24215 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prv'ed Idemifkatlon PERMIT N2421 5
Qa4215
BuOding Address:
APPLICATION SUBMITTAL DA M
UD 13u� 13 �� .
are: one:
CITY OF CUPERTING-BUILDING DIVISION r �^`'1.e� M
Contrsdors Name: Lm.No: APPLICATION I PERMIT l
IIIc . BUILDINt ELE TRICALPLUMBING-MECHANICAL CATLGORY CONTROL N
ArchitM neer. k.Nce
/Engi
11 T QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: CAt� 0%MN PERMITISSUANCE ❑ ❑ ❑
LICF.NSED CONTRA OR'S DECLARA ION
I berebyaBlrm that l am licensed under provisions of Chapter9(c mmen APPI.IANC6RFSIDENIAL JOB DFSCRI ON
Ingwlth Sedion7000)afDWhlan3ofthe Bustnesaand Profs .nsC-ode,andmy
license Is In full ex' and d(M. PANELS V�'w
Lken Chea A Lk.N
Date Contractgr UP TO 0AMP5
ARCHITECkTI N
9O Zp I understand my plats shag records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
!i Licensed Professional' SIGNS ELECTRICAL
QQ OWNER-BUILDER DECLARATION
lye a SPECIALCIRCUIT/MISC
*7 ORP
Thereby...(hatlo731.5,Business
Camndore License Law fort he
following reason.iSection 7m15,Business and Profession,Code:My.p it
F f.§ TEMP METER OR POLE INST.
'
� aarntywhlrh rcquheapemNtbcomtnuct,alter,Improve,demolhh,orrepair
and
ystruure priortolts kaomorahorequiresthe appllnrtfor such perrdtto InW.ER DEVICES
flk a signed statement that he is licensed pursuant to the provisions of the
3 u.� Contradors License Law(Chapter9(commencing with Section 7000)of DM. SWIMMING
O sion 3 ofthe Bushes and ProfembwCode)orthat heh exemptthandromand VALUATION
O_ the basis for the alleged exemption. Any violation of Section 7031.5 by any OVILETSSWI ES I
CCCM^ccc appLuntforapemtsubjedstheapplkanttoadvilperoltydnatmorethan
five hundred doll.($SM. NEW RESID SQ TYPE CONSTRUCTION
Sf0 6
❑I,as owner of the e property,or my employewith wages as their sok
a compensation,wOldothework andthe structure is not Intended or offend for t
O sale(See 7096,Bushes,and Pcofenlans Code:The Contractors Llcerse Law DATE
$$ does net apply to an owner of property who Wilds or improve thereon,and .GROUP RFS.UNITS
whodoes suchwork himsel(orthrough hisownemployees,provided thatsuch
Mprovemenb are not intended oroffered fee sale.If,haweeep thebullding or TOTAL:
Improvement hsokl within oreyearof completion,the owner-builderwill have
t rden of proving that he,did not build or Improve for purpose o(sak.). QTY. PLUMBING PERMIT FEE
4 as courser of the property,am excludvety contract...with licensed _ FLOOD ZONE APN
PQ4MITISSUANCE
contrxctorstonstmct the project 7046,BusloenaM ProfessionsCode:
cc
The Contractor's License Lw does not apply to an owner of property who ALTER-DRAIN kVENT-WATER RN
Wilds or Improves thereon, and who contracts fee such p{o)em with a FEE SUMMARY
cqL cug(s)licensed pursuant to the Contractor's License Law. BACK FLOWPROTECT.DEVICE
LJ 1 am exempt under Sec. B Is P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑1 hereby affirm that 1 have a adifiau
te of consent to I-Inwm re, a RECEIPT N
certificate ofWorkeni Compernatlonlnsurmea ora mrtifled copy thence(LSec. GAS.EA.BYSIEM-1 INC.4 OUTLETS PARK FEE Y N
3800,Lb C. RECEIPT M
Pollry M GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Co������mppppppaaaa�nv nLDt=Aa 'aG
ertl(led copyh Fere y furnished. CREASE/INDUSTRI.WASTE INTERCEPTOR PLANCHECK FEE
CedNed ropy h filed with the dty W pMlon divlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS" GREASETRAP PAID `
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA pBF1• Date Remi t# J•LYJ
fThh section need rad becomplded Bthe permit hfor one hundred dollars
(SItO)or lens) WATER HEATER w/vENT/¢EcrR ENERCYFEE Y_ N_
7 certify that In the performance o(thework forwNch this permit is issued,
1 shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Lwsof C``ajj��l�II((-o�}m-k.Date PAID
Z Z licant-
NOI3CE TO APPLICANT:lf ft akingthh Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT• Date Remi t#
O should become aubj=ct to the Worken'Campewtlon provlslo�s of the Labor / r i1 TOTAL:
N Code,you mu at forthwith comply with such pmvlslens erthb permit shall be L !s BUILDING
ILI j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC ITE
CL c
Ihereby alRrm'r at them whichtharomtIs Issud(Sec. agency Cle. .) perform TOTAL: ELECTRIC FEE
0 Z anceotthe.Nwork(car which this perMtkleaned(Sec.3097,C1v.C.)
LL O Lender's Name PLUMBING FEE .atj
ly F Lenders ythatl QTY. MECHANICAL PERMIT ISE MECHANICAL FEE
O W Imect.I agrectvemply w ppgatlon and state tordina ccs and fomaaw
1 iscoing tobgreeto computio ,ith a ndhembyty and auhoebe representatives
and state lawe PERMIT ISSUANCE FEES PAID:
Y relying ter upont comUuction,andhereby property
ori inspection ntatWn o(lhh
F fD d (wto enteree to thea indemnify an d keepertrodestCitpurposes, ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date RCCCI t#
V against liabilities,Judgments,cos4endepeme which may lnanywayacuue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago lost said City In consequence of the gnntlng of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EYHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha Odle hazardous HEATING UNIT(TO IOLOD0 BTU) Date Recei t#
material as defined by the Cupertloo Municipal Code,Chapter 9.1 2,and the
Health and Safety Cade Se Ian 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ye o
Will theappllnntor tare building occupant use equipment or d evices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
• Quality Management D's d7 BOILER-COMP(3HPOR 100,(X0 BTU) T p B a�
4Yes Ir PSI ((J
havereadtheb r ouermteriabrequimmntsundePChapter6.95of BOILER-COMP(OVER100,000 BTU)
the California Healt ASsfety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDFNITAL MECH. SQ.FT OCT. 19akar
respomlbility,to notify the occupant of the requirements which must be met /AyC
P' I.Lssuanceo(aCeit exteolOmpanty. 224P
CITY Ur
nen or aulho adage Data ISSUEDBY: M-11
TOTAL:
OFFICE COPY