24430APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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24430
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OFCUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAI.PLUMBINGMECHAMCAL'
J�jA
Contra _ Na
/_ =
�T� `! (
Archne /Engloner LR,. N.
CATEGORYCONTROL#
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address -
❑ N 1:1 1:1-
PERMTEISSUANCE ��
LICFNSEU CONTRACTOR'S DECLARATION
IMmbyafflrm that l am licensed under provWons of Chapter 9(commenc
Ingwfon7000)olen3ofthe Buslnssand Pro(essloneCodeand my
licenscisinfutIftnexanddfoct.
APPLIANCES -RESIDENTIAL
103 DESCRIPTION
Y 64.
PANGS
License Class #
#
Date Contractor
UP TO 200AMPS-
_
101-1000AMI
ARCHITECPSDECLARATION
lundentand my plamshallbeused aspublicenoerds.
OVERI000AMPS -
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL'
Licensed Professional -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contnnor's License Law for the
following reason. (Section 7031.5, Business and Peefved mCode: Any city orq�(g
county which requires a permit to construct, alter, improve, demolish, or repair
anyawctvre pdortolb Umance, alw rcqulreathe applicant (ouchpereatto
n
file a signed statement that he Is licensed pursuant to the provisions of the
Conlractorb License Law (Chapter 9 (commencing with Section 7000) of Divi-
el..3ofthc Buslecsaand Professions Cede)orthat he he exempt therefrom.nd
SPECIAL CIRC[IT/MISC-'Z
ry.( '
(" I�'� • -
METER OR POLE INST. ,
POWER DEVICES 1
SWIMMING POOL ELECTRIC
. VA UATION -
the boats for the alleged exemption. Any violation of Section 7131.5 by any
applicant fora permit subjects the applkant too dull penalty dnot mare than
flue hundred
as hepre
I, as owner of the property, or my employees with wagers their dole
OU7LETSSWITCHFSFIX3VRE5
-
NEW RESIDENTIAL ELEC SQ.FT.
qp
i
n
STORIES TYPE CONSTRUCTION
will the work, and a not Intended or offered for
r
-
(See aptly kmhe
.In CS,compensation, 0K Business
alne Co
Code: Th Licerue law
C.etraorimp
-
doe to owner f grope ty builds over
whodoes tapply tornurgiofp rough whobuilds
employees,povidedreoRand
provided that such
wheaoeuentsamwork hiotended
ownor
OCC.GROUP RES. UNITS
ormghed
improvementsarenotIntended .Ihowever, g or
improvement bwld one earo(cd pletio. the e
owns bu Elder ill have
s
'
proving that did natfbuild or Improve for purpose of le.).
tlLurden ofonerof the pM1eerty,a exclusively contracting
contracting with Ilmved
(cense.
u c as owner of the property, Be ea044, Business
Business and Cade.
contnctontemmwnseLawdoes
QTY, PLUMBING PERMIT FEE,
-PERMIT ISSUANCE
FLOOD 7ONE APN
The Contractors es the Law does not apply tct an owner of property who
ot7 apply of
builds or Improvice thereon, and who contracts Lice such ptojem with a
the Contnctofa Llrenm Law. �
m,pp((�Iactar exempt under Sm
Lj I am exemp under Sea B k P C for this reason
ALTER -DRAIN 4 VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
GRAINS FLOOR A, COINED, ROOF, ARE
F��RES'PfR TliAls
SANITARY Y_ N_
RITEIT #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby dfirm tM1at I have certlRote to
SCItOOL TAX Y N_
• of consent self -Insure, ora
re00,La eofWorken'Compewtlen lmurana ora artifled ropy themof (Sec.
3500, lab Cd
RECEIPT #
_
GAS- F.A. EM
A. SYST-I INCA OUTLETS
-
PARKFM Y N '
Policy #
RECEIVE M
GAS EA. SYSTEMOVERI(FA)
ray
ccrtlBed
BUILDING DIVISION FEES
copy V tiled with theertified copy Is hereby Furnished.GREASE/INDUSML
Ce city
inspection division. ry
WASTE INTERCEPTOR
PLANCHECR FEE '
GREASETRAP -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisdedi.e need net be, completed If the permit is forces hundred dollars
(8100)otifyth
all net that In any Examenhe I any a n ner so as tobeca e. bj lc issued,
I shall not employ any peas In any manner de es to become mbject to the
Workers Compensation Laws of California. Date
PAID•
Date Recei tN
SEWER -SANITARY -STORM EA. WERE.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y ' N
' . '
PAID
WATER SYSTEM/TREATING -
AppliNOTICE If,
Nouldb co APPLICANT:e after making thio .ti.n catepm ,i... the f Exemption,
the Workers' Camp of the Labor
should bemmat
Da[e Rece) [g -
NEW RESIDENTIAL PLMB._SQ.FT.
' .
'NOTAL:
forthwith ewtlon s or this
deemed v.kad.orthw0h comply with such provisions or thio permit shall be
deemed revokes.
FEE
_11UILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lendlegagency, for the perform
Lece of the work for which this permit Is Issued (Sec. 3097, Civ. C,)
TOTAL:
-
ELECTRIC FEE
pders Name
Lender's Address
Icertifythat I have readthisappllcatlonand drat. thattheabave information
is correct. I agree to comply with all city and county ordinances and state laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
�'
PERMITISSUANCE
FEES PAID:
relating to building mmtmetion, and hereby authorize, representatives of this
city to enter upon the alxcw-nentloned property for inspection purposes.
(We) agree to save, Indemnify an d keep 'h..Mess the City of Cupertino
against liabilities, judgments, costsand expenses which may In anywayaceue
aganstsaid Ci in4 sequenthe ntingot 1.N.lt.
L
Date ReceiptA
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING IINTT (OVFlI t0,000CFM)
CONSTRUCTION TAX
geatureooff Apppllnnt/Contractor Date
EXHAUST I EOOD(W/DUCT)
CONSTRUCTION TAX PAI D:
HAZARDOUSMATC LSDISCLOSURE
HEATING UNIT (TO I OQ000 BTU)
Will the applicant orfrc uwbuilding occupant store or handle hazanlous
resterlal as defined by the Cupertino Municipal Code, Chapter 9.I$ and the
Health and Safety Code Section 25532(a)7
ED Yes No
Date B.tk
HEATING UNIT (OVER 10),000 BTU)
'TOT
VENTI LATION PAN (SINGLE RES/D)
- ISSUANCE DATE
'
Will theapplica nt or.tu re bu lld ing occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP DEEP OR 100,IX0 BTU)
Quality Management District?
Yea ❑ No
BOILER -COMP (OVER 100,000 BTU)
Ihave lead the hazarJomaterials requirements underChapler6.95of
the California health A SafetyCode, Sections 25505,25533 and 25534. I
p P
Pi E
NEW RESIDENTIAL MECH. _ SQ.IT
understand that if the building docs not curmotly have a tenant, that it is my
responsibility to notify the occe pa on of the mqu Imment s which must be met
prier to Issuance of a Certificate of Occupancy.
'
'V
Ov 06, 11asas
99
C/w (f(
ISSUE BY: r,..
- .:
Owner or authorized agent Data
TOTAL:
OFFICE COPY'