24109 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY.
Building Project Identification ,�19
/ _ PERMIT NO
Building Addrersa: r ,$•'�y ,� 2 410 9
® �
j one: A
'n12 --yr-00. CITY OF CUPERTINO 3UILDING DIVISION I(y rs
/- Cuntractr'e ame:. h Lic,N. APPLICATION /PERMIT L 4—
-BUILDING- LECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Englnoor. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
'
LICENSED CONTR under S vision ATION
Ihereby edionaffirm that D)of Di licensed m3ofheBusi emandsof Chapter9(mmmcnc APPLIANCES-RESIDENTIAL JOB DESCRIl']7QN
fog whh Section force and
(the Buslneuand ProfeulonsCade,and my
Lana Is In fug force and effect.' PANELSLicenseclass k.# asaseP p
Date Contractor
ARCHITECTSDECLARATION 301-1000 AMPS
NO ZpO I understand my plana shag be used u public records. OVER 1(100 AMPS �.Ff.FLOOR AREA $/SQ.Ff.
z(WWW) Limned Professional SIGNSELECIRICAL
z 't y OWNER-BUILDER DECLARATION .SPECIAL CIl2CUfT/#LSC
I hereb affirm thaYl am exempt fromthe Contractor.Llanse Lawfrnthe
p following reason.(Section 7031.5,Business and Profession,Code:Any city or TEMP METER DIPOLE INST.
Fri"' muntywhichrequiruaPermltmcomtract,alter,Impmve,dem iWh,orrepair
yy .'�- anystm=mPr rtoifts imc alsorequireelheappliantforsuchpermitta POWER DEVICES
CG file a signed statement that he is licensed pursuant to the provblom of the '
3µ, Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl-
�OS ,lona ofthe Businessand Professions Code)orth»hekexempt there(mmand SWIMMING POOL ELECTRIC VALUATIQ[iec _
the bash for the ilkged ezempllon. Any Nolatlon of Section 7031.5 by any CJC�
appllant fora permit subjects the applicant toacivll penslry of eat morethan OUTLETS-SWITCHES-FIXTURES f 006 .
five hundred dollars($500), L VGJ
�n ❑I,as owner of the property,or my employees with wages u[Mir sok NEW RESIDENTIAL ELECTR SQ.FL ---STORIES- TYPE CONSTRUCTION
compenutlon,wgldothe wrnkand thestrocture isnot intended or a(fered for
q ak(Sec.7014,BueNees and Professions Code:TM Contractols License Law
R does not apply to en owner of property who hulkle or Improves thereon,and OCC.GROUP RFS.UNrIS
who dceasuNworkhlmeelorthrough hlsownemployees,provWed thmauch
improvemenm are not Intended orot(ered foreale.$howevegthe bulldingorTOTAL:
Improvement ksold wlthinoneyearo(complellon,theowner-bu0derwillhave
t ben o(proving that he dW not build orimprove(or purpose of ale.). QTY, PLUMBING PERMIT FEE FLODDyANE APN
[as owner of the property,am exclusively mntraaing with licensed PERMIT ISSUANCE
contactors to comtmct the project(Sec.7094,BuaNess and Professions Code:
The Contractors Lkxone Law does net apply to an owner of property who
bugds or Improves thereon, and who contracts fee such ptibJern with a ALTER-DRAIN kVENT-WATER(W
cgRjfactor(s)Bansed pursuant to the Contractor.Licenae Law. ,BACK FLOW PROTECT. FEE SUMMARY
[_f I am exempt under Sec. B&.P C for this reawn
Owner Date D FLGOR'n9opF, � . SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION i^• �Z RECEIPT#
®I hereby affirm that I have a certifiam of consent to ealf4raure,ora FI%TURES PER TRAP _ - SCHOOL TAX Y N
cedlfiate ofWorken'ComperuatloNuurana ora artlfied copy thereof(Sec. ` Ali RECEIPT#
Poa
cY
00,Lab C.) ! / x.3 �y GAS :SYSfEMr1 INC.60 0 �^S PARK FEE Y— N_
_/ RECEIPT#
`� GAS AVER
Com any n BUILDING DI VISION FGES
Certified copy b herebydwithfurnished.tcity ORRASE/INDUSTRL WA PLANCHECK FEE
Certified copy b files with the city Inspection division.
CERTIFICATE OF EXEMPfION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissection need not be completed lithe Parrott in forone hundred dollars SEWER-SANITARY-STORM EA.200Ff. Date' Recei t#
($100).rInd.)
WATER HEATER W/VPNs/ELECTR ENERGYFEE Y N
'Ill net employ
in the person Tan [mannerhework ,as to b comehis ennit b Wued, —
Whazlnotemployanyperson f any mannered roto become subject tot# WATER SYSTEM/TREADNG
Workera'Compenution laws of California.Date PAID
Z Z Applicant - - Date Recei t#
Z O NOTICE TO APPLICANT:If,after nukingthiiCertlfkateo(Exemption,you NEW RESIDENTIAL PLMB._SQ.Fr.
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
-� W Code,you must forthwith comply with such provisions or this permit shall be BUILDINGFE I
y doomed revoked.
CL CONSemis a0NLENDING AGENCY SEISMIC FEE
Ihereby amk for at whichency
CIv. .) perform TOTAL: ELECTRIC FEE
n O onceo(the work(or which this perMtbbsued(Bac,3097,Civ.C.) '�
V _ Lenders Name I PLUMBING FEE
LL F- Lenders Addresa QTY. MECHANICAL PERMIT FEE . MECHANICAL FEE
O W IcertltylM1atl have read thisappliationand statethattheabovelnformation
M is correct.I agreeto complywith all city and county ordinances and state laws PERMIT ISSUANCE FEE$PAID,.
�- W relating to building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify and keep-harmless the City of Cupertino Date Receipt#' s
against liabilities,judgment,costsand expenses which nay In anywayaccrue AIR HANDLING UNIT(To 1Q000 CFM) SUBTOTAL:
against said City in consequenm or the granting of this permit. -
AIR HANDLING UNIT(OVER 10,000CM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT(TO 1 W,000 BTU) - Date Recei [#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the
Healthand SafetyCode Sectton25S33(a)?' HEATING UNIT(OVER 100,000 BTU) IOTA L
Ej Yea �]No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit haaurdous air contaminantsas defined bythe Bay Area Air ,
Quality Management District? BOILER-COMP PFI°OR 100,000 BTU)
4NoYes
havamadthehazar'Sou,materiabrequirementsunderChaptei6.95of BOILER-COMP(OVER 100,000 BN) {k p py '
the Ca llfornia Health k Safely Code,Suct tom 75505,25533 and 35534.I P4 L V
understa nd that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ-FT,
reeporriorto pity to canotitytheompant=Parcqulremenla which must be met A�� q
o can ythe occupant
t oft of the req
-/t"
Owner oharlud age
I I Y 1,,wrCn l un•
rtnt Data ISSUED BY:
TOTAL:
OFFICE COPY