24364APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Idenil(lotlon���
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PERMIT N24364
Building Address:
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ensksitq
Z 4 3 6 4
nevaName: one:
GPFs•CQQ�aTcy )252-05%
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
A A
—
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l
Comeactm't Na : L3e No:
O
BUILDING-E.ECTRICA PLUMBINGMFCH LAICAL
CATEGORY
CONTROL It
Architect/Engineer. Lie No:'
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PERFITISSUANCE
❑ ❑ ❑
h ED CONTRACTOR'S DECLARATION
Lm
t
that
I hereby ion 70 shall amecrosedhe under Businessprovisions ofChapter 9(mmmenc-
11...with Section force at Dlvffict. (the BualncssandlPrvfessiens Code, and my
limnu la In full force and effect.
AI'PLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
Liccma Class Llc.p
Date Contractor
UP TO 200AMPS
211-1000AMPS
ARCHITECI'S DECLARATION
l understand my plane shall be used as public reands.
OVER IODO AMTS
SQ.R. FLOOR A9FA
Licensed Professional
SIGNS ELECTRICAL
it
hereby OWNER -BUILDER DECLARATION
Itywh affirm lamexto fromthe
following ..a. (Suction 70315, Beat.. and Profembns Code: Any city or
lte Contractor's License Law fmair the
county which requires a permit to comtmct, aiteq Improve, demolish, or repair
E'
L`� ITJ I'� ~N l�
LJ' LL Q Y 111....��
SPFCLLLCItCUIT/M15C - (
TEMP. METER ORPOLE INST.
any structure prior, to its issuance, also requlresthe appecantfor such permit to
file a signed statement that he b licensed pursuand, to the provident of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3ofthe Businessand Pro( ions Code)orthathehexemptthemfmmand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of net more than
five hundred dollars (S.50I).
1, as owner of the property, or my employees with wages as their sole
POWER DEVICES UA
TE
SWIMMING POOL ELECTRIC
VALUATION
OUTLETSSWITChUSFIXTURES
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TY E CONSTRUCTION
compensation, will do the work and the structure b net intended or offered for
sale (.Sec. 70K Business and Professions Code: The Contractors License law
does not apply to an owner of property who Wilds or improves therron,and
who doessuchworkhimulforthrough hlsown employees, provided thatsuch
OCC GROUP
RFS .IINITS
improvements are not Intended oroffered fanatic. If, however,thebullding er
Improvement asold within oneyearofcempletion,the owner -In ilderwlll have
TOTAL:
t e rden of proving that he did not Wild or improve for purpose of sale.).
L as owner of the property, am exclusively contracting with licensed
contractors to mvtruct the project (Sec. 7054, Business and Professions Code:
QTY- PLUMBING PERMITLj FEE
H.ODD TONE
APN
pF1LMIT ISSUANCE
The Contractor's License law don not apply to an owner M property who
Wilds or improves thereoq and who contracts for such pitojene with a
mq(pctaKs) licensed pursuant to the Contractors License Law.
Ll I am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT - WATER (EA)
gr,«plpVl PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOG R
R OOP, AREA GOND.
SANITARY Y— N_
RECEIPT' N
Owner Dale
WORKMAN COMPENSATION DECLARATION
f ❑i hereby affirm that I have a certi/un o! consent to apythet (Sa
FDnURF_S PER TRAP
SCHOOL TAX Y N—
certilicab of Warken'Compensatlonlnsuranmora certlhd copy rhereo((Sm.
lab C.)
RECEIPT N
GAS F.A. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
Pol3300
N
RECEIPT' M
Com
Cr.Y
GAS EA. SYSITM-OVER 4 BEAT
BUILDING DIVISION FEES
CertlBed copy at hereby ththafurnished.
Certified copy V filed with e city inspection division.
GREASEANDUSIRL WASE INTERCEPTOR
PLANCHECRFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhissectionneed nabecompleted ifthepermi[ isforanehundreddollare
(5100)orlenJ
Icertl(y that lathe perfoanceof the work W
forwhich spermit le hawed ,
I shall not employ any person In any manner an u to become subject to the
Worker: laws of lawof California. Date
Applicant
NOTICE TO APPLICANT: If, sleet making this Certificate of Exemption, you
PAID
Date Rece1 [#
SEWER -SANITARY -STORM EA. HAFT.
WATER HEATER W/VENT/FLECTR
ENERGY FEE Y N —
PAID
Dale ReCei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT,
should become subject to the Workeri Compensquon provisions of the Labor
Code, you must fort hwlth comply with such provisions or this permit shall be
deemed revoked.
TOTAL:
BUILDING FEE
TOTAL:
CONSTRUCTION LENDING AGENCY
I hereby afOrmthattherehsa ronstructlonnding agency for the perfor
lem
ance of the work u t which this =t in heated (Sec. 3097, Civ. C.)
SEISMIC FEE
ELECTRIC FEE
lender's Name
Leader's Address
I cenifythat l havereadthbappliutionand aatethat theabove information
BanI agreeto comply with all city and county ordinances and state taws
relating rebuilding construction, and hereby authorlu representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to live, Indemnify an it keep harmless the City of Cu pen Into
against llabllid it ma 'mansard expenses which may unary wayamme
against uid tyi con—se–q�ue�nce (the granting of thlt permit.
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE
ALTDi ORADDTOMECH.
AIR HANDLING UNIT GO 10,000 CFM)
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER I0,0WCFM)
CONSTRUCTION TAX
l°Yr I0jIc,42
Signature of pacat/conlrac r Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DICT)
CONSTRUE; fIONTAX PAID:
HEATING UNIT (TO 100,000 BTfJ)
Will the applicant or future building occupant store or handle harzrdoes
material as defined by the Cupertino Municipal Code, Chapter 9.1; and the
Ifeauh and Safety codera�Ssmion 25532(a)?
M Ye U No
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTA
^�
VENTTLATIONFAN(SINGLE RESID)
ISSUANCE DATE
P W p�
6
Willthe applicant or futurebuilding occupant use equipment ordevices
which emit havardous all contamlunts as defined by the Bay Area Air
Quality Management District?
` Yrs ❑ No
/ / haveread the hawrcloutmaterials requirements under Chapter 6.95 of
he
the Callfornla I lealth&Safety Code, Sen ions 25505, 75533 and 75534. I
BOILER -COMP OIIP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECIL SOFT.
understand that ifthebuildingdoes ret currently have a tenant, that it is my
responsibility to notify the o atpant of the requimments which most be met
,y
l:/'1
Oc
prior to Issuance of a Certificate of Occupancy.
z^as,
Q8 !
ISSUED BY: a IlluU
Owner or authorised agent Date
T
OFFICE COPY