24076 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMIT NQn/.
Building Address: [,)4076
�yS3 DF � A aRG
nero amc: one: AL DAIT.
SCITYOFCUPERTINO-BUILDING DIVISION d�
c°^o-aao .Nam : uc.No APPLICATION / PERMIT —`
IFMNr" $Q[G/Q L/S�f//1/G �Q eU LOIN -I1ECTRICA1,PLUMBING-MECHAMCAL CATEGORY CONTROL If
Architect/Engineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �"' �I ❑
LICENSED CONTRACTOR'S DECLARATION �J
T hereby. ly that l am Dcensed under provisions of Chapter 9(rommene MPLANCESRESIDENTIAL JOB DESC ION
'ngwith Sedton70W)of DlWslon3ofthe Busimssand PmfessionsCodGand my
license Is In full fo a and effect q PANELS \
Date Chas LlcM 6 6 J � � O
Date £?��Cmemcor
ARCHITECT'S DECLARATION 201'1000 AMPS
reO I, I understand my plans shall be used as pubiterecords. OVERI"AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
Q E Licensed Professional SIGNSELECTRICAL
a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
Ihembyaferm that l am exemptfrom the Contractors License Law for the
�9 following reawn.(Section 90315,Businessand Professions Code:Any city or
O/t-apermitcommuct, TEMP.METER OR POLE INST.
In aoontywhkh requires husuartoalsoreuices theaprovnt forsbh,ormitto
y�a any stacturcpdorto lb lssuancGCisorequlmtheappllant(orsuch perMtto POWER DEVICES
a0 I,O file a signed statement that he,V licensed pursuant to the provisions of the
mContractor's Llcene Law(Chapter 9(mmmtlg WI
ennwith Section 7000)of D - SWPIMNGPOOLELECTRC
VALUATION Jhv`
�30� don3of the Bush.and Professions Code)orthatheisexem therefromand V
the basis for the alleged exemption. Any violation of Sections 70H.5 by any
ap¢i app8antfirs permit subject/ not theappllcant to a civil penalty of more than OUTLETS-SWITCHES-FIXTURESOUTLETS-SWITCHES-FIXTURESII%TOUTLETS-SWITCHES-FIXTURES
c a eve hundred dollars($room.
I,as owner oftheproperty,or employees with wa es as their sole NTW RES[DENTTAL ELFLTR SQ.FT. STORIES TYPECONSIRUCTiON
j Q ❑ Pert,• r^YB
compensation,will Bothe work andthe structure tsrm Intended or offered for
O sale(Ser.7044,Bu sinessand Professions Code:The Contractors License Law
Q docs not apply
to an owner of property who buildsor improves thereon,and
who doss such work himself or through his ownemploym,provided that such OCC.GROUP RES.UNITS
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement b sold within one year ofcomplellon,the owner-builderwill have -
U�udenorproving that he did nes build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L1 FLOOD ZONE pPN
I,a toner of the property,am exclusively Business
and Pro with licensed PERMIT ISSUANCE
TheconContractors
construct the project(Sec.apply
to an o and of property
Code: '
Wil Coor Impre Lcene Law does nes apply tct an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda t r Improves thereon, and who contracts de such projetts with a
,,l1uurractmexe nt underPursuant to the Contractor's Llcene Law. BACK FLOW PROTECT.DEVICE FEE
OUSUMMARY
EFEES
aLJ 1 am exempt sneer sec. e&P c for this reason . .
DRAINS F1.00R ROOF,AREA,COND. SAN Y N_
•
Owner DRAINS- RECED7 x
WOR ILMAN COMPENSATION DECLARATIONrs01
171 hereby affirm that I have a certificate of cement to self-insure,or a FIX'IURF_S PER TRAP SCHOOL TAX Y N_
l RECEIPT N
cenifiabC.) ricers Compensatlonlaurancernacertlfled ropythercof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
Policyab C.) 6p
Ce i 5' G I T—61 GAS E.A.SYSfEM-0VER4(EA) RFLED IV
Com any o /_L�._t f OrRu1LDwc mvivoN Fr.IS
ElCertlecd copy is hereby tGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
the
gCertified ropy V filed withh the city
inspection division.
CERTIFICATE OF UEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20011. Date Rcmi t#
(this section need nes M completed If the perrtdt is!Drone hundred dollars
($100)IAdyor a.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N
Iartoy thaththe person
unceofthework se tats cbthispenultcLswN,
I shall not employ any person In any manner e a to became subject to the WATER SYSILM/TREATING
Workers'Compensation Laws of California.Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQFI. Date Recei t#
O NOTICE TO APPLICANT:If,esker rtuking this Certificate of Exemption,you
should became subject to the Worken'Compensation pmvl•ions of the Labor TOTAL:
Code,you at forthwith comply Mthsuch provisions orthb permit shall be BUILDING FEE
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby atOrm that there h a construction lending agency for the performn ELECTRIC FEE
7 Z ancetfthework for which this permit uusued(Sec.309],Civ.C.) TO `.
V O Lenders Name PLUMBING FEE
LL ~ Leederapddmsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW leech(ythatlhavercadthuappliatl°nandpatethatibeaboveinformation
M ocareact.Iagrecto comply with all cityand county ordinances and pate laws PFAMITISSUANCE FEES PAID:
>. W rciatingtobulldingconstadi..,andhercbyauthod ercpmwntallvesofthis -
Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
agaWtliabilltla,pdgments,roan and expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agA I{Bald City in rmur ceof the t tog of this permit.
�� AIR HANDL NGUMT(OVER I0,000CIM) CONSTRUCTION TAX
Sig moff A-p_peant/Contractor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies of or future building coca pant store or handle haasrdous HEATING UNIT(TO 100,000 BTU) Date Recel tic
mantis as defined by the Cupertino Municipal Code,Chapter 9.12,and the _
I Iealth and Safety Code Section 25532(a)? HEATING UMT(OVER 100,000 BTU) TO
❑ You M No
Will the applicant or future Wilding occupant use Nulperent or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Arca Air
Quality Management District] BOILER-COMP OHP OR 100,000 BTU) e Q
P Yes No
have read the Nazar sus materials requiremcnts under Chapter 6.95 of BOILER-COMP(OVER IDJ,00087U) /
the California Health&Safety Code,5ectiore 25505,25833 and 2S534.7 V
and cmtand that if the W ilding docs not comentiy have a tenant,that it ei my NEW REN DENTAL MECH. SQd7 v77
aponsibd ymnaifythe oavpantofthe requirements which mustbemet C11 Ir
prior m' u nceota Ccrtleateof Occepancy. ur b(/rc I rw
Owner uthorized agent Dat ISSUIiD eY: y ( �1
TOTAL: 1
OFFICE COPY