24347 Wpc,ANjTTib FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building reoicr Identification PERhf1TN0
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ie CITY OF CUPERTIN6BUILDMG DIVISION I
�� APPLICATION / PERMIT Z�'e
1 BUILDING-ELBCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Englnar. Lk
ELECTRICPERMIT FEE BUILDING PERMITINFO
Address
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dtirmthat lent Bement under prwLdonso(Chapler9(mmmmc- APPLIANCESRESIDENML JOB DESCRR'DON
IngwilhSMla 7000)of Dlvielon3 *1d fesslmeCde,mdmyKeens lindPANELSLI=IC Ld, UP p 20DAMPSHITECTOZ ]understand plane shall be rda OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
I+n SPECIAL CIRCUIT/M15C
Z ]hereby...0'hat lam31.5,Bfromthe Cantraemi Ccns fawfarthe
o (ogawing reason.(Section 7031.5,Business and Professbne Code:My tlty ar
0, say ecomywhlch requlresa permlttomrutrucL alter,Improve,demolish,orrepalr TEMP.METER OR POLE]NST.
q� 3 anystm=m priorto its ismance,alw requlrestheappliant("such perretto POWER DEVICES
f5
IT.a signed statemnt that he is licensed pursuant to the provisions of the
Contnctori License Law(Chapter9(commencing with Section 7000)of Diel- VALUATION
t~n SWIMMING['DOL ELECTRIC
��OS don3o(the BustnneAnd PMesbneCode)orthat hob eumptihere(romand
Othe basis for the alleged exemption. Any violation of Stolon 70315 by any OUILETSSWI7CHESFI%TIMES
applleanl fora permit mbjectstheappBant t°a civil pemltyofna more than
five hundred doll..($500).
- NEW RESIDENTIAL ELECTR JQFT. STORIES TYPECONSTRUCUON
�I,as owmru(theproperty,orhe employeatwith wages r their sole r
compensation,will B..us.hew"kendtheswae:TheCure tat ContraIntenctors
or Lawed for _
Is(Sec.apply
to An owner
and f property
Code:The C improves License Law
Q donnor
casuch tomowmr orproperty who own employers,
improves cor,andthat such
1'
3^ whod"eeuch work himself or through his ownemplayem,provlded thal.uch C.GROUP RES UNITS
Improvements are not Intended oraffered fee sale.14 however,thebullding or 1 .� TOTAL:
Improvemea bwid withlnomyearofwmpidioM themvner-W Rderwlllhave
th rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PER IT
u L as owner of the property,am exclusively contracting with licensed D 7ANE APN
contrators to construct the project(Sec.7044,Business and Profenlore,Code. P IT]SSU IC
The Contntor.Limns Law does na apply to en owner of property who ALTER-DRAM&VEM-WATER(EN
Wilds or Improves thereon,and who contra for such piojem with a FEE SUMMARY
optlactor(c)BremM pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B&P C for this reason
DRAINS.FLOOR A,ROOF,ARRA,CONTI. SANITARY V N�
FEES
Owner Dale RECEIPT N
WORKMAN COMPENSATION DECLARATION b7X•IVRFS PER,TRAP SCHOOL TAX Y_ N_
1 hereby AIR.that I haus a certllkate of consent to self-Inca,ora RECEIPT I
certficateofWorke.'C tool unnp�m aaytIW copy thereof(Sec. GAS EA.SYSTEM-1 wctloUTLE15 PARK FEE Y_ N
3800,La I V/ DING DIM
PoliryM /� (/ GAS EA.SYSI7MAVER4(EA)
Com any QwA hO,Y/ BUILDINGDIVISIONFEES
�Cprtul re furnished. GREASE/INDUSTRL WASTE INTFACEPTOR PLANCHECK FEE
tLc]'eF^ 1fled copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA.l00F1'. Date Recei tN
(hl.aetlonneed na becompleted tithe permit isf"onehundred dollars
(B1E0)"I..) wATmHFATERw/vENT/n.EGTR ENERGY FEE Y_ N_
I artlfy that In the performance of thework forwhlch this permit is issued, -
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Werkers'Compensation laws of California.Date PAID
zZ Appllant NEW RESIDENTIAL I'LMB, SO.FF. Date Recei t#
Z Q N'OTICETO APPLICANT:H,after making this Certificate of Exemption,you
should become subject to the Workers'Compnneatlon provisions of the Labor TOTAL:
fA Code,you swat forthwith comply with such provisions or this permit shall be
BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
fl I hembyafOrm that them b a rm stmtlon lending agency for the perform ELECTRIC FEE
Z ane ofthework forwhlchthis Permit is based&c 3097,Clv.C.) TOTAL:
(.) 2 Landers Name PLUMBING FEE
LL 1.ender.Addren QT'v. MECHANICAL PERMIT FEE MECHANICAL FEE'
OW IadlfythatlhavereadlhisappBationond tlatethattheabovelnformatlon
LU bmrrect.l agree to complywith all tltyand countyordln.Amand ante laws
W PERMIT ISSUANCE / FEES PAID:
>. IL tobuliding construction,and hereby authorize representatives of this
(— city to enter upon the abovcmentioned property for Inspection purpose. ALTER OR ADDTO MECH.
? (We)agree to save,Indemlfy an d keep sanies the City of Cupertino Date Recei t#
V againstliabNti , meats,orstsand expen ,which rayl anywayaatue AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
against As C'y e' o an ng oflhis V.
f1 II ( AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of pat/ ont.cta Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS E
Will the applicant or future building occupant store or band Inhamdous T
BEATING UNIT(TO 100,0OBTU) �_ Date Rec
material as defimd by the Cupertino Municipal Code,Chapter 9.1$end the
Health and Safety Cudee�-Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOT L:
No
❑Will the Applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RRSID) ISSUANCE DATE
which emit hamrdous air cents mimnts as defined by the Bay Area Air
Qualay Management District? BOILER-COMP DHPOR 100,000 BTU)
Yes Na
have read the Fav oua materials requirements under Chapter 6.95 of BOTLM-COMP(OVER 100,000 BTU)sk R1 p Q ql
the California Health&Safety Code,Sections 75545,75533 and 75534.1 P Pit lV
understand that if the building does n"arrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQT7 '
rcaponsiblllty to nol ify the occupant of the requirements which must be met DEC ��
prior to issuance of a Certificate of Occupancy. 1
Owner or aulhorlmd agent Date ISSUED BY:Of.' I /
TOTAL:
OFFICE COPY