24139 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building I'miet ldemlficatlon PER14TN
Building AddgsS ,.,, F, r6`t�P�C'6S .� . 9 Z 413 9
nem ares. f �7a� . 4 � CITY OF CUPERTINO-BUILDING DIVISION A
Contra Name: 7"r"eekrwLiee.No. APPLICATION / PERMITC"It `8 �.l•✓�[i
BLZLDINGaL TRICAL PLUMBINGMECHAMCAL CATEGORY
Architect/Englneer. Lic.N. CJ V
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE "r
LICENSED CONTRACTOR'S DECLARATION
hereby afffimthat l am licensed under provisions of Chapter9(commenc APPLIANCESRESIDENDAL JOB DfSC ON
mgwlth Section 7000)ol DtAsion3ofthe BuAncssand Pmfesslom Code,and my D
Itcense la In full force and affect. PANELS
License Clea LION
Date Contractor UP TO 2DOAMPS
ARCHITECTS DECLARATION 2II-1000 AMPS
q�u OC I understand my plans shall be used as public remrtls. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
e Z(/ Licensed Professional SfGN TRICAL TO ��
<c. OWNER-B UILDER DECLARATION / "/ \.� t
owing reassert.affirm that I Sectio m 31.5,B fmm the d Prolmlo License law forth¢
O 9 F. following (Section 7031.5,Business and Pmfeubna Cede:Any city or
l=y county which requlry a permit to construct,alter,Improve,demolish,m repair
<< .� anystruture priorto its Wuance,ah0 requirestheappUcent for such permitto xF\ y1�\�.F` �• s
K^
O c Ole a signed statement that he h r 9(commencing
c m pursuant it the provisoes of the - �-
��.55
Contractor's License Law(Chapter9(co e)orlingwith Setionhe0 f) fDivi-
-ate
�O slon3a(the Buslnmaand Pro(emiov Code)orthat hebexempt therefromand F" VALUATION
�3vil y •-t the boats for the allegedaloud exemption.the
Any t tolatbn of Section not
by any /� _ ai•.7VT
� app cant Lve^dredapermBsubjecb the applicant too civil penalty o(nu more than OU77'E7SSVJI F7X'['URF3V
c. nae u drd dollars(¢500).
Twho
1, a owner of the property,or my employees with wages as their sale NEWRESIDENTIALELECTR SQd.7. TYPE CONSTRUCTION'
C ation,wflldo the work,and thestruture is not intended or offered for
5 O Sec.7044,Busineas and Profeaslov Code:The Contractors License law
cosnot apply to an owner of property who Wilds or improves thereon,and OCC.CROUPRFS.UNITS
oes such work himself or through his own employees,provided that such
Improvements are em intended orofferedforsale.If,however,theb.0cling or T T
Improvement isaold within one yearof compltbn,the owner-W 0derwill have
theS*den of proving that he ala net Wild or Improve for purpose of sale). QTY. PLUMBING PERMIT APN
Ij L as owner of the pmperty,am exclusively contrating with llrensed pgRMIT ISSUANCE
contractors m coram t the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does nt apply to an owner of property who ALTER
Wilda or Improves thereon, and who contracts for such p\ojets with a DRAIN&VENT-WATER(EM,
,,➢➢..tt{ator(s)licenaed pursuant to the Contrator'sLicense Law. gAIX FLOW PROTGCT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this reason
DRAINS FLOG ROOF, SANITARY Y_ NOUTSID_
FEES
Owner Date R AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION FO(TURES PER TRAP '�� SCHOOL TAX Y N
❑1 hereby affirm that I have•certificate of consent to self-insure,or a RECFJPr N
ceniicate of Workers Compensation leenmance or a certlfid ropy themcf(Sec. GAS EA 5YSfFM lINC.40UTLETS
3800,Lab C.I PARK FEE ' Y N
I'ollcy# RECFOxr#
Cam any GAEA.SYSTEM-OVER 4 CFA)
[�CS edified copy h hereby furnished. BUILDING DIVISION FEES
❑CetOld copy is filed with the city Wpetion division. GREASE/NDUSTRL WASTE INTFRCEPTOR PLANCHECK FEE /)
ALL 1'C�
CERTIFICATEOMPE SATIO I N FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE sae
(ThlsaMlon need not be complied if the permit hforov hundred dollars SEINER-SANITARY-STORM F.A.20F7. Dale RCCCI
(SI N)orythain 1 WATER HEATER W/VENT/ELECTR ENERGYFEE Y
(certify that employ
an person
in an the so as to becomis e
esubjecrmit is hard,
I shag not employ any person in any manner n as to become subjet to the WATER SYSTEM/TRFA,DNG
WorkerA Compenwdon laws of Callfornh. Date PAID
O Z NOTICE
Applicant
Z D NOTICETO esub)ertothe orkersfter k ompe Certificate Exemption,you NEW RESIDENTIAL PCMB. SQFT, Date Recei t#
shouldbecome subjectit the Workers'such prsaHonprovhionsomits Labor TOTAL'
WN dermad umust fonhwith comply with such provisions orthh permit shall be a!
j ._. dermad revokd. BUILDINGFEE
CL
CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby affirm that there U a cum uction lending agency for the perfomr T ELECTRIC FEE �,
ance of the work(or which this permit Is Wud(Sec.3097,Civ.C.)
(� O Iandara name PLUMBING FEE
LL I- teneeranaarea, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenify(hall have mad thhappUVBonand aatethattheabove information
h cormat.Iagreemcomply with alltltyand counryadinanmand tate laws PERMIT ISSUAKCE l FEE$PAID:
> N reh0ng to bullding conswtion,and hereby authorize reprexntativea of this
1" Z city to enter upon the abo,mami.nd property for ivpmbn purposes. ALTERORADDTDMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
ago Wtliabilltica" dgmenb,cosband expenses whkh may In anyway accrue AIR HANDLING IINTT(TO 10,000 CFM) SUBTOTAL:
agabutszid Ci con ming of thio pemnit.
_ AIR HANDLInc uNrr(OVER la,000cFx) CONSTRUCTION TAX
Sig pa eo ontrator Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Ill the applicant or future building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTU) /
material as ae(Ind bythe Cupertino Municipal Code,Chapter 9.12,and the Date Recej t#
I kalth❑ Yand Safety Cod Set Icon 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
Willthe es applicant
or❑future bullding occupant use equipment or devices VENTILATION FAN(SINGLE RESd0) ISSUANCE DATE
which emit haaaous air contaminants as defined by the Bay Area Air
Quality Mavgerrcnt District? BOILER-COMP pHI'DR]W,IXD BTU) n O
Yes ❑No W
Nave read the hazarclowmnetab requirements under Cha pier 6.95 of BOMER-COMP(OVER IDO,000 BTU)
the California I lealth&Safety Code,Set tors 25505,75533 and 25534.I
understand that if the building does not cumently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr DEC 309
msponsiblllty to notify the occupant of the requirements which of must be met 19
prior to issuance a Certificate of Occupancy. 9
ch
OWner or authorised agent Uate ISSUED BY-.
TO A
OFFICE COPY