24328 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _USE BALL POINT PEN ONLY
Building Project Identification - - PERMITNO.
Bueding Address: 24328
/ 0 -C 1 CA V
nera ame. hone: p
'TOS67 l4,voi C 733 -6z3 CITY OF CUPERTINOLBUILDING DIVISION s Z
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Com
red.ra Name: Lie.No: APPLICATION /.PERMIT ,
Gn "1 S l Z-
I 6YO O BUILDINC-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that Iam licensed under provisions of Chapter 9(commenc. APPLIANCESRESIDEMMI, )OB DESCRIrl'[ON
ing with Sinton 7000)of Dlvfect. ftheBusineaand lProfesslontCode,and my `
Ltenseisinsc and effect. PANELS ID UP TO 200 AjMS ^
License Class�(�L4.# �a N04a)/ �P-Q
Dale Contractor/V,yl�ti' 201-1000AMPS
ARCHITECTS DECLARATION
o
lz Iunderstand my plans shall be used as public records..- OVER1000AMPS - SQ.Ff.FLOOR AREA '$/SQ.FT..
Licensed Professional SIGNS ELECTRICAL �, ® '
6 OWNER-BUILDER DECLARATION
I"n 3 SPECIAL CIRCUIT/MLSC �, PUT E
Xs, [hereby a((Irtn that[ism exempt(romthe Contradorb Llrense Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
Ft- C TEMP.METER ORPOLE[NBT.
� ountywhich require,,permitle core[run,alter,improve,demol4h,orrepair
g anystrodom priori.Its aam.n,.4orequlrestheappllcant forsuch perMtto POWERDEVICES
t5 O file a signed statement that he is licensed pursuant to the prevalent of the IE lJ
Q6 µ Contractor's License Law(Chapter 9(commencing with Section 7000)of DintDN
-
�0 gon3 ofthe Businessand I'mfessioreCode)mthat he is exempt therefromand SWIMMING IDOL ELECTRIC VALUATION
,the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500).
E]L as owner of the pmperty,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFT, STORIES TYPE CONSTRLCTION
compensatlon,willdothe work,and thestmdure 4 entimanded or offered for
p sale(Sec.7044,Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
who does suchwork himself orthrough his own employees,provided that such
Improvements are not intended oroffered forsale.If,however,thebulldinger TOTAL-
Improvement issold
OTAL:Improvement,sold withinoneyearofcompletion,the owner-builderwill have
tl(9�urden of proving that he did nor build or Improve for purpose of sale.). (TTY. PLUMBING PERMIT FEE_ FLOOD ZONE APN
u I,as.caner of the property,am exclusively Contracting with licensed -
cemr.cmto cometnact the project(Sec.7654 Business and Professions Code: PERMIT ISSUANCE AA
The Contactors License Law does not apply to an owner of property who --- ALTER-DRAIN k VENT-.WATER(ENIrY
Wild, or Improves thereon, and who Contacts for such p(ojects with a
<q➢tfador(0 licensed pursuant to the Contractor.License Law. FEE SUMMARY
L�I am exempt under See. ffl B h P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION affirm FIXTURES-PER TRAP �j QxC SCHOOLTAX Y N_
QI hereby arm that I have•certificate of consent to,elf-insure,or a RECEIPT#
cemficate of Works.'Compevrtlonlrourned,or a Certified copy thereof(See.
3800,Lab C3' GAS-GAEA.SYSIEN-11NG4 OUTLETS PARK FEE Y N
Policy# GAS EA.SYSTEM-OVER 4(EA) RECEIPT#
Co any BUILDING DIVISION FEES
MCCAlfied copy a heed with he City CREASE/INDUST'RL WASTE INTERCEPTOR PLANCHECKFEE
ffMlfled copy I.flied with the City inspection divlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANrTARY-STORM EA 2001T Date Recei t#
(Ih4 sess.) need notbe completed-(the permit 4(or ane hundred dollam
($100)mftifyss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
[certify thatln the performanceI.any
wok f.rwhibecomepermit jectIssued,the N—
I ork not employ any person In any manner ao as to become subject to the WATER SYSTEM/TREATING
Worker Compensation Laws of California.Date � - PAID
'
ZZ Applicant NEW RESIDENTIAL PL.MB. SQ}7. Date Recei t#
O NOTICE TO APPLICANT:[,after making this Certificate of Exemption,you
should become subject to the Worker Compeaation provisions of the Labor - TOTAL:
M Code,you mu at forthwith comply with such provLslore orth4 permit shall be BUILDING E
> deemed revoked.
III G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirm 4
that there 4 a Construction lending agency forthe perform, SQ ELEC'T'RIC FEE
Z ance of the workfor which this permit 4sued(Sce.3097,Civ.Q TOTAL:
V Q Lender.Name PLUMBING FEE .Q
LL F Lender'apddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcertBythatl have read th45pp11rallonand state that Nfornutlan
IL acorred.I agrerea comply with all city and muntymclina ed,and nate laws PERMIT ISSUANCE FEES PAID:
N relating to building Construction,and hereby autho ,a,repreaenlallves of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDED MECH. Dale Recti t#
V — (We)agree to ave,Indemnify an d keep harmless the Cityof Cupertino
against habiluies,judgments,.9...d expenses which may in any way accrue AIR HANDLING UNIT(TO I0,"CFM) SUBTOTAL' -Q
against said City In consequence of the granting of this permit
�jy///-,yea_ uJ AIR I;ANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signa/N �fApplic nt/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS) IALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recti f#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the ^a
Health and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: / �0
r-1Yea ,La_�,No
Will theappilant orfuture building ocapantmeequipment mdevice, VENTLATTON FAN(SINGLE RESID) ISSUANCE DATE
which emit hateardous air contaminants as defined by the Bay Area Air
• Qu lily Management D4Md7 BOILER-COMP QHPOR 100,000 BTU) y� ik Pi f D
❑Yes MTL�1I No r
[have read the haza Tous materials requirements underChapter6,95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Section 25505,25533 and 25534.1 12 1992
understand that if the building does not currently have a tenant,that It a my NEWRESIDFNTIALMECH.- $Q.FI. OCT (� �7G
responsibility to notify the occupant of the requirements which must be met
prior 1.Issuance of a Certificate of Occupancy. ' )+{T1111VV
X11 Y yr l 5
Owner or authorized agent - Date - ISSUED BY:
TOTAL:'
OFFICE COPY