24220 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulidin Pro en Identification uPEJUA TN24220
, 4 2 2 0
Building ddre : -
D / E 1
ners ams: �— one: LAL DAM
E G. CITY OF CUPERTINO-BUILDING DIVISION
Rct
d .Name: umNo: APPLICATION I PERMITt/� BUILDING-ELECMCAL-MUMBING-MECHANICAL CATEGORY CONTROLN
En neer. Lk.Na
LT QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add 9Vu �j�,_OK/ PFRNI TISSUANCE ❑ ❑ is ❑
LICENSE ON ACTOR'S DECLARATION I)9
[hereby affirmthat l amlkensed under provisions of Chaptcr9(commenc, APPLIANCESRESIDENTIAL JOB DFSCRE'ITON
ingwith Sedion7000)of DlWslon3 ofthe Buslomand PrefeWonsCods,and my 1
licence I.I.full— and effed.� I' PANELS
Lirense�laq=._N- LIr.N yB�IY • v
Date_? [L ' j Conten a�� UP TO 2DOAhM
ARC HITE DECL TION ZOI-1000 AMPS
aO 000q 1 understand my plans shag used u pu Be rcmrdw OVER 1000 AMIrS SQ.FT.FLOOR AREA E/BQ,FI'.
Licensed Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIfiC
Iherebyaflimethat I see exempt from the Contrador's License Law forthe
following mission.(Section 70315,Business and Professions b-8 Code;Any d or county which enquiries a permit toennsbuct,alter,improve,demolish,orrepair TEMP.M=OR POLE INST.
4 � anysmicture priortolts briance,alsorequireathe applicantforsuch permit to
015 file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3wG Contractor.Lk¢me Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC Joe VALUATION -
i„�O� don3 ofthe Business and ProfeasionaCode)arthat he is exempttherefromand
0 the basis for the alleged exemption. My violation of Section 70315 by any OUILETSSWITCHFSHXTURES
applicant for a permit sabj ctsthe applicant to a civil penalty of net more than
Q five hundred dollars(S500). �Fp STORIES TYPE CONSTRUCT ION
b: NEW RF9DFMIAL ELECTR
❑Lasowner,will oche work,andhe property, my employmwith wagn rofftheir able
mle(Scompeea 0KBusdess and Professions
stricture Code:The
not Intendedorconse Law
sale(Sec 7094,Bushes and Prooperty Code:Theon impdorm Ikarus Law
$ does notapply torn owner ofproperty who nImporimprwnthereon,and .GROUP RFS.UMTS
whodoessuch workhimself edoraughhisownemployees,er theb that such
improvementsare net ith none earofco locule.ILhowever, flder iiI have TOTAL:
improvement baold wilhinoneyearofcompldlon,lheowner-buuderwlllhave
Iti.�urden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
u APN
4 as owner tr the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to wn.wd the project(Sec.appy Busmen and of property
Code:
The Contractor's License Law don net apply to an owner of o*u w who ALTER-DRAIN k VENT-WATER IFN
cc
or Improve thereon,and who contracts for such pCojectm with a FEE SUMMARY
ado a order ttothe Conlractw'e Lkenm Law. BACK FLAW PROTECT.DEVICE
L..11 am exempt under��e�/J B A P C for this mason '
- - I "! DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_
Owner r Date RECEIPT N
e WORIGIAN CO PFNSATLON DECLARATION
FlX7VRES PER TRAP
SCITOOL TAX Y N
R
C31 hereby affirm that I have•cactificate of consent to self-Insure,m a _ N
certi(lale of Worken'Compewtloninauranceora certlfiedcopy themof(Bac. -
38 bC. a/ / // �Q GAS FA.SYSTEM-I INCA OUTLETS PARKFEE Y N_
6/( -! RECEBT N
Poll p GAS EA.SYSTEM.OVER 4(EA)
Com any, p f—��( L �¢� BUILInNc mVIS ION FE ES
�rtl e co yis hem to shed. GREASEANDUSTRL WASTE INCERCEIrIDR PLANCHECK FEE
c it(led copy is Nes with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID t`out
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200IT Date Recei 1# J�
Crhiasection need net becompided lithe permit is forone hundred dollars
($100)orlcn') WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I nrtifythat In the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner au as to became subject to the WATER SYSTEM/TREATING
Worktn'Compensation Law e Iifomia.Date PAID
Z Z Applicant�'x / NEWRESIDENTIALPLMB. SQFT. Date Remi t#
Z Q NDTICETOAI'PLIC N7 ifternukingthaCediflnteofE..re Ion,you
should became subject tat Workers'Compensation provisions ofthe Labor TOTAL:
N Code,you nest lorthwltA reply withinch providom orthis permit shall be
� > deemed revoked. B LD G "E
CLC CONSTRUCTION LENDING AGENCYLIAI F ,DD SEISMIC FEE
1 hereby affirm that there is a construction lending agency forthe perforC3 m ELECTRIC FEE
Z ance ofthe work for which this per is Issued(Sec.3097,Civ. TOTAL: s,�o
(-) 2 Lender's Name PLUMBING FEE .�
LL I= Liould.Addren _ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I udifythatl have east is pplication and statethatthe above information
1 bcormd.I agreeto comply with all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
�. W misting to building construction,and hereby authorlm representatives of this
F
city to enter upon the above,mentionad property for Inspection purposes.? ALMRORADDTOMECH.(We)agree to save,Indemnity an d keep harmless the City of Cu Faction Date Receipt#
V against llablilt4a,jidgment,ends and expenses which may In any way admit AIR HANDLING UNIT(TO 10,OD0 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) - CONSTRUCTION TAX
Sigmmm of Applicant/contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the.pplicant orfam.building occupant store or h.oil le hazardous HEATING UNIT 90103,0DO BM Date - Recei t#
materialasdefioedbytheC ell Murddpal Code,Chapter 9.12 and the
Health and Safetyc Ian 25532007 HEATING UNIT(OVER 100,000 BM TOTAL:
❑Yes No
Wllitheapplic, for building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamrdcua r taminanb as defined by the Bay Area Air T -
• liallty Management Dist d7 BOILER-COMP PTB'OR 100000 BTU) �l
4Yea No
have mad the has materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BM
the Califomia Health Safety ode,Sectiam25505,25533and25534.1 7
understand that if th Ilding does not cumetly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT i'OCT�JJ
res Ibllitytondi the occupant of the requirements which must be met
p to isuance olaCe to of Occupancy. ,
D CITY-C-g�
nen or anal 'zed ant Date TOTAL: ISSUED BY:
OFFICE COPY