24368APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification
Building Address: �
ioktr► N, 6 `vv eV .7A� e A- so l LI
PERMITNQ 4 3 6 8
am : hon
—87;-8=Mj r
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
�O •- "�^ I'
—q
Contractor's Name: Lk. N.
BUDAING-MECTRICAUMUMB)NGMEC #CAL
CATEGORY CONTROL#
Archlteci/Fnglwer: Lk. No:
Q'IY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERh9TIS5UANCE ���
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
APPUANCFSRESIDENTIAL
Iheh Sactoirmthat laiv Bceneedhe under Hosdessand of Chapter9(mmmm
Buelnessand ProfeulonsCode, and my
inrose Is Infos force and
LI.. Is la fou sores ane erred.
D.te Class C.rtr
Date Contractor
IQ#DFSCRIP]ION
PP i��''�/'�-�"]��
4 y
T' �I''��a Ld
L-ft.3`I♦
PANELS
ARCHITBCTSDECLARATION
]understand my plan shall be used vpublicrccoede.
AM
M14OVERT
M , �Y
OVER 1000 AMPS
SQ. FT. FLOOR AREA
E/SQ. FT.
SIGNS ELECTRICAL
Licensed IR.femlovl
OWNER -BUILDER DECLARATION
I hembyafRrm that I am exempt from the Contraciorb License Law for the
following reason. (Section 7031 S, Business and Professions Code: Any city or�s
countywhlch requires a permit tocotm
vct, alter, Improve, demolish, orrcpair
mystmeture pri.rto its beuance,aborequiers theapplicant forsuch permit toppWpR
file a signed statement that he b licensed pursuant to the provisions of the
Contmourb License Law (Chapter 9(ex.rclog with Section 7000) of Divi.
Sion 3 ofthe Business and Plamaov Code) or that he b exempt therefromarW
the bash for the alleged exemption. Any violation .f Section 7031S by any
appVcant fora permit subjects theappllcant to a civil penslty of not more than
nae ndred delta. CE500).
as owner of the property, or my employees with wages as their sole
m neatmr, will do the work and the structure is not intended or offered for
le(Sec. 7094, Business and Professions Code: The Contractols License Law
does not apply to an owner of property who Wilds or Improve therms,and
who does such work himselforthrough his own employee, provided that such
Improvements arc not Intended oroffend for sale. I( however, the build Ing w
Improvement Is mid within oneyearofcompletion, the owner-budderwill have
tl)L.Ilurden of Proving that he did net build or improve for purpose of sale.).
u I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and professions Code:
The Contractor's Licanse Law doe not apply to an owner of property who
builds or Imrove pthmcornets me, and who nets ffor-uch ptojeds with a
ccpWdor(s) Beenwd pursuant to the Costnctnr's License Law.
Lf I am exempt under Sec B & P C for this reams
IN w
�.
SPECIALCIRCIRT/M15C
TEMP. METERORPOLEINST. /
DEVICES
SWIMMING NOL ELECTRIC
(� /n L n Vp 770
a xv Y/ y
'XL
VER
OUTLEISSWITCHESFIXTURFS
NEW RFSIDEN7IAL ELFCTR SQ,ET. p
STOW ES `TYPE CONSTRUCTION
j
OCC. GROUT' RES. AMTS
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALS(-DRAIN & VENT WATF
A (EA)
pLOpOWNE APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FEES
Owner Date
DRAINS FLOOR ROOF, AREA, CUN
FIXTURES PER TRAP
SANITARY Y— ND. RECEIPT#
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that I have certificate or consent to
SCHOOLTAX Y N—
o
caDO,lAbofWorken'Compensalionlnsunncaoracerti(hd copythereof (Sec.
opytheure, (S .
' Polk IAS C.I
Policy #
RECERT #
GAS- FA. SYSTEM -1 INI OUTLETS
PARK FEE Y N
RECEBT #
Com any
Certified copy b herebyth the city
Certified copy b (liod with the city W)aMion division.
GAS EA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION NSURANCE
INSURANCE
(Thisudlonneed cadWNSATI NIfthe permit b(Erose hundreddollen
PAID
Date Re i t#
SEWER -SANITARY -STORM EA IWEI.
(5100)wless.)
eemdtbblued,
Icenet employ any ersonI any e of wwkso as to become
1 shall net employ any perms In any manner m e to become subject to the WorkeWATER
Applicant CompemLaws a o(GII(ornb. Date
Applicannt
NOTICEAPPLICANT: after king this Certnlprenionsothe you
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
pAlp
Date Rocef t#
SYS'TCM/TREATING
NEW RFSIDENTIALPLMB. e•'�•FT•
co CompevaHonprovbiovmthe allbe
Code,shoulbecome subjectto the ply with
Code, you must forthwith comply with such proWlons orthb permit shall be
deem# revoked.
TOTAL:
BU
TOTAL:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there he a construction lending agency for the perform-
ante of the work for which this permit is bored (Sec. 309], Civ. C.)
1<ndees Name
Lender's Address
I certify that l%ve mad this application d-oatetheth¢above in(ormatlon
SEISMIC FEE
ELECTRIC FEE ��
QTY• MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FBG
bcorred. I agree to comply with all city and countyerdinarces and state laws
relating to building constrodion, and hereby authorize representative of this
city to enter upon the above-meatlowd propertyfwivpectionpurpwea,
(We) agree to uve, Indemnlly an d keep harMess the City of Cupertino
against liabilities, judgments, mets and expenses which may In anywayamue
against said City in =sequence of the granting of this permit.
PFRMITISSUANCE
FEES PAID:
Date Recei t#
ALTERORADDTOMFCH.
AIR HANDLING UNIT (T010,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of AppBcam/Contractor Date
IXIIAUSTIIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (10 103,OD0 BM
Wiiltheappli torfuwm Wildingo pantstorcorhandlehazardous
material as dcfi nod by the Cupertino Me Ndpal Code, Chapter 9.12, and the
H¢althand Safety Code�+. -S�ection25532(a)?
❑ Yes u No
Date ReceI t#
HEATING UNIT (OVER 100,000 BTU)
TOT ��
VENTILATION FAN tSINGLE RESID)
ISSUANCE DATE
Rp A e (/Y�
P 'A
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminsnts as defined by the Bay Area Air
Quality Management District?
Ye. nn No
BORER -COMP OHP OR 100,DM BTU)
BOILER -COMP (OVER 10Q000BN)
have read the hazQ us materials req. Inernanb under Chapter 6.95 of
the CaiBornla Health & Safety Code, Sections 25505, M533 and 25534. I
understand that if the building does not coreand haveatenant, that it is my
responsibility notify the c n Tips req meets which must be met
'r issuance of fi a mpan
!G
B IW
OCT
19
^/lYAFAI
V Ur c ,�tK ,f
ISSUED BY:
NEW RESIDENTIAL MII SQ.FT.
er m authorised agent to
TOTAL
OFFICE COPY