24257 APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prv'ca Identification - PELWTN24257
, 4 2 5 7
Building Address: Z
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rnem:
V L� r bonen s A
CITY OF CUPERTINC BUILDING DIVISION q
c naso Mame: Lie.No: APPLICATION I PERMIT — 2
O �s v BUILDINr- LE RICAT.MUMBINGM FC NICAL CA CATEGORY CONTROL9
A tea/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
' Address:
-
LICENSED CONTRACTOR'S DECLARATION PERhIITISSUANCE El 1:1 ❑
I hereby oirmthatlaiv Bconwd under eBuW mandP fChapter9de,and c APP11ANCESRESIDENffAL JOB DFSCKE'IION
Ingwllh Sete d1fQr)a ddfeon3ofthe^B7usl7neCu-a-nfd1Pro(esalonsCode,and my
License(Cls fu8 rc�andLle.N / J V "7 r PANELS$in (�
Date an
47- Contracter LIP TO 200AMPq
W
ARCHITECTS DECLARATION 201-1000 AMPS
gg ZpClundemtandmyplanashaBbeueedaspublicremrds. OVERIOBBAMPS SQ.FF.FLOOR AREA $/SQ.FT.
E�tj Licensed Professional SIGNS ELECTRICAL rx nm
WG�6 E OWNER-BUILDER DECLARATION SPECIALCERCUIT/MIST / \' '"!
owing rasormthaton 7031 ,8 from theossa Contractors Codcicense Law fort he U
Zq following reason. i alanr WtwB is Business Professions Code:Mycity it 1
62-[y c°untywhich requirnapermit to constroa,alter,bnprove,demolish,orrepalr TEMP.METER CREOLE INS?.
7 anystma mprlortoltsbwance,alwmquimatheappllcantforsuchperMttmo J
ruE file a signed statement id
t that he ls licensed pursuant to the provers of the POWER DEVICES
O�fn Contractor's License Lan,(Chapmr9(co.enting with5ection 9000)of OfvI-
DA
Non 3 of the Be°
usinsand ProfenlonsCode)or that he ls exempt therefrom and SWIMMING IDOL ELECTRIC A �q
the basis for the alleged exemption. Any violation of Section 90315 by any Q V
G applicant mra permit subjects the applicant to a civil penalty of not rrorc than OUTLETSSWITCHESFIX7URES co -VV
dre
eve 1,as
nerofthepr. NEW RESIDENTIAL ELECTR SQ.1rr. STORIFS TYPE CONSTRUCTION
�n ❑I,as owner of the property,or he employees with wages their dole
compensation,will Buss e s ahe work des m atr odure Isnot Intended or coffered for
O sale(Sec.7044,Business and Profeislors Code:The Contraaole License Law
S$'Q does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP° RES.UNITS
whodoessuchworklumaeiforthrough hisewnempioyees,providecithatsuch
Improvements arenot Intended oroffered for sale.If,however thebulldingor TOTAL:
Improvement®sold within.neyearofcompletlog the owner-W Bderwill have
t ` krden of proving that he did not build orimprove forpurposeoale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
..trade.to construct the project(Sec.9044,Business and Professions Code:
The Commetor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER
Wilds or improved thereon,and who contracts for such pWjeaa with a MAI
cgnt{actor(c)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Dare RECEIPT It
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o [esu ate of consent to opytherso ora RECEE'1.N
3800,1.eofWorken'Compensatlonlnsurantt orattrti(kd ropythereot(Sec. GAS EA.SYSTEM-1 INCAOUTLETS
3800,Lab C.I PARK FEE Y— N—
Policy q RECEDING Df N
Com any CAS EA.SYSTEM-0VERd(FA) BUILDING DIVISION FEES
❑pC.hiied copy ls herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Gartered copy V filed with the sty Inspection division.
CERTIFICATE OF h](EMPEION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 200FT Date Recef t#
(Thlsloss.) need notbe completedi(the permit ls(Drone hundred dollars
($1 Immless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Imrtify that In thep;=ntt the work torwhich this permit is issued, —
I shall nme mploy any racoon In t4,manner so a to WATER SYSI.FA7/.I.RFA.I.ING PAID
Workem'Gontp nsulem Laws a]Iternla. DaOa-D
Q Z App�lcadt NEW RESIDENTIALPLMB. SQFT. Date Recei t#
Z Q NOTICE�T PLICANT: aft r.kriog this CertlficateofF creption,you
sheuld become subject to the Workers'Compensation provisions of the Labor TOTAL:
= �) Code,you mu at forthwith comply with such Provisoes or this permit hallM
LU > deemed revoked. FEE
BUILD NG O CONSTRUCTION'LENDING AGENCY SEISMIC FEE T
Iherebyafflrmthat there is a commaction lending agency forthe perform, TOTAL: ELECTRIC FEE
M O ante of the work!or which this permit is issued(Sec.3097,Civ.C.) -
U _ Lender's Name PLUMBING FEE
LL H Lender's Address QTY. MECHANICAL PERMIT FEE . MECHANICAL FEB
O W 1orrtity that have read this application and Nate that the above Information
1 lsmurea.lagreetocomplywithallcityand county ordinances and Nate laws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and hereby auHifiHzd�mpreaentativea ofthls
H Z citymenteruponthe above-mentb`ned property Porins cion purposes. ALTER OR ADD TO MECH. Date ROfeip[#
_ (We)agree to save,Ind hinny an d keep harmieas t e City of Cupedlno
againsthabllitles,pdgme ts,co&sandexpenseswhlch� ylnanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL'
aga Inst said Clty in cones mnceofthegranting ftht rout.
C AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
S reef AppRat ontraaor Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
H RDOUS MATERIALS DISCLOSURE -
Wllltheapplicantorfuturebuilding occupantstoreorhand iehazardous HEATING UNIT(TD 100,000 BTU) Date Recei [#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand Safrty Codion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea No
Will the applicant future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS A TE
which emit hazardous air contaminants as defined by the Bay Area Air
.� Qu a llty Management Di�sAtract? BOILER-COMP DHP OR 100,000 BTU) .
Y" ®1V�r.".° 2 3 1992
have read thehazarpous materials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) SEP
the California Health&Sat"Code,Sections Z505,25533 and 25534. I
understand that lithe buedfng does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT CIIY Ur lrurrriI h4u
responsibilitytonotifytgeoccupantofAh.xe irementawhichmustbemet
.prlortolssuarmofa 'rtlf at Occupancy.
(3 i-� q �? "C 7
Owner or authorise a nt Data
TOTAL: ISSUED BV:
OFFICE COPY