24369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Add res- T 24369
p
wne a arca: onm xx
A
tt AJ K 0 T = 05-3-6634 CITY OF CUPERTINO•BUILDING DIVISION
Lic.No: APPLICATION I PERMIT t 1 —(5o'5.0/ f BUfLDINC-ELECnUCALPLUMBINC-MEGFIAMCAL CALORY CONTROL Y
Architect/Fagmed; Lk.No:
xxxxxx
�����_//t3 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrc 4 V"t-U L -L - ❑ ❑ ❑
PERMIT ISSUANCE
LICENSEDCONTRACTOR'SDECLARA ION
I hereby affirm that l son licensed under provisions ofChapterg(ormumme APPUANCES-RESIDENTIAL JOBDESCRWnON
In8w1th,%di..7000)of DlWsion3ofthe Businesand Profo onaCode,andm
license l.In'fuB feroe and effect. PANELS _
License,,)n Coru (� / � •I
Date/p2- C HIZC r DEG � /- P
ARCHITECTS DECLARATION ✓J 701-1OW AMPS '
r�O Z l understand my plan ehali be used u puble remrda. OVER 1000 AMPg SQ.Fr.FLOOR AREA 5/SQ.FT.
E<P LlrensM Pmfembvl SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION
zIherebyafBmrtla[I.exempt from the Contrador'sLicense Law for the SPECIAL CBRCUIT/MISC
O following mum.(Section 7031.5,Buslnes and Professions Code:Any qty or
countywhich requlresa pereuttomvtrun,alter,Improve,demollsh,orrepalr TEMP.METER OR POLE INST.
anyet.ctureptlortoltslsmance,alsorequreslheappllantf¢suchpermltta
file a signed statement that he is licensed pursuant to the provide.of the POWER DEVICES
3µ Connector'eW¢nse Law(Chapter 9(commencing with Section 7000)of Divi- SWIMM(NGPOOLELECTRIC
H 15 um 3 ofthe Bualneu and Profemb.Code)ortho he is exempt therefrom and VALUATION
the basis for the alleged exemption. Amy violation of Section 713315 by any Ol1iLE.ISSWI.ICf1FSF7%,I,URES
appBcant or
penmt subjects the applicant to a civil penalty of not more than
five hundred dollen($500). NEW RESIDENTIAL ELECIR
QQQ j1,as ow.r of the property,or my employes with wages u their sole _sQj r. STORIES TYPE CONSTRIKTION
mmpenutim,wBldothe worked the.,m=m b rot intended or offend for
O sieCSee 7061,Business and Profetalms Code:The Contractors Llrenu law
dos not apply to—owner of property who Wilds or lmprons thereon,and
whodossuchwork himaelfor through his own employees,provided that such CZC.GROUP RFSUNrM
Improvements am nut intended proffered forule.If,however,the building or TOTAL:
Improvement is sold within oneysarofcompletbM the owner-bullderwlll have
tlXJZurdm of proving that he did net Wild or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
u L as to of the property,am exclusively contracting with limned FLOOD ZONE APN
contncters to cons4uct the Project(S.7064,Business and Pretenders Code: l PERMIT ISSUANCE Sod
The Cmmemr's License law dm net apply to an owner of property who
WO.or Improve thereon,and who comraua for such penjecu with a ALTER-DRAIN&VENT-WATER BRA)
cgRt ad-ns)
Ilomeed pursuant to the Contractors License Law. FEE SUMMARY
IJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE QT TTul run P
net Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPL'NSATION DECLARATION RECEPT#
I hereby affirm that I have a certificate of consent to self-inw¢,or a FLYTURFS PER TRAP rl D,V SC1100L TA% Y_ N
'late efWorkers Compewtlonlnsunn¢oraartlfkd ropy thereof(Sm. •J RECEIPT if
38W LabC) GAS EA.SYSTEM.i INCAOUD.ETS PARK FTE Y N
Pollga Yom.!( 2" aZ RECEIPT a
GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
"A
Certified copy Is a th the
he ed.city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertBled ropy V filed with lh<city inspection dlvlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
TThissectlonneed not becompleted Bthe permit bforose hundreddollan SEWER.SANITARY-STORM EA.70*7. Date Recel 1#
(5100)or les.)
I comythat in the performance ofthework forwhlch this permit is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I shall not employ any person In any manner so u to become subject to the
Worken'Compenutlonlaws of California.Date WATER SYSTIM/TREATING PAID
O z Applicant
Z G NOTICETOAPPLICANI:I,after making thio Certl(kate of Exemptlory you NEW RESIDENTIAL PLMB. SQJ-7 Date Re i t#
shmld become sub}at to the Workers'Compe.atbn provhio.of the Labor TOTAL:
LUN Code,you mustforthwith mmplywithauchpmWimuorthbpem it allbe
> deemed revoked,
d (] CONSTRUCTION LENDING AGENCY — BUILDING FEE
SEISMIC FEE
Iherebyafflrmtrwich then thiam.t.ctlonlending agency for d(Sec.397,Civ.Cj perform- ELECTRIC FEE
n Z anre of the work(orwhich this perMlb blued(Sec.3097,CIv.CJ TOTAL:
02 to°der.No. PLUMBING FEE r0
LL F Lenders Adre
dss QTY. MECHANICAL PERMIT FEE IMECHANICAL FEE
O W ¢rtBythatlhaveresdthisappBatbnand siatethattheaWve informa0on
fl incorrect.l agracto comply with all city and county ordinances and state lawn PERMTr ISSUANCE FEES PAID:
>. N relating to building comt.ction,and hereby authorize representatives of this
F— Z city to enter upon the above-mentioned property for Inspection purposes. AL1E60RADDTOMECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupert Ino Date Reeei t#
against liabilities,Pcigments,Cost...d expense which may In anyway am.e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.gala Id City 1 rase en¢of the granting of this permit.
AIR HANDLING UNIT(OVER f0,0D0CFM) CONSTRUCTION TAX
Ig..reof Appllanf/Contmeme Data EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE fh Fi?_ -OJT
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM _
nuteriafas defined by the Cupertino Municipal Code,Chapter 9.IZ and the Date Reeel t#
Health and Safety Code Section 25532b 000)7 HEATING UNIT 100, BM
TOTAL: S•�
❑Yes r]No'
Willtheeppllom orfuwro Wllding.p.m.seaquipment ordrAcoa VEMIIATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanedous air rontami.rata as defined by the Bay Area Air pp�� pp
Quality Management Dided? BOILER-COMP OHP OR 100,000 BM P FA
❑Yea n No
7have read the It..9o.materials requirements under Cha pier 6.95 of BOILER-COMP(OVER 1 Og000 BTU) ��
the California Health&Safety Code,Sen ions 75505,25533 and 25534.1 DEC 1992
understand that if the Wlldingdcea not currently have a tenant that it b my NEWRESIDENTIALMECH. SQ.FT
mpo.ibllltyw notify the ocmpa rat of the requirements which must be mat
prior to Issuance of a Certificate of Om pa ney. CI 11 Ur CUMFll umv
Owner or authorized agent Data ISSUED BY: Y' e_
TOTAL:
OFFICE COPY