24404APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Building Address: T
i o FTI lJ 2
PERMIT "24404
Z 4 4 0 4
ere ams:one:
AI/)� IL2.4Q UY{cS3
CITY OF CUPERTINO-BUILDING DIVISIONt�
APPLICATION I PERMIT
_ A
16'Z7-ck"L.
Contractoram
' N: Lie. No:
r ' A/ �
BUILDINGELECTRICA4PLUMBING-MECHAMCAL
CATEGORY
CONTROL H
+ ArchitectEngineer Llc Na:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑ [2LICENSED
CONTRACTOR'S DECLARATION
Ihereby Socti firm n70thetlam licensedoftheRrleassaomofChapter9(le,and a
mense I, cction force and affect. gltheeusinessand Pro(emlonsCode,and my
license is in full force and affect.
APPLIANCES -RESIDENTIAL
y `
?!
ST�IOLU �
PANELS
License Clan LILY
Date Contractor
— UP TO 200AMPS
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my pons shall be used as pubbe records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professforal
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
SPECIAL CIItCU1T/MLSC
TpMp METER OR POLE INST.
IVWER DEVICES r^ n
following reaaon.(SMion 7MI5, Business and Professions Code: Any city or
countywhichmq.trcsapermltwmntr u,altegimprove,demolbh,ormpair
anystmu mpriartoltsbsuance,aoorequimtheappbcartforsuchper to
file a signed statement that he o licensed pursuant to the provisions of the
Contractor's License Low (Chapter 9 (commencing with Section 7000) of Divi-
sion3 oftheBusiness and ProfessionsCde) orthat he b exempt therefromandTION
the basis for the allegd exemption. Any violation of Section 7031.5 by any
fora permit subje ts the applicant to a civil penalty of net morethan
hundred dollars ($500).
as owner of the ro party, or my employees with wages r ffer sok
rkand
T
1
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIKIURES s/}appOwnt
"'\-Dfive
NEW ftF3DENTfAL ELFOTRI, SQATE.--
'sale&compeneatlon,will
FRO
ECONSTRUCTIONp
Busdothe essand
alnowand
feaskestrudurcbn ontrendedo icense Lforsale( Sec 7014,
Code:The Contractors Licenselaw
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE rpt
ALM -DRAIN k VENT- WATER (EA)
to property
does whodetappift toanumariner o(prough whoa ilds emor improves ym,prvided tatandRFS.IIMTS
who doessuch workhimsel(nrthreugh his ownemployees, provided that such
Improvements are not Intended oroffered for sale. IL however, thebuilding or
Improvement bsold within, ayeargfeomplaion, theowner-buBderwill have
tlittlurden of proving that he did not build or improve for purpose of sale.).
L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Business and Profession Code:
The Contractors License Law docs no apply to an owner of property who
builds or Improves thereon, and who contracts for such pipjects with a
�gDlTaact(.) licensed pursuant to the Contractor's Llcenw Law.
LJ I am exempt under Sec It k P C for this reason
p(OODZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
CH ITI..Ie FEES—
. Owner pHs
DRAINS FLOOR ROOF, AREA, COND.
FDCPURES' PER TRAP
SANITARY Y N_
RECEIPT Y
WORKMAN COMPENSATION DECLARATION
❑[ hereby affirm that I have a certifrate of consent to seB-insure, w a
certificate of Workers' Compensation Insurance ora cemfied copy thereof (Sec.
3800, Lab C.)
Poll Y
SCHOOL TAX Y N
RECEIPT M
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
A LETTM
Com any
�Cehified copy o herebyfurnished.thehd.
Certified copy b filed with the sty W pectlon division.
GAS EA. SYSI'FM-0VER4(FA)
CREASE/WDUSTR. WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKER$'
COMPENSATION INSURANCE
(Ihissess.) need not bucomplaed ifthe permit bfor one hundred dollars
($100)wfy that
(certify emanon any person
1 shall not employ any person In any manner at u to become subject to the
in any manner so as to b co permitwbec issued,the
W plicae Compensation Iowa of Cali(arnb. Dace
ani
PAID
Date Recei tq
SEWER-SANITARYSTORM EA. 200FT.
WATER HEATER W/VENT/ELDCTR
ENERGY FEE Y N
PAID
WA /TR ,DNC /'
R' AL PLMB. SQ,FT,
NOTI
NOTICEco esPLICANT:eWtar maComprationCertificate of
purwis Exemption, you
shouldbecome subjectto the plywit Compemationprovisionsr the Labor
Cde, you most forthwith comply with such proadslons Ortho permit shall be
docened revoked.
Date Reeel t#
TOTAL:
BUILDING FE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a construction lending agency for the perform
arca of the work for which this permit o Lord (Sec. 3097, Civ. CJ
laodces Nacre
IedersAadreaa
Irrect. I agreet c mply is wth allcit andco my hat Orth nabs ed gatelamreroingt building complywo, andhereyauhoordinancesand matelaws
relatobuildingcaboveienandherebyauthorzercctionatives ofthiserupon the, Indic mentioned property for Wpecibn purposes.
save, indemnify an d kap harMess the Clty of Cupertino
asblllties,' dgments, cotlsand expenxs which may fn anywayacwe
City In n fthe granting ofthis m,if.
SEISMIC FEE
SEISMIC F FEE
Qn. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNR (TO 10,000 CFM)
BING FEE
ANICAL FEE
!ELECTRIC
te Receiptit
AID:�o.t
SUBTOTAL'Id
AIR HANDLINGUNIT(OVERIiLoDocFM)
CONSTRUCTION TAXgwof
Applicant/Contraar to
HAZARDOUS ATERIALS DISCLOSUR
Will the applla of or future building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Cd�Se�Ion 25532(a)7
❑ Yes _ U No .
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Recei
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
IOTA
Will theappliantw(uturc building oavpant use equipment or devices
which emit hazardous air contamimnts as defined by the Bay Area Air
Quality Management District?
4 d No
f haveldad the hares oua materials mquirements under Chapter 6.95 of
the California Health k Safety Code, Sections 25505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requlrements which most be met
prior to Issuance of a Certificate o(Occupancy.
VFNIILATION PAN(SINGLE RFSID)
ISSUANCE DATE
{fig 11 a pa
G P4 L BJ
OCT �� �
�! o
`rITV 1r�Urjy'i
ISSUED 6Y:
BOILER -COMP 0HPOR 100,0(0 BTU)
BOILER -COMP 100,000 BTU)
N'EWAEIDENTIALMECH. SQFT
Owner or authorized agent Date
TOTAL: I
OFFICE COPY