24214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT N2421 4
Qe4214
Building Address:
u�a
wnere ams: qty one: A
01-0-- 408 1 /�0 � CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lic N. APPLICATION I PERMIT
BUILDINGS.ECTRICALPLUMBINC.MECEIAMCAL CATFSfORY CONTROL M
'Architect/Engineer. Lb.No:
` .,1 QTY ELECTR/CPERMIT FEE BUILDING PERMIT INFO
rc
Addu Q C �swK PERhBTIS5TIANCE ❑ ❑ ® ❑
LICENSED CONTRACTOR' DECLARATION] 2!,
Ihth Sb on7OOO)ofDi lm3othe Busimmand Pm Chapter4jcemrdnc APPI]ANCESRESIDENTUL JOB DESCRIPTION.
Ingwlth SeMon7000)ef DiNslon3 ofthe0usimssend ProfealoneC�Qe,and rtry '
license le In Mlform and died. p c r PANELS ���Q
License Chss Llc.x .24 44 1 C L
Data Contndor
ARcxITE Ec 1
r
X14"AMPS
pkp�vv otO ZpC Iundemm�d my pisco shag be usedn cremnla OVER 1000 AMPS - SQ.FT.FLOOR AREA f/SQ.FT.
k o U Licensed Professional SIGNSELECTRICAL
<<�g OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
'ZE. 7? Ihercbya(0rm that l am exempt from the Contractor's License Law lm the
ppp following reason.(Section 7031.5,Business and Profassiom Code:My city or
F1"ry coon:ywhlchrequU apemdttommtmd,alter,impmwdemolbh,orrcpalr TEMP.METER R INS(.
qBI 3 anystmu mprbrtolb Wuance,alwrcquimtheapplicaniforauchper tto ,I
� R DEVICES
I
P�rYG file a signed statement that he]s gnaed pursuant to the Provisions;of the
mns
30� Commerce.Llcerselaw(Chapmr9(mmmencingwlth Section 7000).(Divi- SWIMAUNG POOL ECTRIC ,
Mon3ofthe Butlnessand Professlmet Coote)artid hats exempttherefmmand ^ VALUATION
he basis for the alleged exemption. Any violation of Section 70115 by any ° K
applIantfora permit subjecbthe applicant to a civil penalty of not more than OUTLETSSWITCHFSFTKIIIRFS
leand dollar(fA0), NEW RESID AL FTWE GGGIII �n ❑I,..td es owner
of the property,or my employ.with wages as their sole �2 SIO1B' TYPE CONSTRUCTION
compensation,will do the work,and the structure Is not intended or offered for �..
O sa ie(Sec.7041,Business and Pro(esslom Code:The Contractor's Llarue Law
$ docs not apply to an owner of property who build,or improves thereon,and •
E, whodoes such.,it himself or through his..employees,provided that such OCC.GROUP RES UNITS
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is add within oneyearofcompletion,the Owner-builderwlll have
tllILliurdan of proving that he did na build or improve for purpose of ole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed
contractors to consumer:the Project(See.7044,Business and Prolessloru Cade: PERMITISSUANCE
The Contractor's License Law don not apply to an owner of pmperty who ALTER-DRAIN k VENT-WATER(M)
bulbs or improves thereon, -
n,and who contracts for such plojects with• FEE SUMMARY
cgnjTad.(.)licensed pursuant to the Commetms License Law. BACK FLOW PROTECT.DEVICE
lJ I am exempt under Bee B k P C for thio rcawn
OUTSIDE Mpg
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Dat RECEIPT 0
1 WORKMANC MPENSATIONDECLARATION _
[]I hereby of iren that I have a certificate of consent to self-insureFIXTURE� SCHOOLTAX Y_ N
,or RSC®N
certlflate of Workers'Compematlonlmunnce ora certl(kd mpythereof f9ec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y_ N
3800,[ab CJ RECEIPT#
Pollry tl 13 I a 9 GAS EA.SYSTEM-OVER/(M)
Co BU IL13INC DI VISION FE ES
Certilled mpybhere (umished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F.�eniBed copy Is filed with the city Wpection divlelon.
r" CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TMP PAID
COMPENSATION INSURANCE
(TSEWER-SANITARY-STORM#2MPI' Date RecciEA# S
Ms session need na becampleted tithe pertNt m(Prom hundred dollen
(f1less.)
larti WATER HEATER W/VENT/FIFCTR ENERGY FEE Y N
Icertlly[hat lathe par(ornunce of the work forwhich this penult ie 4sued,
I shall not employ any person in any manner an as to became subject to the
WATER SYSTEM/TREATING
Wwkers'Compenutlon lawny( la.Date PAID
OZ Applicant A// NEW RESIDENTIAL PLMB. SQFT. Date Recei tN
Z O NOTICETO APPL%Jz If;a =klug this C.Aillote of Exemption,you
Amid became subject to the Workers'Compensation provislom ofthe Labor /� TOTAL:
N Code,you must forthwith comply with such provision orthis permit shall be Zia B NG
FEE
LU `Jcc — deened revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby orkfowhic rcls,comtmsslonlendingd(Sm agency Civ. .) pedorrry TOTAL ELECTRIC FEE
0 O an.o(the work for which this permit is Issued(Bee 3097,Civ.C.)
(� Lender's Name PLUMBING FEEU. tQd
F Lendcrb Address QTY. MECHANICAL PERMIT FEE
O W Icert(fythatl haverc lh appbatbnanddatethatmeabovelnfomvtlon MECHANICAL FEE
S incorrect.Iagreetocomply ilhallcityandmun,or din ancnandstamlaws PERMIT ISSUANCE FEES PAID:
7. W relating to holding construction,and hereby authortee representatives ofthb
F.. Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO METH. Date Reeci tN
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,j dgmentgcosmand expenses which may lnanywayaceme AIR HANDLING UNIT(TO 10,(100 CFM) SUBTOTAL:
ago int said City In comequee or of the granting of this permit.
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signature of Apphom/Cmtndor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ear future building occupant store or land Is haaarduus HEATING UNIT(TO t Ot BTU) Date RCCeI IF
memrlal as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety CotfeSyetion,25532(a)7 HEATING UNIT(OVER IDO,000 BTI) TOTAL: .�
❑ Yes No
Wllltheappliad Mturc building occupant use equipment or devices VEMILATION FAN(SINGLE REBID) ISSUANCE DATE
ivhichemltharavlousair tandmnm as defined by the Bay Area Air
Quality Mamgcment Ls _? BOILER-COMPOHPOR100,OWBTM PAI D
Yen
have read lheh oils materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the CaliloraMElealth Safety Code,Sections 25505,25533 and 25534.1 OCT _ �v9(]9(]� .
understand that if the building does not currently have a tenant,that it is my NEW RESI DENTIAL METH. b SQFT
responsibility to notify the occupant of the requirements which most be mat
pri Issuance ofa Certi(lote of Ocmpancy. Crry U� UUYL.In
net or au or d eat Data ISSUED BY:
TOTAL:
OFFICE COPY