24158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ, 41 5 8
Building Address: Z
/O x3EV 'cls, P c_
weer. ams: - t'I one: A
IL
T CITY OF CUPERTINOLBUILDING DIVISION / Z
C.ntradm. ams: Lic.No: APPLICATION I PERMIT Q
BUILDING-ELECTRICAL.PLUMBING-MFLHAMCAL RY CONTROLM
o:
ArcMtM/Engl neer. Llc.N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I PERMITISSUANCE D ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I�
]hereby affirtnthat lam licensed underprovlslane of Chapter9(commmo- APPLIANCESRIESIDENTIAL JOB DESCIUPHON
ingwlth SeMon71XD)of DiW.ton3 ofthe Buatnessand PrefeulonsC-ode,and my a
LIcar.cense slns forte and Nett. PANELS �� 1
Date Class LIcI C l l..
Date Contractor UP TO 2DOAMPS
ARCHITECTS DECLARATION 201-1000 AMPS
O
Z l understand my plasashall be used u public record.. OVER1000AMPS SQ.IT.FLOOR AREA b/SQ.FT.
CO
(t LlrnasM Pro(eselonal SIGNS ELECTRICAL
6 LCd�
OWNER-BUILDER DECLARATION /7 / l A �' C � 3
IhercbyafBrmlOWNE exempt ER the LARATor'sllcenec law for the SPECIAL CIRCUIT/MSC MISC �(/ G
pp following reason.(Section 70315,Business and Professions Code:Any city or
O Z F TEMP.Ml'f1R OR POLE]NST.
p� c.antyctur,requlresaperMttommrequtltheapmvgdemoWh,orrepao �//�I q7�
J anya sigaerc statement
that he I,Ifte raed pursuant to the re,ixihpermit e e a s u 1 l-
y POWER DEVICES
PG � Bk a signed etatemenl that he V licensed pursuant to the provlsiow of the
Contractor's LiceveLaw(Chapter9(commencing with Section 7000)o(Divi- SWIMh1INC POOL ELECTRIC DA
sion3acthe Licenses sad(Chapt r9(code)arthat he Vexempt therefrom and
�n S the basis for the alleged exemption. Any violation of Section 7031S by any
0 applIcantf.ra permltsubjects the applicant too civil peachy of net merelhan 2—OUTLETSSWITCHESFf%7LRE5
it
undred dollars(g500).
v�
NEW RESIDENTIAL ELECTR FT.
�n I,as owner of the property,at my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,willdothe work and thestrueture is not intended or offered for
0 In(Sac.7094,Business and Professions Code:The Contractor's License law
does not apply to an owner of property who Wilde or improves Iherearc and OCC.GROUP RFS UNITS
whodeassuchworkhimselforthrmgh Neownemployees,provided that such
improver nbarenmffitendedoraffemd(ovule.I(,howevegthebuildingor TOTAL:
Improvement Issold wlthinoneyearo(completlon,theowner-W elderwill have
tl(Ok.�den of Towing that he did not build or improve for purpose a(uk.). QTy, PLUMBING PERMIT FEE FTppp7pNE. APN
LJ I,as or of the property,am exclusively contracting with licensed pERMLf.ISSUANCE
contract."'to construct the omject(See 7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTQtDRAIN&VENT (EN
Wilds or Improves thereon,and who contracts for such pEuk - -
cts with a FEE SUMMARY
co5act.oWlcensed pursuant to the Contractor's Lt...Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under I&P C r this rc to
t SAMTARY Y_ N_
Owner to DRAINS FLOOR,ROOF,AREA,CONE).
RECE PT R
WORKMAN OMP ION consent
ON FIXTURES PER TRAP SCHOOLTAX Y_ N—
❑I hereby affirm that I have•certi0ate of consent to self-iwm,w Ale a RECEIPT N
3800Q38 .(Worken'Compevatlonlrourance oraartBied copy thertrof(Sec. CAEA.SYSTTM-11NC4 OUTLETS PARKFEE Y_ N
0,LabTab CJ S
Policy p -
RECEIPT M
CGAS EA.BYSTFM-0VER4(EA) BUILDING DIV
ISION FEESmCYlLed
copy is hereby tthe city
Cavilled GREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
copy V(Bed with
the ty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORM EA 200FT Date Reeei [#
f0)s section need not W completed L(he permit V Ionone hundred dollars
(4103)rtifytJ WATER HRATERW/VENT/F3 FCTR ENERGY FEE Y N
Icertlfy imp Nthe performance o(the work brwNchto sppqe.rtnl yis&bwed, —
I shall not empl an Tenon In an mann °adT'a._`�"` WATER SYSTEM/TREATING PAID
Workers Corp¢Jey�y n sus o(CayyQcola.
O Z ApT0antr N. 4 NEW RESIDENTIAL PLMB.—SOFT. Date Recei t#
Z O N'OTICET IJ.I Lafter making this CertRlaExemptbn,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you=at forthwith comply with such provbiay.,this permit shall be U INC
> deemed revoked. ELE
OW. G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a conutoct..lending agency forthe perform TOTAL:
ELECTRIC FEE
O arm of work for which permit owed(Sec.3097,C1 v.C.) PLUMBING FEE
V Te69-.00
nder's Name
LL F Lcadaea Address QTY. MECHANICAL PERMIT FEE MEC14ANICAL FEE
O O Imrtlfy that l have mad this appliation and YatethatthcIII above information
IL at correct.I agree to comply with all city and county ordinances and nate laws PERMIT'IR5UANCE FEES PAID:
>. N relating to building construction,and herebyauchorlureprexntativeso(this
H Z city to enter upon the aEove-mentioned property for Inspection purpose. ALTER OR ADD TO MECH.
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,coetaand expenses which may In any way cove AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalru laid City In con aceof a granting ofthis it.
// AIR HANDLINGUNIT(OVER 1B,BBBCFM) CONSTRUCTION TAX
IC
i
Slgmture of Applicant/Contractor I Data IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the .fined by the Lure building omipalCode, hhand In hazardous HEATING UNIT(TO 100,000 LTU) Date Recei t#
material as defined by the Cupertino2(t)? lCoda Chapter9.11 and the -�
Health and Safety Cade Section 25532G)7 HEATING UNIT(OVER 1 W,000 LTU) TOTAL:
❑ Y® r]No
Willmilth. liantorr occupant equipment ordevices VENTILATION FAN(SINGLE RESID) I UANCEDATE
which emlthagemnt airrict? nbas de0ned by the Bay Area Air I,a P6 11u!
Quality Management District? BOILER-COMP THP OR 100,000 BTU)
❑Yes ❑No
]have readthchazardoua ma terlaisrequimmenbunder Chapter Q95o( BOILER-COMP(OVER 100,000 BTU) �,•� n Ls a�F
the Cellfernla Health&Safety Code,Sections 25505,75533 and 25534.1 U �i111 L
understandthat if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECN. SQ.FT
mi,porsibllity to notify the occupant of the requirements which must W met 111X1)
prior missuanceofaCcrtlfhateof Occupancy. , CITY Ur Vtjr CST
Owner or authorized agent Date ISSUED
TOTAL BY_�� `� V
OFFICE COPY