24160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ea Idemlfkadon PERMIT N24160 416 0
BuOding Addreea:
oar .
s ns: 'r
hone: APPLICATION DA 11
f-r C I CITY OF CUPERTINO-BUILDING DIVISION A ^ .1 L SGL Z
no- °'•Name: Lk.N«^ APPLICATION / PERMIT L—b
BU[LDINGELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL p
Architect gfecer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ '�/� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION f JOB
[herby Sectio 7(XXEo lam licensed ofthe erpmvWnns°f Chapter 9(rommenc APPUANCESRESTDENML JOB D[SCRIIPI'ION
Ingwitloonseh infonforneafd effi on3 ofthe Buslaaeand Pro(eWonsCode,and my - �I
license is In(uB forte and d(e<. I PANELS
F:-,:(
1l(�
License Class Llc p
Date Contractor
ARCHITECI`S DECLARATION MI-1000 AMPS
I�q++NZPS p I understand my plamshatl be used as public records. OVER IBRO AMSQ.Fr.FLOOR AREA
E (s Llrenxd Professional SIGNSELECTRICAL
6 EG'71 OWNER-BUILDER DECLARATION SPECLILCD2CUIT/M75C
ZR—(, � IFerebyaf0rm that l am exempt from the Contractors License Law for the
following reason.(Section 70315,Bushes and Profeslona Code:Any city or
OI.. TEMP.METER OR POLE INST.
r,4 tountywhlch rcgrto It issuance, .It
th .provcdem..th,orrepatr
anyelrodure prlartolts Wuance,also rcqulrestheappBcant forsuchperf t e POW,ERD��
0 filCe a signed statement that he b licensed pursuant to the provisions of the
pµ�-• Conno e.License Law(Chapler9(rommencing with Section 7000)of DIA-
H OS slon3 ofthe Business and Profess mCode)orthat he k VALUATION
exempt therefromand SWIMMING POOL ELECTRIC
yd the basis for the alkged exemption. My violation of Section 7031S by any
applicant fora permit subjects the applicant tone civil praltyof not more than OUTLETSSWITCHFSFIXTURFS
flue undred dollars(ISM.6I,a owner of the property, NEW RESIDENTIAL ELECTR SQj-T, STORIES TYPE CONSTRUCTION
(^n a perly,or°ty employees with wages thele dole
mmpcnuHon,wllldothe work,end i..C ciurc V not Intended or coffered for
O dale(net. pply to an owerf property
Code:'The or improves,
License law
�$ don nonsuch torn owner ofp f or rough isownemwho orlmprwmted thateon,such
OCC.GROUP RFS.UNITS
and
whom,eme.to.orkhlmte ded.mughhlsow ak.If,Zees •nide providedthatr
Improvement are not Intended orolfercd Torok.If,however,the building or TOTAL:
Imp vement idsold withinoneyearofcmnpletlogthe°caner-bullderwlll have
to rdenofpseving that he did mat bund orlmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontoodors to mmtmct the project(See 7094,Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN k VENT-WATER(E,U
builds or Improves thereon, and who contracts for such pcojrcts with a FEE SUMMARY
&or(. Iiccr, pursuant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE
LJ
IS=under Sec B k P C far this reason
Owns DRAINS FLOOR ROOF,AREA.COND. SANITARY Y . N
Date RECEIT M
WORKMp`➢ COMPENSATION D Data A ION p1X13JRFS PER TRM SCI IDOL TAX Y N
❑1 hereby•(firm trot 1 have a certificate of consent to seB-mare,or a R �r
cedifiateo(W°rker Compensationlmuranmmaunifkdmpythereof(Sec.
3800,Tab C.) GAS EA.SYSfEM-1INCA OUTLETS _ PARK FEE, Y N
Policy p - RECEIPT p
Com an GAS A)EA.SYSTEM-OVER BUILDING DIVISION FEES
Certified copy to herebyte GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CeHlfied ropy t(Bed withh the city tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS` GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAhgTARY-STORM EA.200RT. - Date Recvi tN
(Thlssese.) need rad cecompleted ItM permit tfm oro hundred dollars
(9100)orlythat In WATER HEATER W/VENT/F],ECTR ENERGYFEE Y N
ell son employ
anhe y
1.an t...orhe work forwMN thispermitc blued, —
I scull not employ any person In any manner an nee to become subject to the WATER SYSTEM/TREATIN'G PAID
Compensationcrv'CompensationOwe o(Ca California.Data Q Z ApplIcart
raNEW RESIDENTIAL PLMB. SQ.FT. Date Recei tic
Z O NOTICETO APPLICANT:If,after king this Certificate of Exemption,
Hshould berome subject to the Worken'Compevait..provisloa of the Johor TOTAL:
L4 Code,youraw.tforthwlthmmplywlthauchpmvklomorthhpemdtshallbe
W > deemed revoked. 13 1 N
LU C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafflrmthat there is a construction lending agency for the perf mmry ELECTRIC FEE aa,lzv
7 Q ance of the workfor which this permit is issued(Sec.3097,Cly.C.) TOTAL:
(� Lender's Name PLUMBING FEE
LL I— Lender`.Addres QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IsmnImrtlfytharee t l haveread this appilcatknand state thattheabovelnformation
1 ect lagtocomply wIth.11 city and countyordie...and nate lows PERMITISSUANCE FEES PAID:
>. relating to building construction,and hereby authorise reprenotatlyesofthis -
H Z city toenterupon the above-mentioned propertyfor Wpetloopurposev. ALTER OR ADD TO MECH.
Me)agree to save,Indemnify an d keep harmless the City of Cu portion Date Revel t#
V
against liabilities,judgments,meta and expenses which may In any way sector AIR HANDUNG UNIT(To J0,0D0 CFM) SUBTOTAL:
sit i tea id City
sit eons once,(the a ting of thio permit.
. AIRHANDUNG UNIT(OVER lo'colu ) CONSTRUCTION TAX
_J
„ren AppOcant/C racior Date EXHAUSTHOODM/DUCT) CONSTRUCTION TAX PAID:
I OUS MATERIALS DISCLOSURE
Will the applicant orfuturc building ottupantat.m or handle hazardous HEATING UNIT(TO 100,000 BM Date Recei t#
materUl as defined by the Cupertino Municipal Code,Chapter9.12 and the
Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yrs M No
TV III the applicant or hours building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE ATE
which emit havrdous air contaminants.,defined by the Bay Area Air pp��
Quality Management DWHct7 BOILER-COMP pP-0'DR 100,IXD BTU) 1f. A '
�4 Ym ❑Na
4have iii the h toHeath&Safety Code,terSections
hundeand 25534 6.95 of BO LFRLOMP OVER 100,000 BTU) AUG �js 'g92
the Gltandt Health&Safety Code, otc currently
75505,ve at and25539.I nvG
understand that notifythe the occupant
not ce require encs which that 11 troy NEW RESIDENTIAL MECH. SQJT
responsibility to notify the ocmpant of the requirements which most be met
prior to issuance of a Certificate ofOccupa ncy.
CITY Ur vuY[n 1 114U
OtornI m authorized agent Date
TOTAL: ISSUED BY: _ CX'
OFFICE COPY