24100APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Addw:
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PIXWTN'4100
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CITY OFCUPERTIN4BUILDINGDIVISION
APPLICATION / PERMIT
to Lk. Nix
BUILD[NGdBCTWCALPLUMBINC-NfW AMCAL
CATEGORY
CONTROLY
Archted/Fsglrcrr. Llc. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
FEIU.RTIb5UANCE �s
UMB 911711
❑ El ❑
LICENSED CONTRACTORS DECLARATION
lhembyafflrmthatlambkmaeduMerprwWl otCFapter9(mmmme.
e oflhe Budnmand AsfesY¢uCMe,and
70rce
APPLIANCESRFSIDENTIAL
JOB DESCRIPTION
lice. iSectbn
I lanae b anDlvielm7
fin. fora and effect.
PANELS
License Class L
�
oIemY
Datenct
�ARCoCr
IuMeataMmyplaneluBMudupubhcecvda
OVER 1= AMPS
SQ. ET. FLOOR AREA 5/SQ. FI.
I SIGNS ELECTRICAL /
LlaneM professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt /roe. the Contractors LI¢nx Law for the
LI
SPECIALCIRCUIT/MLSC
TEMP. MEERORPOLE INSP.
folbwfngmm.(Se im7WlS,Buslnmarid Pmfmloru Code:Anydtyor
countywhk mqu aaper tommtruc Ater,lmpr dertowhormpalr
j�`� B I�
anystructurt prior [calla le�rarce, also rcqulrtstheappt¢ntfaeuch permitte
file a signed statement Char he is Ilansni s pursuant to the pexwaha of the
Cuntramoes lkeme Law (Chapter 9(commencing with Section 7000) of Dnv
ebn 3 of the Resinms and Pim
rtl a. Code) or that he Is exempt therefromaM
POWER DEVICES
ue✓ 1�
'
SWIMMING POOL ELECTRIC DTE
the basis for the alleged exemption. Any violation of Stolon 7MI5 byany
applicant fora permt subjects iheapplicant to. dull pewlty da nmomtlun
OVILEISSWITCI FIXTURES
72
NEW RESIDENTIAL ELECTR SQFT.
Ov hund owner ofpro
owner a( the property, or mry employesr with wages u sok
STORIES
TYPECONSIRLCTION
e si ructure offered
Welled orm.Lfor
sale(Sxs DK3.1rutlework,andthes
sale Inot 7014, Bushes all Prtt Code: The ors
The Taw
.
Dims who
deo oessuch apply loan owner or property who bum orlmprw.ted that and
or Impr hereon
who do.euch work hlveelfarthmif..d his owns.
OCCGROUP
RES UNITS
Improvemew art na Intended oroffaed (a sale. If, however, the W Iding re
If,W xp,,he building
ImprwemeN beold wlthlnoneyearafcompletbecthowner-buOdttwW have
t1alaunden of proving that he did not Wild or improve for purpme ofeale.).
C as owner of the property, am exchsively contracting with licensed
contractors to construct the project (See. 7014, BuelnmaM Prefmbm Code:
QTY. PLUMBING PERMIT FEE
PELMIT'LSUANCE
FLOOD ZONE
APN
The Contractor's License law does not apply to an owner of property who
Wilds or Improv. thereon, and who mntnca for such plojeas with
crA[+ma(a)B¢naed pursuant to the Contractor's Literate Law.
LJ I am exempt under Sec B k P C for this reason
ALTEt-DRAW & VFNf- WATER (EN
FEE SUMMARY
BACK FlDWPRO1TiT. DEVICE
DRAINS-
DRAINS- ITOOR, ROOF, AREA, GOND.
pp(0vI(pg PER TRAPSCHOOLTAX
SANITARY Y N_
RECEIPT
Owner
WORKMANCOhIPENBATIONDECLARATION
❑I hereby affirm that 1 have a certificate of cmtaent to sell -Insure, or .
artlBcate of WOrk¢ri Compewtienlnsuran¢ ons ¢rtBied copy Ncrtof $ec.
38(0, lab C.)
Y_ N_
RD= a
GAS FA. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N
Pdky Y
GAS FA. SYSTEM -OVER 4 (EA)
Co ny
DING 01
BOILIDI VISION FEES
MITH copy b hereby furnished.
MCcrtiBed copy is filed with the city Inspection dlNsion.
GREASE/INDUSIRL WASTE INTFRCEPTUR
PLANCHECK FEE
GREASE TAMP
CERTIFICATE OF UEMPIION FROM WORKERS
COMPENSATION INSURANCE
CMseembn need nd 4 compidM if the permk b fororc hundred dollars
PAID
Date Recel tit
SEN'FR SANRARY STORM EA. iTOPf
610medlytJ
Ia esmtbbo
thatoy
WATER HEATE(W/VENT/ELI)CM
ENERGYFEE Y N
not any
1 shall not employ any person d any manner an aa to become subject to the
mawork an as t beam the
Waken Compensation Taws of Callfomla. One
WATER SYSTEM/TREATING
PAID
Applicant
NOTICE TO MPLICANT: If,.fer ma king thio Cerdf ate.( Exemption. you
ahmld become subject b the atonics.' Compnrmatbn provbiom of the Labor
Cnde, you must forthwith comply with such prvvbbse or thio permit shell he
Date Recel tic
NEWRESIDENTTALPI.MB. SQFI.
TOTAL:
deemed revoked.BUILDING
SEISMIC FEE
CONSTRICTION LENDING AGENCY
I hembyafPnnthat there Is• mrotruclon lending agency for the perfomm
ana of the work for which this permit b utsued (Sec. 3097, CW. C.)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
IaMera Name
Lenderenddnbe
I ¢rtBythat I lave read thio apptatbn all watethat theabove Inlamadm
bmmem. InmetocomplywithW dtyand oountyordbuemand kite laws
MECHANICAL FEE
PEItMIT ISSUANCE
FEES PAID:
relating to building oncer uction, all hereby autharire repnecntaNs of this
city to enter u pon the a nrxrntiuned property fee lnepectbn purposes.
(We) agree to save, IMenro fy an d keep harmileas the City of Cupertino
ALTPRORADDTOMECK
Date ReCCI til
BabBlties dgmew,msaaM.pene.wh may Y..e
sue o(t ant
AIR 11ANDONG UNIT (IO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFTO
CONSTRUCTION TAX
sore pp ant nn a
MiAUSTHOOD (W/DLC'D
CONSTRUCTION TAX PAID:
HAZAR MATERIALS UISC'LDSURE
IIFATWC UNIT (TO 100,000 BTU)
Will theappllcard or future Wilding omrpaotnoreor hand! le harandws
iratedal as defined by the Cupertino Mu Ntlpal Cede, Chapter 9.11, and the
Date Recei ted
HFATING UNIT (OVER 100,000 BTU)
_
TO TIZVI
ISSUANCE DATE
M I u
AGG1�
health all Safety Code Stolon 25531(a)?
Y.
4Nc
llthe appllant« turcbullding occvpnt use equipmem «devim
which emit hararduusair cone-dosdaa defined by the Bay Area Air
Quality Management District?
4Ya No
hascmad thehavr�&YCWdala requirements under Chapter M.I of
the er Wanla Heath k Safety Code, Sidism 15505, 25577 and 25530. I
VENTILATION FAN (SINGLE RFSTD)
BOILER -COMP OFM OR 100,000 BTU)
IR7fLER{OMP(OVFR 100,000 BIin
NEW RESIDENTIAL hSCH. SQdT
understandthatyto if notify
eespoeulbWty to natty the ocapatLL of the requlmmems which rtust be met
theonupard oftmmently li.uIreen els hick, that it mets
prim to fsuana daCertifkate otOsrparuy.
C�
CITY
lufu�f'rti Ii �
IS
\Vr
ISSUEDBY'—yy I -a
Owners aalharl�agem Date
TOTAL:
OFFICE COPY