24291 PERMIT
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
N`Z4291
Building Project Identification
Building Address:
2 OAVVUA DA IL
s one:
e CITY OF CUPERTINO-BUILDING DIVISION
tncou'.Name: a Na: APPLICATION / PERMIT
��
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CO I
ten/Eaglmer. Lk.No:
/��! QTY BUILDING PERMIT INFO
ELECTRIC PERMIT FEEBLUG
Address:Vqi7 �/`�1. li(,�' PERL4TISSUANCE
IOR'SDECLARA �—
LICENSEDCONTRACTION
lhmbyaffirmthmlam Bcrnsedunderprovbionsof Chapter9(o.mmrn APPUANCESRESIDENTIAL JOB ON
iLnicgewniseth=S ®on7000)of DLivleisim3ofthe Busimmand ProfeneionsCmy PANELSlicense bin full and died. D aC ^
w
M sp/- 3
e Ganl.nar UP TO 2DO AMPS
ARCHITECT'S used public ION 2VERI0AMPS
µQS�2 I understand my pions shall be used n public rerorda OVER 1(IIjB AMPS SQ.FT.F1'ODR ARG 8/may/Q'fE�il''
E c Licensed Professional SIGNSE EC — OL-Wo %L V
G a OWNER-BUILDER DECLARATION gpp�MLC1R
I hereby affirenthat l son exempt fromthe Commences License Law for the
70' 1-2 following reason.(Section 70315,Business and Profembns Code:Any dty or gyp. EppR POL INST.
p5 countywhicn mquiresaperrNttommtmdalteylmpmve,demolish,orrepeir
a anystructum paortaibL ance,aborequrestheappBcentfwsuchpermitto TOWER EVICESDATE
V Bk a signed statement that he Is hcansed pursuant to the proallora of the
Owl Coatnctor's License Law(Chapter 9(commendog with Section 7000)of Divi- SIMMIMING POOL ELECTRIC VALUATION
sion3o(the Businenand Prof.Wb Code)orthathebewmptthemfmmand O�
< the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWI7'CHESFIX11)RES
applicant for a permit subjenathe applicant to a civil penalty of no rrore than Le l L
f=v xmdred dollars(>M. NEWRESIDENTIAL ELECTR_ STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sok
compensation,wllldothe work,and thestructure is net Intended or offered for
,r q xle(Bac.70K Business and Professions Code:The Common
le Llcaue Law
({r$$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES UNITS
E whodonsuchworkh4 lforth.ghhlsownemplW.,providedthatuch
improvement am not intended oroffered fw sale.lf,howevegthebulledegor
improvementbwtdwithinomyearofc=p]MWkthe owner-bullderwill have
tt-,ju rden of proving that he did not build or improve for purpose of sale.). QTY.1 PLUMBING PERMIT FEE FLOOD LONE APN
L1 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract..to construct the project(Sec"074 Buaineo and Profead.ns Code:
The Co tractor's License Law dm nd apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such Io jells with a FEE SUMMARY
�gB�Tador(s)llcansed pursuant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE OUTS I DE FEES
LII am exempt under See. B &P C for this reawn
DRAINS ITADR ROOF,AREA,COM). SANITARY Y_ N_
i Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIX•fUR6S PER TRAP SCITOOLTAX Y_ N_ -
.QI hereby affirm that I have a certificate of consent to. 4exurs,or a RECEBrf N
cenl0cete of Workers'Compereattoolu memor a certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N
3800,Lab Q BBC=N
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any
�Certifledcopylsherebyfumisheel. GREASE/INDUSTRLWASTEINTERCEP'NR PLANCHECK FEEr
Certified ropy b filed with the city Inspection division. �� 1��]
CERTIFICATE OF UEMPIION FROM WORKERS GREASE TRAP - PAID LSO
COMPENSATION INSURANCESEWER-SAMTARY-SfORMEA.700F1'. - Date Rece'
(Thbsedionneed not becompleted lithe permit bfmcme hundred dollars ENERGY FEE Y N
(810()w l..) WATER HEATER W/VENT/ELECTR
Icerti(yath epepr=nceofthe work forwhich this permit Is Issued, / Q
shall end pin_.)h any perwn In any manner so as t me sub to the WATER SYSTEM/TREATING
orkeri C t La .f Calif .Date PAID
Z Z t PLICANT:ILafter me t m)xl.ry You NEW RESIDENTIAL PIMB. SQFf. Date
O should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Codgyou.,Iforthwith complywltli provisions orlhis permit shallbe UILDIN "E
W >
deemed revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
3 CL G Therebyaork for w them bammtIsissu lendingagancy .C.) perform, ELECTRIC FEE
� Z ' an of the workforwhkhthbpermit b issued(Sec.3097,CIv.CJ PLUMBING FEE
u O lender's Name
LL Iendees Aadnne QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -
Ow I ceNfythatl luvereadthb application and auteNat theabove Wfomudo" PEES PAID
(U bcorred.I agreeto comply wlthall dtyand countyordlnam,esand state laws PERMIT ISSUANCE
} reading to building construction,and hereby authoize,representatives ofthb
F N A.gai. bii
n the above-mentioned property fns Inspection purposes. ALTER ORADOTO MECH.
? o save,IndemNfy and keep harMess the City of Cupertino Dale Reeeiptii
V ,pdgmend,costs and expenses which me innywayamue AIR HANDLING UNIT(f010,000 CFlN) SUBTOTAL:
irems quanm°f ins grant tni. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CIIIplicant/Conlrad.r Date 09 IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Future budding occupant store or handle hazardous HEATING UNIT(TO 100,0DO BTU) Date Rec '
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
iln lth and Safety Code Section 15537(x)7 HEATING UNIT(OVER 100,000 BTU) TO
❑Yes ,I+�—,1 No
WBlthexpplANQ
lant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
whichemithazardousair rict? nb as defined by the Bay Area Air ���
Q�jalry h eManaga entdou DLSWct7 BOILER-COMP OHP OR 1 WOOD BTU)
Yes ❑No
have read the haxeR us materials mquimments u oder Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU) pp
the Callfomla Health&Safety Code,Sections 15505,25533 and 75537. 1 1' ® 01.
undo.tondthatifthebuildingdoesnot.vr tlyhavcatena.tthatltbmy NEWRESIDENTIALMECH.
no"
to notify the occupant of the requirements which must be rect APR prior to issuance of a Certificate of occupancy. pFa!
Owner or authodud agent Date L ISSUED BY:
OFFICE COPY