24238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PaoMemlfkatl® PELWTN24238
, 4 2 3 8
Building Add.: — Z
S0.rCi �QV1 Y t2 Z 1 CITY OF CUPERTINO-BUILDING DIVISION
cantrenl �AJFiQ. u .Na APPLICATION /PERMIT
BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
Architect/Fsglnean Lie,No:
QI ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMUISSUANCE ❑ ❑ T% El
CONTRACTORS DECLARATION
I hereby affirm that lam Bcensed under provttlovof Chapler9(oxn a APPLIANCESRE5rDENp1AL BDESLREPTION
Ingwlth5enbn7000Iof Glvitlon3ofthegutlrrssand Pro(eWovCode,and my w+�
license la In full faro and k,#
PANELS IL`i1T1
DateClam Lon I �
Due GOnranOr —UP TO 2DOAHM
ARC/IITECPS DECLARATION "1000 AMPS
X'Z I understand my plans shall be used an co
public rerds OVER IDDO AMPS SQ.FF.FLOOR AREA $/SQ.FE.
COC
U Licensed professional SIGNS EI.FLIAICAL
< OWNER-BUILDER DECLARATION SPECIALCIR=T/M19C
t., 3 owing reason.
a(Rrm Sectio 7 31.5,B aom she d profession Lbeve Any dr the
7 Q
following re req(Section 7 to By d and professions, Code:My dry or
F G I—� TEdP.METEi OA POLE INST.
4� must:ywhk pre toiapemmt a6 reqs tlmcaph=tfmoLLsh,ar rtpalr
anya signed
statement
lasuancp ace licensed purNeat to the rovisions of t e pITVF.R DEVICES
5 Ole a acor'3 sUtemeLa that k b r9(ompurring to the pmWbns of the
ContranorS Llcemelaw(Chapter9(mmmenWg wlthSM1on 7000)o(DIW- SWIM AING1WL ELECTRIC
t, the Nab
thealnand Profembns Cade)or Nathe le Sodlcm therefrom and VALUATION
the barb for the alleged ucta the n. My vidad vi of Smbn 70115 by any
0� appBcantfora permit subjene the applkanitoaadvll penalty dnot court thin OUTLETS-SWITCIffSFLC[i1RE5
LW,h ndred dollars($SM. NEWRESIDENTIALELECTR SQFI.
I STORIES TYPE CONSIRIIC-LION
a owner of the property,or my employees with wages as their wle
7a c naatian,will dothe wokandthe structure hral weneed or offeredfor
❑ (Sm.7044,Bunkess and Professions Code:The Camra...Lcova law
$$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who don such work himself or through his own employees,provided that such
Improvemem.art rat Intended uroffered for sale.If,however,the wilding or 'TOTAL
impmverrcnt is sold within one year ofcompletbR the ownerbulk erwill lave
t rdan of proving that he did build or Improve for purpoae of sale.). QTY. PLUMBING PERMIT FEE
UI, m roas owner of the Property,am aachsively contracting with licensedFLOOD ZONE APN
contradma to mnslnun the projeet(Sec 70K Busbies and Professions Cade: PFRAL[T E3SUANCE a
The Contranor's Llaeve Law don not apply to an owner of Property who ALTER-DRAW&VENT-WATER(EA)wilds or improves thereon, and who contrans for ch suptojeaa with• -
'gW�adone)Bceraed poomant to the Contrenor.Limnse Law. BACK FLOW PRO FEE SUMMARY
LJ I am esemp under Sec B &P C for this maso.
DRALNSO
TF
OLTSIQr ES
FTOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECENT I
iWORKMAN COMPENSATION DECLARATION Y
\❑1 hereby.111.that I have•arttRate of consent to self-insure,or a pp^ rr PER TRAP SCI100L TAX _ N_
adlfime of Worken'Compevatlmlmuranre as artifled ropy thereof(Sec RDCEBT I
7800 Lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
iviey Cpm I AEY:EIITI
GAS FASTS OVER4(EA)
y U1L ISION FT.FS
Certified ropy in hereby furnished. CREASE/INDIISTRLWASIEINTTRC K '
Certified mpy b filed with the Inspection Inspen division. V ISM
Q
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP IyC 1
COMPENSATION INSURANCE gAyplygAM.I.ARy STORM FA IO�T. [ n, 1 [�I
(fhla section need na be completed If the permit Info one hundred doUu
(Dib)or less.) WATER HEATER W/VENT'/E D= N
Irl nor employ
an peaon In of Newark forwhith Ihl.pemdtclasued,
I shall not employ any person N any manner u s to become subject to the WATER SYSTEM/TREATING
Woken'Compewuon Laws of Ghfamla, Date � PAID
O Z Appllant
Z O NOTICETOAPPLICANT:R,afler makingthla Certifinbof Eaemption,yau NEW RE9DENIIAL PLMB. sQFr. Date Reoei tM
Mould become subto t to the Workers'Cmmpernation provisions of the Labor TOTAL:
CC (n Code,ymr fl hwnhmmplywithsuchprwL morNbpem J llbe
W > deemed revoked. BUILDING FEE
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihercbya(flrtnthatthereisamrntauniwkndingagencyfortheperfomm ELECTRIC FEE
Z ance of the work for whkh thin permit is Lvsued 6ec 3097,Civ.Q —s
U O Iandar:Name PLUMBING FEE
LLI— Lander.Addrea, - QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O LLJ Irerti.lNati hoc=plyN h&Batyaa ante Nat Nea andf telawa
11 rviallrbmrrm.lagreeto complywLLh andtaaMmuntyL,a nepncoasnd�alelaws I'FRh11T 155UANCE FEES PAID:
} titytogtowllding cansW¢lon,and Fertopertyotr petsionpurposo(thla -
FZ cLL(Wr)aaree to aw,inve-mentbvd propertyfoinspmbn of Cups. ALTER ORADDTOMECH. Date Receltri
— (We)abicc to save, arts,c sisify an d keep hvmless the Cha of a pert W ,
agaWtllabBltka,jadgmentq mMsaM expenses whldt may In any way accrue AIR IiANDIJNC[R�TT(TO 10/W CFM) SUBTOTAL:
a alnst CRY In of the grantiogpfthlapemdt. AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCIIONTAX -
- 16-9
Slv reof AppBont/Cmtranor Date DMIAU6E HOOD(W/DUCT CONSTRUCTION TAX PAID:
DA 7ARDOLS MATER ALSDISCLOSURE
Wllltheappliant or mmbuDdingaaupant AomorhaMkha>,r HEATINGUMT(TO 1DO,WOBTTP Date Recd [ll
material as deflmd by tit Cupertino Murddpal Code,Chaptcr 9.17,and the
E4vnhaad Safety Codc Sedhtn75532(a)7 HEATING UNIT(OVER 100,000 RMTOTA
n
Y. �]No
IB the applfant mfumm wilding oreupant useaquipmou mdevkca VENTILAT'10,\e FAN(SINGLE RFSD) ISSUANCE DATE
whkh eMt havrdms ale contamivnts as defined by tM Bay Area Air
Quality Maoagcmran District? BDI ODMP 0HPOR IDO,OW BTU) A O D
4 Ya ❑No
Y
have read the b—Nm.materials requbemenb undo Chapter 6.95 of BOILER-COMP(OVER IMOOD BTU) ���
tM Glibmla Heahh&Safety Code,Smians 25505,25513 and 75534.I a„
understand that lfthewilding docs rent eartently have a tenant,that it is my NEW RESIDENTIAL MEt71. SQ.FT ` 1(T(]eF
rnpovlbuity to notify the occupard of the roquirtments which=at be met
priortoimuancodaartifkateofoc opamy. CITY r'1 t- VUI,/
Owner a authorized agent Data
TOTAL ISSUED BY:
OFFICE COPY