24349APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proed identification
Building Add ma: 1660
PERMTTNO.
24349
e. p Phone!
CITY OF.CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
NG -ELECTRICAL PLUMBING-MECHAMCAL
APPLICATION SUBMI I I AL DA IL
/O
Conti or'eNa L�.,Noy
�EJTI
CATEGORY
CONTROL#
Architect/Englneer. r
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ � ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby.
thb ion7OW)ofIII. that Di llcensed 3oftheunder pravWdPmfeWonsChapter 9(mmmenc
lnenseiSection force and effct. o(the Butlnauand Pro(eailowCode,andm
Ilanse dein full force and effect.
Llano CJf Licp
Date (? /`7_Contrador—
ARCHITECTS DECLARATION
[understand my plansshall.mN
be u�edpubllcre d.
Licensed Prdemiorul
OWNER-BUILDER
mptfro DECLARATION
Iherebyd(I.(SotIarrtexempt (rovxx.Contractors License LawAny for the
fell -wing ywhichmqutmap7 tit Ruelneu end Professions
emle hnympaLr
countywMch requlrea eladan e, cowttucL esthe applicant provq demolish, er mit to
anya df;: rc Priertutatemeit thalnwQabo sed Potsdamto[herevisionsorsuch of the
Ole a aigned statement that to t rl) (commencing
c m pursuant to the tion provisions of the
Contactors License dProfm mCode)entlngavlth Section 70ro)of Dlvl-
abn3 o(the 8ualneu and Prolenbns Code)or that he b exempt themfmmand
the bash for the alleged exemption. Any vielallon of Section 70113 by anyOVILETSSWITCTIESFIXT[IRES
applicant for a permit subjectslhe applicant to a civil penalty d not nom tha
five hundred1, as owner pro
❑ I, as owner o! the property, or my employees with wages [herr sole
compe.abon,will do the Business andwork, and the atmtlure b not Contactor or License Lawor
ask (Sec.pply BusinessandCode: The Cimproves Mce.e law
don no empty torn unser of p rough who Wild,empl r improves con, and
property
who doements.ork himself ffe ed owns. If,ho eprovidedthat.uor
Improvements arc .& Intended orollered (orale. If,hmvevegthebuilding or
ImPmmenentissold withlnoneyesro(completlon, theowner-builderwill have
tlte_iurden of preving that he did not build or Improve for purpose of sale.).
Lj 1, as owner of the property, am exclusively contracting with licensed
roMr.d. to construct the project (Sec. 70M Builnem and Profes.low Code:
The Contractor's License Law does not apply to an owner of property who
builds or Improved thereon, and who contacts for doth ptejetla with a
uy)(Iactor(a) licensed pursuant to the Contractor's License Law.
LII am exempt under Sec. T� B & P C for this revers
APPLIANCESRESTDENML
tris DESCR[IMON
/l/J��I`—hf{,�.�7 I`p,�-', aJ�'C
PANELS
UP TO 2DOAMPS
0 AMPS
OVERI
OVER 1000 AMPS
SQ. FT. bI,00R AREA f/SQ. FT.
�� ED 114
I� n C—�
M Imo' U T ER
ILII 777
SIGNS ELECTRICAL /
SPECIALCIRCUIT/M1SC
TEMP. METER OR POLE INST.
POWER DEVICES
—SWIMMING POOL ELECTRIC
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
- TYPECONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE ��
-
ALTER -DRAIN & VENT - WATER (EA)
OCC.GROUP
RES. UNITS
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE, FEES
DRAINS. FLOOR ROOF, AREA, COND.
FD('NRF_S PER TRAP
SANITARY Y N_
RECEFT #
Owner Date
WORMAN NSATION DECLARATION
C31 here K
by doI haw a
affirm that have a certificate of convent me
self-Inrt, ora
MOD, aof Worken'Compe.rtlonlwurence oraartlflod mpythereo!(Sa.
Polic Labb CJ
I'oilcy M
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 WC#OUTLETS
FEE
PARK Y N
RECEIPT M
Ca any
GAS FA.SYSTEM-OVER4(EA)
BUILDING DIVISION FEES
ertified copy b herebyfurnished.the city
Certified ropy b (fled with the city Inspection division.
CERTIFICATEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMssectdon need not becomplctM little permit b toronehundred dollars
(flrp)orfyth)WATER
I snot that o any pehe rson In an the sef.as t btmmhis esub)ecrmit 1. Issued,
I shall not employ any person 1n any manner n. to become subject to the
Workers Compensation mb.
tlon Lawn of Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subjdt to the Workeri Compewatlon provisions of the Labor
Code, you at forthwith comply with such provide. or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyof rm that there is a construction lending agency for the perform-
once of the work forwhlch this permit is issued (Sec. 3097, Civ. CJ
Lender's Name
Lendce.Addre�
tion
is correct. l agree to comply with all city and county ordinances and date laws
relating tobulldiag constmctdon, and hereby authorize mp.od tattw. of this
city to enter upornhe above.mentioned prop for Inspection purposes,
Ve) agree to save, Indemnify and enless the City of Cupertino
agal lilies, ltd menti, sand seaw ichmayiaanywayacc.e
a .t CI In o grandn this P.
Al /S
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei Ile
GREASE TRAP
SEWER SANRARY STORM EA ZO�f.
HEATER W/VENT/ELECTR
ENE•RGYFEE Y N
PAID
Date Recef tN
WATER SYSTEM/ TREATING
NEW RESIDENTIAL PCMB. SQ,FT.
TOTAL:
BUILDING FEE
S* daas
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
ALTER OR ADD TO MECH,
Date ReeeiptN
AIR HANDLING UNIT (TO 10,M CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
5 nature of Applrant/Contractor AERIALS Dale
HAZARDOUS MDISCLOSURE
Will the applicant orfutumbudi i occupant store or handle hazardous
nuterfalasde(Inedbythe Cupertino 1unrtlpal Code,Chapter9.IZ and the
Hcahhand Safety Code Sxcdoo2S532(g7
❑ Yes N No
Will the applicant or future building occupant use equipment or devices
which emit harardou. ab contaminant. as defined by the Bay Area Ab
Quality Management District? -
Yea ❑ No
m
have ad the hazardous materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 75534. 1
understand that if the building don not currently have a tenant, that it b my
responsibility to notify the occupant d the requirements which must be met
prior to issuance of a Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Revel IN
HEATING UNIT (OVER 1(0,000 RTU)
TOTA
�a
VENTILATION IAN (SINGLE RESID)
ISSUANCE DATE
pa p M '
P
'
9(1(10
OCT 's9s92
C11 ur coital if
ISSUED BY:__a�.•—�-7-a
BOILER COMP (3HP OR 100,IX0 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESID=AL MECH. SQ.FT
Owner or authorimd agent Date�.�.�./��a►��/y��/
TOTAL:
OFFICE COPY