHCCKFEE
❑Certified copy la filed with the dty Wpection division.
CERTIFICATE OF EXEMPTION FROM WORKERg' GREASETRAP PAID
' COMPENSATION INSURANCE .
(Thisedionneednot becompleted lithe permit lsforone hundreddollans SEWER-SANITARY-STORM EA.zooFr. -Date Remi t#
($l00)orfesJ WATER HEATER W/VENT'/ELECTR ENERGYFEE Y N
Icertifythal Nthe orma of w k(orwNch thio penitis issued, -hall
not employ a pere a her an
as to ecoryg to the WATLR 6Y
Workem Com n Han of �- /TREATING PAID
O Z ,Applicant RESIDFNTIALPLMB.
Z O NOTICE TO I NT:IL rrw g tide Certiflute of Exemption,you SQ.FT, Date Remi t#
should become subject to the Workere'Compamatlon provlsIm fthe Labor - TOTAL: '
N Cade;you must forthwith comply with such provisions or this pe
rMtshallbe BUILDING -
�j deemed revoked.
a, 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE " 1
I hereby a((Irmthat there B a com atruction lending agency for the psrforro-
Z ance ofthe work for which this permit isissued fSac.W97,CJv.C.) T ELECTRIC FEE
O 4 Under'.Name �
PLUMBING FEE e
LL H Landcr.Address - p7Y ''•`,', M CHANICACiP1_RMITtX „'FE&(;` MECHANICAL FEE
O W Icertifythatl have readminappacatlonand statethatthe above information
(L is correct.I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
,} to relating to building construction,and herebyauthorize representatives ofthis _
I— U) city to enter upon the above-manlloned property Join inspection purposes. ALTERORADDTOMECH, -
_ (We)agree to ave,Indemnify an d keep harmless the City of Cupertino - Date Receipt# '
against llabiVties,pdgrrenls,coe[a end expense which rosy In anywayacorue AIR HANDLING UNIT(TO 10,000CFM) SUB
TOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTION
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTIONX PAID:
HAZARDOUS MATERIALS DISCLOSUREWill the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date t#
material as defined by the Cupertino Municipal Code,Chapter9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU . TOT
❑Yes ,+u—,No ' -
IYeseappllcantorInbuildingoccupantuseequipmentordevices VENTILATION FAN(SINGLE RESIU ISSUANCE DATE .
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DlsMd7 BOILER-COMP OHP OR 100,000 BTU - . 1
4 Yes No p�
haverthe haze etYC-dus ,
ectt-o 25505, 5533underand 25534.
of BOILER-COMP(OVER 100,000 BTU) P AID ,
the Californiala Health&Safety Code,Sections 25505,25533 and 25534.1 '
understa rad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. {
reeporedulitylonctifytheompant of the requirements which must be met - O/'�T
prim miSauanceofa CertBicateof Occupancy. X - r t9���
Owner or authorved agent , Date- �5D 11- ', U� 7
TOTAL: ISS ue BY:\\ 1�1_y_YIN3�'J�l�i
OFFICE COPY