24432APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT.'
BUILDINGELECTRICALMUMBING.MECHANICAL
Contrast 'm J Lic.No.
CATEGORY
CONTROL N
Architect/Gglmer. - Lt. N.
QTY �. ELECTRIC PERMIT FEE
BUILDING PERMIT,INFO". ,
Address:PERMITISSUANCE
❑ ❑ ❑
��
LICENSED CONTRACTOR'S DECLARATION
I ith Sa i e that l am Bceneed under provolone of Chapter9 (commas
Ingwith Section 7000)of Disislon3ofthallugeassand PrefeeslonsCode, and my
license le In full force And effect.
License Claes
Date Contorm ndor -UPIQ200ANIPSAy�/II�"S��13V'1�•
ARCHITECPS DECLARATION
I understand my phmahall be used as pubkcreaords.
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby affirm thatI am exempt fromtheContndorbLlcArAALawforihe
following reason. (Section 70'31.5, Business and Profession Code: Any city or
county which recta hes a permit to coasllud, alter, imp=, demoBsh, or repalr
any stmMure prior to its Issuance, also requires the applicant for such permit to
Ole a signed statement that he k licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(ommencing with Section 7D00)of Dist-
ivi-
at.
eion3olthe Business and Profemlam Code)ortha/hakexemptthereframand
bask for the alleged exemption: Any violation of Section 70315 by any
appilontfora permit ubjedsthe applicant toa civil penalty of not more than
five hundred dollars ($500).
FIL as owner of the property, or my employees with wages as their sok
compensulon, wllldothe work andthe structure k not Intended or offend for.
dale notppto ainan ow and f Eurpa ons Code: The or imp eves Llceme Taw
applynd
doesnotapplylorkbi ml orth=rtywhobulmplay m,pv lded thateat, ch
whodoes ntsaor th tededoroffe isowale.If owevrthebthmuch
improvementsarenal Intended earofred pies e. TLhowever, Hderwdingve
bnproverrcntkwld withinonayearo(complMbn,theowner-buBderwlll have
(h'e,kurden of proving that he did not build or improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to romtruct the pm)m (Sec. 7044, Business and Prefessiom Code:
The Contractor's License Law dues net apply to an owner of property who
builds or Improves thereon, and who contracts for such p(rs ofecwith a
o�j0t_[aet r(n) licensed pursuant to the Contradoes License Law.
Lj7 am exempt under Sec. B A P C for this reason
-
APPLIANCESRESTDENTIAL
J DESCRIPTION '
PANELS
201.1000 AMPS
OVER 1000 AMPS -
T.
FL4E]
S;11)�
i�.4
I , e
�V
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
TEMP. METER OR POLE INSI.
[OWER DEVICES
SWIMMING POOL ELECTRIC
f
OUTLETS-SWITCHES-FIXTURESOUTLETS-SWITCHES-FIXTURESthe
VALUATION
"
- -
NEW RE9DENTIAL ELECTR SQ.FT.
STORIES
TYPECONSIRUCTION
_
PLUMBING PERMIT FEE
OCC.GROUP
RFS. UNITS .
'
QTY,
pp n.35;VANCE
ALTER-DRAINk VENT- WATER (EA)
FLOOD ZONE
APN
FEE'SUMMARY
BACK FLOW PROTECT. DEVICE
n[jTq111V MIN
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY. Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that 1 have a mrtiBmte of consent to self -Inure, or a
cediflote of Workers'Compemallon lmuranm or a mMified copy thereof (Sec.
3600;1ab C.)
Policy
SCHOOL TAX Y N _
RECEIPT N
CASFA.SYSTEM-IINCAOUTLE1'S
PARK FEE Y N
RECEIPT M
GAS EA. SYSTEM -OVER /(EA)
M y
BUILDING DIVISION FEES
CcrtlOed copy k herebyth the a d.
/p(ouTm$jp_e- eMlEad copy k filedhere with the city W pectlon divlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb section need rad be complMed If the permit b forces hundred dollars
(Y1I emit that
' [artily that In the perfamunce ollhe work lorwhkh/his permit ie blued,
I shall not employ any person In any manner n u to become subject to the
Workeri Compenwtbn L.Wan(C.Itfornk. Data
Applicant
NOTICE co APPLICANT: a After makingthis Certlfk o iof sonempt the
should bemmcsfmhe lathe Wplyet Compematlonprothlp.o he Labor
Codgyeu muet(orthwlth amply with suchprovbkm or this permit shall be
seemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirenthat there k a construction lendingagenry for Me perform
W
ance of the work for which this permit k issued (Sec. 3097, Civ. C.)
Le.der's Name
LendefaAcidre.s' -•
leartlfythatlhavereadlhkeppliewlonandatatethattheabovelnfmmation
bored. I agree to comply with all cityand county ordlnancesand Male law.
relating to building comtrudlon, and hereby authorise representatives of this
city toenter upon theabovcment[rand pmperty for Inspection purposes,
(We) agree to save, Indemnity an d keep harmless the City of Cupertino
agamollabillks, Judgmenk, costa and expenses which may lnany wa a
agalastsaid City i ofthe ceratin thiepermit
�J IP,
CRRASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
DR'
ate CCeIPt#
GREASE TRAP
SLIVER.SANITARY-STORM EA. 20017.
WATER HEATER W/VENT/M TR
ENERGY FEE Y N
PAID
Date Remi t#
WATIR SYSTEM/TREATIN'G
NEW RESIDENTIAL PLMB._SQd7.
.TOTAL:
BUILDING
- - 70701:
SEISMIC FEE
EI-ECTRIC FEE
-
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
'
MECHANICAL FEE'
FEES PAID:
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(TO 10,000CFM)
Date ReCei t#
SUBTOTAL:
AIR HANDLING UNIT (OVER 3D,000CEM)
CONSTRUCTIONTAX
_
Igrutu, of Appimet/Contractor De
HAZARDOUS M RIALS DISCLOSURE
.. Will the applicant or future building occ'upantatoe or handle hasardous
material as defined by the Cupertino Municipal Cade, Chapter9.12, and the
Health and Safety Code Sedlon 25532(.)7
❑'Yes r] No
Willtheappllcam orfumre building occupant use equipment or devices
which emit harardous air ontamlnants as de0md by the Bay Area Air
Quality Management Dlstrld)
4 Ym f 1 No
have read the bass aus materials requirements under Chapter 6.95 of
'the California llealth k Safety Code, Seri Tom 25505,25533 and 25534, 1
understand that if thebullding does not currently have.(ceart, that It is my
respomibility tosance of a Certificateof t of theOccpa requirements which must be met
prior to issuance cola Certillotc of Occupancy.
.'EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HEATING UNIT (1() 100,000 RTU)
-Date Recef #_
FIEATINC UNIT (OVER 100,000 BTU)
TOT
VFNULATION PAN (SINGLE RESID)
ISSUANCE DATE '
`
e
P A 11'1
PAID
_ RJ
_ ND
I5✓< BY:. QC \
y ,
BOILER -COMP (3FI'OR 100,000 BTU)
BOILER-COMP(OVERt0G,000 BTU)
-
NEW RESIDENTIAL MECH. SQ.F-I'.
Owearm.uthodredagent Data
Ny
OFFICE COPY