24150 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project.Identification 77777 PERMIT NQn/
Building Address: '1 - 2 4 1 5 0' .
' - - ��I hr-�rz-E •P '1Phony A
Owners ame4Z\•� - /aO . CITY OF CUPERTINO-BUILDING DIVISION r
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^ Cono-attoraNa / o Lie.No:.. APPLICATION / PERMIT 9 xax2
:BUfLDING-ELECTRICAUPLUMBINGMECFIANICAL CATEGORY CONTROL#
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Architect/Engineer: Llc o:
- .4TY +t., t•IxEI.E,CTRICPERMITI' 1 " 1 FEE x' �'' �:' BUILDING'' EMIT,IMFOs;s'
Address: 11131; [' PERMITISSUANCE ❑ ❑ - ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirrnthat l am licensed under provisions o(Chapter 9(commmc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwilh Section7000of DiWtlon3ofthe BusinessmdProfemionsCade,md my -
lii is In full force and effect. C/ PANELS
Llos Class — Lic,a��],LJS 0 �•
Date;3 07 Contactor Ea CH r^m I ILA I I tViCJ, UP TO 200 AMPS
ARCHITECTS DECLARATION 2014000 AMPS
{oq ppOp I understand my plans shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
E U Licensed Professional SIGNS ELECTRICAL
0000�6� OWNER-BUILDER DECLARATION SPFf_1ALCTRCU[T/MISC
e., Iherebyafliem that l am exempt fromthe Contractor'sLianse Lawforthe
pZ o ❑qq following reason.(Section 7m1.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST..
t" county which requires a permit to construct,alter,improve,demolish,or repair -
g ,py3 any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
6 file a signed statement that he Is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWB.fMING 700E ELECTRIC VALUATION
slon3ofthe Buslned Prof
s... .ssb Code)orthathekexempttherefromand
Q the basis for the alleged exemption..Any violation of Section 7031.5 by any OU7LE.IS5WI•ICI-)ESFUCf[1RF5
applicantforapermitsubjedstheapplicanttoadvllpe.aityofnotm mthan
five hundred dollars($500.
❑I,as owner of the property, NEW RESIDENTIAL ELECTR SQSr. STORIES TYPE CONSTRUCTION
p perry,or my employees,withwages r their
compensation,7B will BosBothe work andthes Cdure Vn ontracded oroffered(or
sola(Sec.apply
Business and f property Code:The or imp owas hereonLicense Law
r$'$ does not apply m an owner of property who builds or improves thereon,and OCC.GROUP RFS.UMTS
who does
ments.orkhimself dedoroughed fans e.If,ho employees, ded that suchebulldlegor _
Improvementeare not intended oro!(eredfasale.If,howeve6 thebulldinga TOTAL:
Improvement bsold withinoneyearofcompldlogtheowner-builderwlllhave
' ttiLtu rden of proving that he did not build or improve for purpose ofsak) 'Q"T"Y, _' ? 1PI>UMEING•1?ERMIT',x tt is"FIiG{.'Y.' FLOOD ZONE APN
L j L as owner of the property,am exclusively contracting with Ilansed PERMIT ISSUANCE ��
contractors to construct the pm)M(Sec.7044,Bualnees end Professions Code: -
The Contactor's License Law does not apply to an owner of property who pLTkR-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pl jects with a t y
co,ttBBfTpursuant actor(s)licensed pursuano the Cmtmdm's License Law. ' BAIX FLOW PROTECT.DEVICE t `•'"'t EEE'sUMMARY•.,
LJ I am exempt under Sec. B&P C for this region
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
• SF DE FEES
Omer Date RECEIPT# -
WORKMAN COMPENSATION DECLARATION
QFIXTURES PER TRAP SCHOOL TAX Y N
I hereby affirm that I have rate of consent to self-0nemoor . RECEIPT N
3800,Labb CJ
certtllao(Workera'Compensatlonlmulnsurana ora artifkd copythereof(Sec. GAS EA.SYSTEM-I INC4 OUTLETS PARKFEE Y N
Policy# GAS EA.SYSTEM-OVER 4(EA) RECD N
Cam any BUILDING DIVISION FEES
❑pCcelifled copy la hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID,
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recel t#
f Thissedion need cut be completed if the permit la forone hundred dollars
($t6))niletrtify h WATER HEATER W/VENT/ELECTR' ENERGY FEE Y N -
Icenote ployt an an pennon Zany of manhe ner
forwhlbecoch pesubjecrmit is leased, -
Ishallnotemployanypersonla alifmannerso all to become subject to the WATER SYSTEM/TREATING
Workeae'Compenaatlon laws o(Gilfomla.Dale PAID
.OZ Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recel t#
Z O — NOTICETO APPLICANT[f,aicer making this Certificate of Exemption,you
should become subFoi to the Workers'Compensation provisions of the Labor TOTAL:
~ N' Code,you must forthwith comply with such provisions oethis permltshall be BUILDING IPE
Wj deemed revoked.
'.n. G CONSTRUCTION LENDING AGENCY SEISMIC-FEE
I hereby affirm that there is a constmctlon lending agency for the perfom, ELECTRIC FEE''
Z ance ofth.work for which this permit is Issued(Sec.3097,Civ.C.) T
Txj O O Lender's Name PLUMBING FEE ��
IL H Lender•.Address QTY 1NECHANICA4'1 ERIv1IT;. i" 's ZaFEEi.. MECHANICAL FEE
., O O Ialai!ythatlhavemadtMsappllaRonandatatethattheabovelnfor.tion 5 ,. -
iscorrect:I agree to comply with all city and county ordinances and date lawsPERMIT ISSUANCE FEES PAID:
>. 1 relating to building construction,and hereby authorize representativesofthla
I— 2 city to enter upon the aWwv mentImdd1 property for fispectionpurposes. ALTER OR ADD TO MECH. Date R2Ce1 [#
V — . Me)agree to save,Indemnify and keep harmless the City of Cupertino P
agaimtllabllltlea,jydgments,cue[sa dexpenaawhichmaylnanyway.c.a AIR HANDLING UNIT(to Wp00 CFM) SUBTOTAL: .
against said ty in consequence of the granting a this permit.
AIRHANDLINGUNTT(OVER10,000CFM), CONSTRUCTION TAX
ig tore of Applicant/Contactor Date IXHAUST}IOOD(W/DOLT)' . CONSTRUCTION TAX PAID:
HAZARDOUSMATER LS DISCLOSURE 4 ,
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Health and Safety Code Section 25532(a)7 HEATING UMT(OVER 100,000 BTU) TO A rater
,❑ Yes M No -
Willtheapplicantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) _ ISSUANCE DATE
which emit hazardous.kcmtamimntsas defined by the Bay Area Air' Q+' A ' D
Quality Management District? BOILER-COMP DHP OR 100,000 BTU).
RhYes nNo pier BOILER-COMP 'i
avereadthehazaousmaterialarequlremenrounderCha100,000BTn 9 A ���
r the California Health&Safety Code,Sections 25505,25533 and 25534.1 s AUGPI V T1f 4 2'
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. ,
responsibility to notity the occupant of the requirements which most be mot /sI I Y UI' V
prior to issuance of a Certificate of Occupancy. V Lit'•CI'Iyd�'t
Owner or aulhorlud agent Data ISSUED BY:�/�/
TOTAL:
OFFICE COPY '