24389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project Identification PERMIT N24389 4 3 8 9
Building Address: Z
lok92 F� ;IrLI+
t-twPRTI
Name: � hone:
CITY OF CUPERTINO-BUILDING DIVISION
4.1
1� APPLICATION / PERMIT BUILDINC ELECTMCAL PLUMBINGMECHAMCAL CATEGORY CONTROL#
Lie.Nce
QTY ELECTRICPERMIT FEC BUILDING PERMIT INFO
Address: 0192 e PERMITISSUANCEICJ '
LICENSED CONTRACTOR'S ECIARATI N
I hereby affirm that[ase 0cmwd under provisions o(Chapter9(mmmenc
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith5 ion�of DiWslon3ofthe Businemand ProfnsionsCode,andm �c �,,� ��++
license is in full and effect. PANELS \�OE)7
L.
Limn Cor p
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMPS
pia reO Zp I understand my pians co
shall be used as public rerds - OVERIODOAMPS 9
y Y V Y n
k Licensed Professional SIGNSELECTRICAL C P U T
�<< Ot Ism exempt
the ComATION CPrjCIALCTRCUIT/MLSC
2 s,�'� Ihercby affirm tharlam exemptlromthe Contractor's License Law for the
p qqqq following reason.(Sectim 70315,Business and Professions Code:An ct r E
Fzf"u3 countywhich requlresa permit to camauct,alter,improve,demolish,ormpalr �' P.MECQ4ORPOLE INST.
°� 3 anystruclure priertolts Issuance,also mquimatheappBant forsuch permit to
r file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Owl Contnctora License law(Chapter9(mmmencing wilts Sea[Ion7000)ofDivl-
30S slon3 ofthe Busleassand ProfesraCode)orthat he is exempt lhercfromand SWIMMING POOL Fl.ECTRIC VALUA'Qa^!�
15 the basis for the alleged exemption. Any violation of Section 7031.5 by any
065
applicant fora permit subjects the applicant to a doll penalty of not more than UTLET'6.SWITCHESF FIXTURES V
five hundred dollars($S00). NEW RESIDENTIAL ELECTR FT.
E]1,as owner of the property,or my employees with wages as their sale SQ' STORIES TYPE CONSTRUCTION
e7a rompensatlon,will do the wor"nd the structure is not Intended or offered for
7 O elle(Sec.7044,Busineaaand Professions Code:The Contractors License Law
s� does not apply to an owner of property who build&or Improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not intended oroffered forsale.If,however,thebuilding or TO L (/
Improvement Issold within one yeacof completion,the owner-bullderwlll have
t rdenof proving that he did wt bund or Improve for purpose°fast..). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj E.as owner of the property,am exclusively contracting with licensed --f—
contractors
icensedPPRMIT ISSUANCE
contractors to m"ateact the project(Sec.7044,Business and Profrssbns Code:
The Contractor's License Law does nor apply to an owner of property whoALTER-DRAIN&VETO-WATER(EA)
bunds or improves thereon, ct
theren, and who contracts for such p(ojes with a FEE SUMMARY
o9ii4ador(s)limned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L-i I am exempt under Sec. B&P C for this reason FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
• Date RECEIPT p
WORKMAN COMPENSATION DECW0.ATION FIXTURES PER MAP 5CHOOLTAX Y N_
01 hereby affirm that I have a cernfiate,of consent to self-insure,or a RECEIPT N
380)00,
ceo(Workera Compensatlonlnsunnco ma certl(led ropythereof(Sec. GAFA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y N
,L.bLab CJ S
I'oliry N RECEDING DT p
Co CAS EA.SY97ChfOVFR 4(EA)
my BUILDING DIVISION FEES
ined ropy V herby(umbhed. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is flied with the tlty
Inspection diWelon.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Ff. Date Reeel ted
Rhlssecti°n nen,ata be complexed tithe permit V forow hundred dollen
(f1 mnifyss.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
thato the persounmofthework so as tobcopermitcis hsued, —
I shall not employ any person In any manner w as to become subject to the WATER SYST M/TREATING
Workcn'Cumpensatlon laws of California.Date PAID
ApplicantNEW RESIDENTIAL PLMB. SQ.FT.
Z Q NOTICbecome APPLICANT:If,afterthuddingpentationthin provisionef s
oft the
Date RCoeI IN
should become subject to the Warken'Compensatlon provisions ofthe Labor
TOTAL:
j= W Code,you at forthwith comply with such provlsiou mth a permit shall be
W > deemed revoked. BUILDING FEE
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEC
� Z ance of the workfor which this#sunk ia toned Tc.309],Civ.C.) T A : ��
V O lender's Name - PLUMBING FEE
LL t- Lendcr'&Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEENO—
OW I certifythall have readthls appllationand etaterhatthe above information
IL lacomed.1agree tocamply withal!cityand county ordinances and state laws PERMTTISSUANCE FEES PAID:
>. relati"gtobullding mmtmdion,and hereby aulhotlu reprcsentatWeso(rh]
1— 2citytoenterupon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
U _ (we)a to uve,indemnify an d keep harmless the City of Cupertino Date ReceiptM
sgainsa '% }.�dgments,coetsend ex mess which may In anyway&esus AIRHANDUNGUNTr(rOI0,000CFM) SUBTOTAL:
agzins s dCi in ronaarye of lh est lngofthlspermit.
PAnlING UNTT(OVER IQ0)0CFM) CONSTRUCTION TAX
Igna re #pliant omractor Date OD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC SURE
Will the applIant or future building occupant at eor handle ho"ardoua HEATING UNIT(TO 10),000 BM Date RCCCI tN
materhlasdefinedbythe Cupertiw MuNclpalC ,Chapter9.lZandthe
Fieahh and SafetyCade Sectio"25531(&)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑Yea N No
Will the applicant°rfuture building occupant u,e equipment or devises VEN'TLATIONFAN(SINGLERFSID) ISSUANCE DATE
which rout hazardous air contaminants a&defined by the Bay Area Air
• Qua lily Ma nageorent DieWct7 BOILER-COMP DEN OR 100,0(c BTU)
Ya 1'�No 11 a
have read the hazardous miderials requirements under Chapter 6.95 of BOILER-COMP(OV0100,000SM W
the Olifornla Ilealth&Safety Code,Sections 25505,25533 and 25534. I
understand that lithe building does not currently have a tenant.that It is my NEW RESIDENTIAL MEIN. SQ.Fr OCTaa y��I�
responsibility to notify the occupant of the requirements which must be reel b l D I�(y^I(•
prior to Issuance of a Certificate of Occupancy.
111
Owner or authorised agent Date GI�Y
SS ED BY:
OFFICE COPY