24151 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Pmect ldendfkallon PERMIT NO
Building Address: /'� /I �I q
O® Lt!-tD V ( G 4 I I
re ane: one:
CITY OF CUPERTINO-BUILDING DIVISION
CJJc.Ne APPLICATION I PERMIT (�"[
JBUILDING-ELBCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Arehltect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE �a
LICENSED CONTR under rDECLARATION D
Iheh Sxdkrmthrtlam Bcm3ofthnderpessaloneofCssions9de,and c- APPLIANCESRESIDENTIAL ] DESCRIPTION
i1 withnection7(1mawIiaffed. althe_BueineaaanO done Code,and my
license is in(u and d(ect. ,G7"#J� lfy' PANELS
License ClanLk.tn#
Date Conctar UPT02DOAMIS
ARCHITECPS DECLARATION 201-I000 AMPS {►f
ot00 Iunde Land plane shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA E/SQ.FC.
(s Licensed Professional SIGNS ELECTRICAL
FLny OWNER-BUILDER DECLARATION
Ihereby afBnnthat I am exempt from the Contractor's License Lawforthe SPECIAL CIItCU[T/MLSC
Ofollowing reason.(Section 70315,Business and Professions Code:Any city or
Pcourtywhich requires a permit reconstruct,alter,improve,dernalish,orrepair TEMP.METERORPOLEINST.
a anystmu mprlrnbitalnuamealsorequirntheappBvantfwauchper tw
r U 6k a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
Ow, Contradoes License Law(Chapter9(mmmencingwith Section 70M)ofDivi-
6,30 sion3of1he Binn
ussand PmfessrsioCodor
e) that he is exempt therefromand SWDrtMING POOL ELECTRIC VALUATI$rJ�
the bash for the alleged exemption. Any violation of Section 7ML5 by any I'� I & M �G�L.�I
4.� appBant for a permit subjects the applicant to a civil pemlty of net were than OUTLETSSWITCHESWXTURES /—yV(`/��/J7
ofive hundred dollsre($SDO.
�n ❑I,as owner of the roe NEW RESIDFXT1ALELECTR SQ.FT. STORIES TYPECONSTRUCTION
property,k,a ci my employees with wages r thele dole
compensation,w8ldotheworkfassio structureh Contractor orofferedfor
O doe(not.apply
to alnow and f property
rope ty Code:The Contractors License Law
whorles nottepchy rk iuwlfner th=gtywho nempluilds yeeppv idedt e,and
atwch OCC,GROUP RES.UNITS
unprov ss rtsare k tintan edoroughhidors em ployees,provided ildingch
Improvementsarenaintende ye veered pleti..If,howevep deer ill haw T
improvement lsaold within one yearo(<ompidiorythe courser-bu0derwill have
the burden of proving that he did not build or Improve fm purpose of sale.), QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
F1 L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Secsin
.7644,Business and Pretenders Code:
The Contractor's License Law does nat apply to an owner of property who ALTER-DRAIN&VFNL-WATER(EA)
Wilde or improves thereon,and who contracts for such ptejects with
tbacter(s)Bcenud pursuant to the Contractors License Law. .---. FEE SUMMARY
I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAIN&FLOG gOry� 8 Y . ' Y N
Owner Date - I - n
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have•ardfkate a!comm�t to ult-Inure,ora IVRFS PER 1' '. f rlSCHAX RECER N#
3BAifCS l.tefWorkers'C.pemati.lrs ...,aanlfW.pythereof(Sec. GAEA.SYSTEbt-I C.6'OUILETS . I B FEE Y N
J
Pdiry M- A) RECEIPT#
Com any GAS FA.SYSTEhf-OVER4(EA) ILDING DIVISION FE ES
❑�CertNed copy is herebyth the cid. CREASE/INDU LWA NTERcePTOR '"- PLANCHECK FEE
❑Certified ropy ls filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARY-STORM EA.200FT Date Recel t#
(This section need not becompleted Bthe permit ls!Drone hundred dollen
($100)or len.) WATER EBFATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the performance of thework forwhIch this permit is Issued,
I shall note toy any person lo any nner so as to become subject to the WATER SYSTEM/TREATING PAID
orkere'C. a on o(GII nl 1
O z. #pliant NEWRESIDENTIALPLMB, SQFT. Date Rete1 t#
Z O OTICE LIG . f,a erma ngthls CertifialeofExemption,you TOTA
shwldb is subject to the Worken'Compevadon pimisbru of the Labor
Ix N Code,you. forthwith comply with etch provisions orthls permit shall be BUILDING FEE �s
LU 1 deemed revoked. '
if
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE 050
I hereby affirrnthat there is a contraction pending agency for the perform ELEC'I'RIG'FEE.
M Z once of the work for which this permit ls issued(Sec.3097,Civ.Q - TOTAL:
O O Lender.Name PLUMBING FEE
LL F Under.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OU I cortitythatl have readthls appliationand datethatthe above information
1 bcoreact.lagreetocompiywith all cityand muntyordinancesand statelaws PERMIT ISSUANCE FEES PAID: ,
} W relating tobuildiag conbuction,and herebyauthorize representatives ofthis '
(— Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADOTO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Refeipt#
-gales Babllitim,Hdgmenw,crossed expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,0D6 CFM) I SUB40TAL:
agal Id City Innaequen o he granting of this L -
AIR HANDLINGUNIT(OVER 10,000CFAD CONSTA7 CONSTJX
Sg
m.fAFpMNCrtmcwr Date EXHAUST HOOD(W/DUCT) C GTION N PAID:
HAZARDOUS MATERIALS DISCLOSURE
WI a .fined by tor he
future Cupertino
gompantstow hapten le hazardous [-[EATING UNIT(TO 100,000 BTU) Date Ret ' t#
out a d Safety Code SCupertino Municipal Code,Chapter 9.12,and the
IiElycnd Safety Code Section 75532(-)7 HEATING UNIT(OVER]OD,fXp BTU) TO
❑ Yea �]No
+ WiillheepplWntwfuturebuilding occupant use equipment or device; VENTILATION FAN(SINGLE RESID) ISSUANCE DA '
which emit harardous air contaminants as defined by the Bay Area Air
Qua lity Management District? BOILER-CAMPOFII'OA 100,000 BTU) p9,Ai '
❑Yes ❑No PP''
I have read the hazardous materials requirements under Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,75533 and 25536.1 as a
understand that if the building don not currently have a tenant,that It is my NEW RFSI DENTIAL MECH. AUG SQ.FT 24 11192
responsibility to notify the occupant of the requirements which must be met 1�7�7
prior to Issuance of a CertiBcateof Occupancy ri7 r LIr vurc'(gi P
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY