24343 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO
BnRdtodear c�r� � CLuPER No
2434.3
w((l1ate.sr�s�,sr�� nn,^, ,1 e: A
V'GS 9`4.7�6'V las- 1 J_+I CITY OF CUPERTINOLBUILDING DIVISION
Co traem' Name e� Llc.No: APPLICATION / PERMIT911AN 6110
BIRLDINGELECTMCALPLUMBINGMECHAMCAL CATEGORY CONTROL X
Architect/Engineer. LIc.No:
CITY ELECTRIC ELECTRIC PERMIT FEE BUILDING PERMIT INFO
� rem
A : �-�4 a "� r PERMITISSUANCE ❑ E:1 E:1LICENSED CONTRACTOR'S DECLARA IO t�
Ihereby affirm that l am licensed under provisions of Chapter9(comnnor APPLIANCFSRESIDENHAL JOB DESCIU19ION
Ingwlth Sectbn7003)of DlAsion3otthe BuslnemandPmtesslmsCodgand my
license is In full form and effect. PANELS n /!a —�I 'PC
License Clam LIeX i 1T
Date ContractorUP TO 2DO AbMS
ARCHITECPS DECLARATION a01-1000AMPS
qq��vv Ore2 Iunderstand my plansshallbsusedupubherecord, OVER1000AMPS 170NELL
�eI 5/SQ.FT.
k� Limned Professional SIGNS ELECTRICAL �/r0NEL • pry�� �. � "
HOWNER-BUILDER DECLARATION
n¢' SPECIAL CIRCUT/MISC
►71.„1-' a owing raffirm Oatlamesemptlmms a Contractor's License faw(or the
following recon.(Section permit
to Business and Pm(mbne Code:Any city or
O pqqqqq�( TEMP.MEITR OR POLE INSI.
F,� a muntywhkh regulroapermitto construct,alter, demollaMorrcpdr E h
Oja anystmu mpAortoltsbwance,alsonqurcstheappllcantfineuchperMtto POWER D�� LJ J,
file a signed statement that he b licensed pursuant to the provisions of the
Contrectorb License Lau(Chapter9(mmnrncing with Section 70M)of Divi-�OVALUATION:I
don of the Business PmfmbuCode)or that he exemptihcrefmmaml SWNTMING POOL ELECTRIC ,
6.•77 the tush(or the alleged exemption. Any violation
of Section 70315 by any OUTLETS—SWITCHES-FIXTURES
O pbcant forapermt subjectsthe applicant to a dull penaltyo(n°tmorsthan -
five hundred
wnerofdollars hepr. NEW RESIDENTIAL ELECTR SQFI. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the p work,a or he employees with wages as thele tole
mmpSec.70 ,wflldothBusiness awork,and Xxv,Code:
w
O
sale(Sec 7014,to an ow and f pafmbns Code:The Contractor's License law
$$ whododoes tapply roan owner or pnperhhis..builds oyees,p veseherc°,and OCC.GR0UP RES UNITS
wprovomntsus.ch work am not
meeRmlbmugh hbm em p,hoverperthe bthatwch
ImpmvemeMbwidotlnteneedoroftemdbruk.ILhowevegflcier ilingm TOTAL: -
impruvemeeuissoldwithlnonyesro(complefb,the owner-buBderwlllhave
tlk);urden of proving that he did not build or Improve for purpose°(sakJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L,f 1,as owner of the Property,am exclusively..leading with licensed Pp n ISSUANCE
mntmeton to construct the project(Sec..7004,Buslnem and Profmbns Code:
The Contractor's Licrow Law dm not apply to an owner of property who ALTER-DRAIN 4t.VENT-WATER IRA)
or improves thereon, and who contracts for such pwjects with• FEE SUMMARY
�gatLattor(e)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B A P C for this reason
DRAINS FLODR ROOF,AREA,COND. SANITARY Y N
Owner Date RFLERef N
WORKMANCOMPENSATIONhave sc'SATION DECLARATION FIXTURF.cr PER TRAP SCITOOL TAX Y N
❑I hereby',form that I have a certificate of consent to salf-irsure,or• - RFLEO'f Y
certlflLateo(Worken'Compeuallanlnsunnco macertlfled copythereof(Sec. GAS EA.9YSTEM-1 INCAOUHLM PARK FEE Y N
Policy# CJ RFL®'T M
C. X GAS EA.SYSTEM.OVER4(EA)
�����C�om�pppyy�Xparray BUILDING DIVISION FEES
eni(led copy is heed with tecity GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
enified copy b tike with the city Inspection dlAslon.
CERTIFICATE OF EXEMPHON FROM WOR KERS' CREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA papT Date Remi t#
(Thhuctlon need nM be completed If the permu Isfor on hundred dollar
($100)orlmJ WATER HEATER W/VENT/ELFLTR ENERGY FEE Y N
I m ttly that N m
the performance of the work for which this pedt is Issued,
I shall not employ any person In any manner so as to become subject to the
Workers'Compenutlon lawsof Gllfomk.Date - I1R /TREATING �e PAID
O Z Applleant NEW RESIDENTIAL PLMB. SOFT. Date Reeel [#
Z 0 NOnCETOAPPLICANT.1f,aaermakingthb Certificate.!Eaemptlon,you
should become subject to the Workers'Compensation pmvblors,of the Labor �a TOTAL:
N Code,you rtwstforthwith comply with such pmvisluss orthb perrmt shall he V BUILDING
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyaffirm that there b a construction kodingagency forthe perform- TO ELECTRIC FEE
M Z anceottheworkforwhlchthb permit is Issued(S..3097,CIv.C.)
02 Lender.Name PLUMBING FEE
I— Lender's Addrem QTY. MECHANICAL PERMIT FEE
U.
U Icortifythat l have read lhbappBcetionand sidethattheabove Information MECHANICAL FEE
O W is correct.I agree to complywlth all rityand county ordlnancesand elate laws PERMUISSUANCE FEES PAID:
} 6 relating tobutlding construction,and hereby authorise representatives of this
[_ N dtytoenterupontheabovamenlionedpmpertyfm Wpedlonpurpom. . ALTER OR ADDTO MECH.
? (We)agree to save,IndemMm
edfy an d keep harthe City of Cupertino Date Rotel t#
V egalnst liabURLM Judgment,coat...d expenses which may In any wayacuus AIR HANDLING UNIT(TO 10,000 CFM) .SUBTOTAL:
against said City in consequence of the granting of this permit. -AICONSTRUCTION TAX
R HANDLING[IMT(OVER 10,000 CFM)
tuof Appcant/Contrador to EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hacardous HEATING UNIT(M 103,000 BTU) Date Recel [
material as defined by the Cupertino Municipal Code,Chapter 9,1$and the
Health and Safety Code Section 25537(a)? HEATING UNIT(OVER 103,003 BTU TOTA
qY. 1 1 No
III the applicant or mrebuildingampant use equipmentordevices VENTILATION FAN(SINGLE RE9D) SUANCE DATE
which emit havardous air=is minants as dell red by the Bay Area Air - PAID
Qua llty Mansgcment District? BOR.Eft-CAMP OHP OR 100,0101)BTU -
❑Yes. ❑No
uIhave read the hardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) TIS /�
the Glifomia Health k Safety Code,Sections 25505,75533 and 25534. 1 S92
understand=lfthebuilding does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT em
responsibility to notify the occupant of the requlrcments which must be met CI T Y ser Curl:
prior to issuance of a Certificate ofOccupa racy. - TL IIIVV
Owner or authorlmd agent Data 1Y)TAL: ISSUED BY..
OFFICE COPY