20824 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
B,2
16,03 �-�71yJ '5r. �u� Jli.JO 2 8 2 4
Jh� aces: one: - A
Kms" SIS&-7 /24,, ,Y' "3- 174 CITY OF CUPERTBJO-BUILDING DIVISION C�
Conmactors Name: Lie.N. APPLICATION I PERMIT --3 �� C
BUILDING-E.F)CTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROL N
^� Architect/Engineer. Lir.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. 'Z �� 3 G�T�7V� PERMITISSUANCE �Q(7 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby alfirm that l am licensed under provolone Ol Chapter 9(mmmene APPLIANCES-RESIDENTIAL JOB DE5CR TION
Ingwlth Sections70W)of DIvWon3oftheguaiw.andProfeesionsC ,and my
Licnselalue force and effect. PANELS �O� TU
LicereChnnLICK V
Date Contractor
liceARCHITECT'S DECLARATION 3111-TWO AMPS
XzIundemtandmtyphnsshaBbeuwdnpubhcremrds OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
z �'' Ihembya/BrtnthatlamexemptfmmtheContractor'.LlmnseLaw for the
following reason.ISOctlon 70115,Busmen and Professions Cade:Any city or
OR— TEMP.METER OR POLE INSf.
Pcny,tmMm requlreeapermite,also rquireatheaprove,dersuch,ormitI
q any assigned statemepriorto nt
shathe is alsorequlreethant W the proouchpermitto POWER DEVICES
PJ rNE laic a signed icons eLa that het licensed pursuant it the tion 7000) of Ne
46130, don 3 ofthe Business
Law(CMsslonsmmmencing withSection7000)of Divi. VALUATION
sbn3oflhe BusInmand PMmlons Code)arthat hehexempt lherelromand SWIMMING POOL ELECTRIC
G,$ the basis for the alleged exemption. Any violation of Section 7031.5 by any V
OUTLETSSWITCIiFSFIXTURES /ry D
gj A applicantf�ra pemNt subjMslheapplicanitoativil penalty o(na more than
.(v�Lhundred dollars(5,500). NEW RESIDENTIAL ELECTR SQ.F[. SI17 TYPE CONSTRUCTION
GGGG7777 �n 7d1(_II,as,owner a!the property,or my employees with wages es their sole
< c mpensation,wBldothe work and Mesburom is not Intended or offered for
$ ❑ ale(Ice.7044 Busmen and Profmbns Code:The Contractors License Law
$ does not apply to an owner of property who Wilds or Improves thereon,and
who doessuch work himself or through his own employees,provided that such OCC.GROUP RES UNITS
improvements are not Intended oroffered forests.If,however,thebulldingor TOTAL;
improvement bsoldwithino seyearo(complellon,the owner-WilderwBl have
tllg,kurden of proving that he did not Wild or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Lj L as,owner of the property,am exclualvely contracting with licensed PERMIT ISSUANCE
mntactom to mnsWtl the project(Sec 704y Busmen and Professions Code:
The Contractor's Licence Law don not apply to an owner of pmperty who
W BdALTER-DRAIN k VENT-WATER(EA)
s or Improves thereon,and who�unlyam for such ptm)ects with a FEE SUMMARY
cqR((+ pl dod.)licensed pursuant lo/ rC0 doe.License Law. BACK FLOW PROTECT.DEVICE
TTI am exe and B h P C for thin... OUTSI DE FEES
_ DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
KM COMPENSATION DECLARATI�— FU(711RFS PER.TRAP SCHOOL TAX Y N
❑I hjs afllrm that 1 have a.certl0cate o!consent to sol(-invert,ora RECEE'r N
certl(lots of Worken'Comperoation lnsumnce0ra certllbd mpythermf iRec.
�f 3800,Leb C.) GAS EA.SYSTEM-1 WCAOUTLEFS PARKFEE RECEIPT
Coll 'a GAS FA.SYSTEM-OVER4(EA)
Com'any
BUILDING DIVISION FEES
Certified copy b herebyth the city GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Cedif ed copy ts filed with the dry InspMbn division. .2S.3T'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.2001rr. Date Recei t#
(This section need not becompleted ifthe permit b foram hundred dollars
I..)
(EIfA)ormd WATER HEAMW/VENT/M ECTR ENERGYFEE Y N
l aor at In man
the perforce0lthe work for which lin.pem
dt la Issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of Calilomia.Date PAID
O z Applicant NEW RESIDENMLPLMB. SQFT. Date Retei t#
Z O NOTICE TO APPLICANT:H,eRer nu king this Certlicateof Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provision orthb permit shall be
W 9 deemed revoked. — BUILDING FEE 12-0,0
IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lendingagenry forthe perform, TOTAL: ELECTRIC FEE
Q ante of the work for which this permit is Issued(Sec.3097,Civ.C.)
Lenders N.ma PLUMBING FEE
LL 1- Loner.Add nv QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertilytbetl have read thbapplicationand rtatethattheabovednformation
1 bcorrect.I.greetocomplywlthall cilyand muntyordinance.and katelawe PERMITLSSUANCE FEES PAID:
} tl1 relating tobullding construction,and herebyauthorbe represenlatheeofthis
F z city to enter upon the abovcnrntlomd erty forinspectlon purposes. ALTER OR ADD TO M1xH. Dale ReCei tin
(We)agree to ave,IndemNty harmiea the City of Cupertino
V against hablbtbs,pdgmentsI con penes whichmaylnanywayataus AIR HANDLING UNIT(TO 10,000 ChM) SUBTOTAL:
a=con to o ing of mnit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
AppO nt/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Itltheapplicant or future building occupant store or handle hazardous HEATINCUN1T(TOIW,000BTU) Date Recei tin
material as defimd by the Cupertino Municipal Code,Chapter 9.13,and the
Iieal1 Ycnd Safety Cad eSSecron 75S33(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
N.
111 thea ppllcant crioture building occupant use equlpment or devices VEN'DI.ATION PAN(SINGLE RESID) ISSUANCE DATE it Il.
whldh emit haaurdous air contaminant...dented by the Bay Area AI
Quality Management District? BOILER-COMP DTI'OR iW.IXD BTU) -
Yrs n❑No
heve read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTI!) JUL 30194
the California Health k Safety Cade,Sections,25505,25533 and 35534.I
understand that if the buildin not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
reior to 0 l of he party.lrertanb which=at be met *, c .a
prior to coo rt t0 o(Ocevpancy. / rI.7 of CB;uil .
7 3,/5'6
Owneroraulhorbedagent Date ISSUEDB .
` TOTAL:
OFFICE COPY