24121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldemlflcali. PERMIT NO
Building AddreQY r 241 21
G am
15 o P' e_-rr rA s 2'-92!51 CITY OF CUPERTINO-BUILDING DIVISION
contra or'.N.me: LIc,1: APPLICATION /PERMIT
-�� �Erl S IV ('V �pL(0491 BITILDINGELECTRICALPLIIMBINGMECHANICAL CATEGORY CONTROL#
act/Englneen Lic.N.
�7 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreas: 3�(� 1 woo r PERMITISSUANCE LU
LICENSED CONTRACTOR'S DECLARATION E Lp
I hercbyaffiren that l am Licensed under provisions of Chapter 9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Dlvidan3ofthe BusirmanandProfessionscods,and my
license Is in full force and effect n _,J�a PANELS
License Class LICK ItAoKsfl f - ,#�^Pa • '/•
DateContnctor UP TO 200 ANU'S
ARCHITECPS DECLARATION 201-IOW AMPS
Q O I understand my plane shall be used as public records. OVER IOW AMPS ^ SQ.FT.FLOOR ARA f/SQ.FT.
IN
E Licensed Pm(easianal SIGNS ELECTRICAL
11 I L S E D
OWNER-BUILDER DECLARATION
6 ,�\ f—• p1
fn]a SPECIAL CIRCUIT/M15C 1 IC�� �••s�
g t"G3 I herebya(Ormthatlam exempt/mm the Contraa[ore Lirenx Law(or the
qq (ollowingreason.deas.n7mIS,Bu.muotand,ftnp.n.Code:Anycityor ',,,✓
n countywhie rcqulresaperMIS,m 1irmse ralPbnprove, Code: h,y city r TESIRMFI'ERORPOLEINST.
`a X77a anyathmbem prior to its lsseance,91.0 requlreathe applicant for such permit to POWER D�� DATE
106 U file a algned statement that he b licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 70ns 00)of Dial- SWIMMING POOL ELECTRIC �' VALUATION
s,307 Mon 3 ofthe Business and PrefeasloCade)orthet he b exempt therefrom and
�'•33 the basis for the alleged exemption. Any violation of Section 7MI.5 by any
« applIcamfor.permit subjects the a pplleant too civil pens try of not more than OUTLETSSWITCHES-FIXTURES
Ove Fj1,as
rcwnerof the 00. NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑Las owner of the property,or my employers with wage a thele cola
compensation,will O dothe workand the s dure Intended oroffered for sole(Sec. y C
Business and Professions Code:Thehe Contractors License law
n
$ donet apply to an owner of property who build.or imprwn thereon,and OCC.GROUP RES.UNITS
who does such work Mmaelf Intendedorwgh his own e.If,ho eprovidedthat such ilding or
improvementsare no ithinone earofcd(orsale.ILh ner-g deer illh ve TOTAL:
Improvement baoW wlthinoneyearo(complNlorytheowner-buliderwlllhave
tittIserden of proving that he did not build or improve for purpose ofsale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
11 L as owner of the property,am exclusively mntraning with licensed
contnciors to construct the project(Sm 70K Business and Professions Code: PERMIT ISSUANCE �r _
The Contractor's License law does not apply to an owner of property who ALTER &VENT WATER[FA)
1 1
y
bullds or Impmvn thereon,and who contracts far such projecs - -twith a FEE SUMMARY
e �actor(O Ilanmd pursuant to the Contractor's Lt...I.. BACK FLOW PROT[CT.DEVICE
LJ I am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEE'T N
WORKMAN COMPENSATION DECLARATION FI%1.URE5 PER.IRAis �r SCHOOLTAX Y_ N
I hereby affirm that I have a certificate of consent to self-buss,,ora RECEIPT N
rertifrrste of Worker'Compereadon lnsunnnora ramified ropy therco (Sec. CAS EA. INC.60UTLE15 PAIU
3800,1.6 Cd C FEE Y N
Policy p GAS G.SYSTEM-0VER 6(FA) RECEIPT N
Com any BUILDING DI VI SION FE ISS
MCehifiedmpylafilM thtl dd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCedified copy la filed with the cityIns)>ectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XpFrl. Date Rec i t#
Uhis lesson need rad be completed If the permit V(ore hund
oored dollars
($1 W)orless) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertlfy that in the perfarmenreafthe work(arwMcA this permit le lased,
I-ball not employ any person In any manner eo as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation laws of Olifornla. Date PAID.
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z O NOTICETO APPLICANT.X.fier making this Certificate of Exemption,you
Hshould Femme subject to the Workers'Compensat ion provisions of the Labor TOTAL:
M > Code,You=at forthwith comply with such provisions or this permit shall be BUILDING FEE
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d IhenbyafRr Chat there U a construction lending agency for the perform-
7 Z ance oflheworkfarwhichELECTRIC FEE
lhis permit is Issued(See.3097,CIv.C.) ELECTRIC FEE
V O Lander'.Name
I LL Lando.Address QTY. MECHANICAL PERMIT PGE MECHANICAL FEE
OW
Iredify thatl have readthb appllratlonand state thattheabove Information
CL 1s carrctt.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorlu representatives ofthis
H Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
— (We)agree to cava Indemnify an of keep harBdess the City of Cupertino Date Receipt#
against liabilities,judgments,coatsand expenses which may In anywayacems AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said Cijty In mmryuenn of1he gra rating cf this permit.
2�_ ,(� 7 AIR HANDLING UNIT(OVER IO,ODO CFM) CONSTRUCTION TAX
Signature-AAppBcant/Contraacct`orTTatta EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA IALSDISCLOSURE
Will the applies at or future building occupant store or hand le hanNous HEATING UNIT(TO 100,ODO BM Date RCmi I#
material as defined by the Cupertino Mu nicipal Code,Chapter 9.12 and the
Healthand Safety Cade Sectur,25532(4)1 HEATING UNIT(OVER 100,000 BTU) TOT r
Yenr]No
Will the a ppllcant or furors building occupant uu equi pemat or device VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which chat havrdous air contaminants as defined by the Bay Area Air
0..Ioy Marugement Dotm,t? BOMFR-OMP(3HP OR 100,000 BTU)
Yea No
OW have read the haza ..materials requlrcments under Chapter 6.95 of BOILER-COMP(Ova too"BTU)
the California Health&Safety Code,Sections 75505,75533 and 25536.I V"
understand that tithebuildingthe occupant of t e rrcuivenoat.ntly have Lenarwench thatb mans my NEW RESIDENTIAL MECIi. SQ.FT
responsibility c of a notify occupant of iherequiremenb which must be reset q
prior to Issuance ola Ccrtifirele of Ocsvpanry. t
Owner orauthomard agent Date ISSUED BY: 1rs �T YP
TOTAL: —
OFFICE COPY