24388APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
N2
BuOdfi Address: C
CT,
4 3 8 8
wrens
4—rT,?s M
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
D_� T __CJ•
J C
Contractors Nairn: _ Llc. No:
h
BUMDINGELECnUCALPLUMBINC-MECHANICAL
CATEGORY CONTROL p
Archtect/Engineer. - Lk. No:
On ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑
PERMI7755UANCE
ED CONTRACTOR'S DECLARATION
Lm,
that
IhthSy .( 70 that Mm ticemand W.3.funderp ..nde=(Cha.. (acumen
InenseI Infull force and a ffeon3ottheBuYnessand ProleeilomCode, and my
license is in s torte and effect.
Ld.pK/Date
APPLIANCFSRESIDENIIAL
JOB 7c ON
1
,
PANELS
DcenseCtss
G=ntrat=r
UP TO
-
201-1000AMPSAm
Ishall e u ed as pu RATION
understand my plan shall he used n public rcmrde.
OVER 1000 AMPS
SQ F7 FL R AREA
S/SQ FT
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
Awing aton.(Seatlam31.5,Btm, andCode: law(m the
(olloywhichon.(Betapeion 7 tw Bun calf Professionspmso le hnytty=r
muntywhich requboapetdtromratt, ilten improve, demoWh,orrepilr
anyst ure priortolts Issuance, also requ� the applicant for such Permit to
file a signed statement that he Is Banned rauent to the provisions of the
Contractors License law(Chaptcr 9(commencing with Section 7000) of Divi-
Yon3 ofthe Business and Pretensions Code) orthat he is exempt there(romand
SPECIAL CIRCUIT/MISC /
1
TEMP. MEITROR POLE INST. \.
POWER DEVICES I-`
� �I"� 1 p�
rat �f 9�
l . q�
LL Y �R l•
/'i i-� ■ l
gWldhgNG POOL ELECTRIC I
VALUATION
the bash forthe alleged exemption. Any violation o(Sectlon 70)15 by any
applicant for a permit subjecttheapplicamto a civil penalty a nes more than
OUTLETSSWITCHESFIXI'I1RE5
1
five relied dollars (SM.
I, as owner of the roe
property, ty, or employees with wags as there woe
X
NEWRESIDENTIALELECTR �'�''
STORIES
TYPE CONSTRUCTION
he
rKandthestrocie:Thecure, is intended for
uHor, wWdess
,
andathe
Business and Code'. The Clintons Limnsred
Law
sale (Sent
an
clocs whodotapplytorkhi nrorthmgtywho
appy to f property theme
ase nemplyee5,pv idedthry and
own�. d a ch
whodoements
OCC. GROUP
RES UNITS
am out dedoroughed
improvement amoutIntended oneyearoeredfaflon the cwevegthderwtIinga
If,hoee however, the build or
Improvement is sold within=neyearo(completiorytheownervbudderwlll have
TOTAL:
th,,,,knrden of proving that he did red bund or improve fee purpose of rule.).
" L as owner of the property, am exclusively contracting with Ilcensed
contractors to construct the project (Sec. 70K Business and Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
TheContractor'. Lt.. Law don not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such p(okm with a
cgRUactor(.) Bernard pursuant to the Contactor'. Lice. Law.
IJ I em exem t under lec. B& P C f r thin reason
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
-
SANITARY Y N_
RECEBT p
Owner AyD4946'1--ate
`WORKC M ATION DECLAR TION
❑I hereby affirm that I have a cetificite of consent to self -Insure, or a
mnifimteofWorken'Comper hmlw =mascertifiedcopythert f1534.
ME01Ub C.)
Policy M
FIXTURES PER TRAP
SCHOOL TAX Y_ N_
RECEIVE#
GAS PA. SYSTEM4 MCA OUTLETSpQ
PARK FEE Y_ N_
RECEIPT M
GAS EA. SYSTIId-OVER p (EA)
nm any
C[�CertNed
BUILDING DIVISION FEES
copy In hereby ttecity
❑ Certified copy t (filed with the city inspection division.GREASEANDUSTRL
WASTE INTERCEPTOR
PLANCIIECICFEE
IGREASE TRAP
CERTIFICATE OFEXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 20017.
COMPENSATION INSURANCE
(Thi.section need not be completed If the permit Is forom hundred dollar
Date Remi t#
WATER HEATER W/VENT/ELFLTR
ENERGY FEE Y N
•-
PAID
(S100)re len.) ce
I tlfy that In the Performance of the work (orwhich this permit is Issued,
I shall not employ any person In any manner so as to become subject to the
Workern'C=mpxm.txmlawsof Cah(=mt. Date
WATER SY5fEM/TREATING -
NOTECApplicant
APPLICAM: a aftermakingtole ationlote=(Exemption, you
NOTICE Weems,
sorely become subject to the Worker' pmv= of the Labor
Date Remi t#
NEW RESIDENTIAL PLMB. SQ.Fr
TOTAL:
such provbhu p
deamcdI meet forthwith amply with each provIslom ortht permit shall be
dMIMd RryOkGd.
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby a(firenthat there Is a construction lending agency for the performELEGTRICFEE
ance of the work for which thin permit t issued (Sec. 3097, Civ. C.)
Lender'. Name
Iandee.Addreu
1 modify that I have read thin application and &ate that the above Infornatlm
Is cones. I agree to comply with all city and county ordinances and Yate law.
TOTAL:
- -00
PLUMBING FEE
_ O
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building eonalruction, and hereby authorize representatives of thin
city to enter upon the above,mentlomd property for Inspection purposes.
Mr) agree to save, Indemnify an d keep harmless the City of Cupedlro
against B IUs,pdgment, roes and expenses which may In any way accrue
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (10 IO,OW CFM)
. SUBTOTAL:
wlext Clt .Ie consequence of ter Ing of this ppQnl
M4� /-r/
AIR HANDLE NG UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
(,s�Q,
SSrgw n�IJca / ort / Z at
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,0008'IU)
Date Remi t#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
I lealth and Safety Code Section 2S532(a)?
❑ Yes No
HEATING UNIT (OVER 100,000 BTU!)
TOTAL:
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
Will the applicant or(uture building occupant use equipment or devices
which emit hazardous air motamleant as defined by the Bay Area Are
Qi a Illy Ma ragement District?
❑❑ No
4havercadlhehavdous
PAID
HOMER -COMP OHP OR 100,000 BTUI
BOILER -COMP (OVER 100,000 BTU)
Y.materials requlrementunder Chapter 6.95of
'Is7s7L.
the California Health&Safety Code, Sections 25505, 25533 and 25534.1
u oderstand that if the building don not currently have a tenant, that It t my
�%9 100Q0Q
OCT 341+
NEWRESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior to Lssuana ofa Certificate of Occo pa ncy.
Cl l r yr GUrCt,I IIpV
ISSUED➢Y: C
Owner or authodu`d agent Datet
TOTAL:
OFFICE COPY