24330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
11olldIng Pro act Identification PERMIT NO.
'Building Address: ,
a,r, c, R; 2433.0'
whesane
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one:
APPLICATIONSUBMiiIALUAlh
CITY OF CUPERTINO-BUILDING DIVISION
LIc.No: APPLICATION / PERMIT to —(
L
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE ,^^ BUILDING PERMIT INFO
Addresa: Qom' PERMITISSUANCE svlJ �
LICENSED CONTRACTOR'S DECLARATION DO
Ihereection 70 that lam Bcrosedunder i.provisions offes p=r9(mmmmc- APPEANCESRESIDENTIAL JOB DESCKIPHON
Ingwith(iectbn7(100)a(Dlvlelon3 b(the Buelmseand Pm(eeaioneCode,and my - -
Iirenm la In tub to and dfect. PANELS
LlcimseCk� Lic.p y�ars,�aaJ Q
Date — Conerador LTJ/C!/A/Jl®yE. pliei'll-D� /
'ARCHITECTS DECLARATION 201-1000 AMPS
Se Z I understand my plans shall be used an public records. OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.Ff.
z� Licensed Professional - SIGNSELECTRICAL
6N OWNER-BOLDER DECLARATION
o There affirm that l am exempt from the Contradorb License Law for the SPECIAL CIRCUIT/MISC• r-q 0 p
OO Z g Q following reason.(Section 7(01.5,Business sad Protevions Code:Any dty or TEMP.METER ORPOLE INST.
OU IFI Ili JI'I
TE R
rr4 countywhich requiresa permittoconstrod,after,Improve,demolish,orrepair
Oanyatmcture prlorto its iswance,alsonquimstheapplimnt torsuch permato POWER DEVICES file a signed statement that he Is licensed pursuant to the provision,of the
3 WOE Contractor's License Law(Chapter9(commencing with Section 7000)of Dist- SWIMMING POOL ELECTRIC
Sion 3 of the Business and Professions Code)orthat he E exempt therefrom and - VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any 3�a
Q
applicant for a permit subjedm
athe appllcantto a civil penalty of nor ore than OUTLETSSWITCHESF[XT'URFS OO ..
GG11� five hundred dollars($500). NEW RESIDENTIAL ELECTR
�n ),as owner of the property,or Rry employees with wages as their sole SQ.FE STORIES ,TYPE CONSTRUCTION
compensation,will do the work and the structure is nor ntended or offered for
q
In(Sec.7044,Business and Professions Code:The Contractors License IA.
does not apply to an owner of property who builds or improves thereory and - .
who does such work himself or through hisown employees,provided that Such h
OCC.GROIII' RES[KNITS
improvements are not intended oroffered formle.IL however,lhebuilding or TOTAL: O�ob
Improvementim dd within one yearof completion,the owner-builderwlll have "
tt,, iurdeno(provingihat he did not build or improve for purpose oriole.). QTY, PLUMBING PERMIT FEEFLOODZONE APN
U L as owner of the property,am exclusively contracting with hemmed PERMIT ISSUANCE -�
contractors to construct the project(Sec.7044,Bushes.and Profsaalou Code: -
The Contractor's License Law does not apply to an owner of property who
builds,or improves thereon, and who mnfeacts fee such piojects with a ALTER-DRAIN&VENT-WATER(FA)
<gBUacto(a)licensed pursuant to the Contractor's Llrenae Law. FEE SUMMARY
If7]am exempt under Sec. B IS P C for thin reason BACK FLOW PROTECT.DEVICE
nimsvnp FEES
A AREA,GOND. SANITARY Y N
Owner Date DRAINSIT.00 ROOF, RECEIPT
WORKMAN COMPENSATION DECLARATION pD(TURES PER TRAP �Ob SCHOOL TAX Y N
❑I hereby affirm that I have a cetBftents of consent to wlf-inwre,or a RFS®rh p
3900,Lab C.) GAS-'certificate ofWrs
orke 'Compensation hnuna certified cepythereof(Sec. GAEA.SYSTEM-1 INC,4OUTLETS PARK FEE Y N
Policy p BECEE'T a
Cam any - CAS E.A.SYSTEM-OVER4 MAI BUILDING DIVISION FEES
certlfled copy is herebytum
O CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertRled copy V tiled with theecity
inspection division.ity '
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.200FT. Date Recei t#
TlI .on need not be completed lithe permit la(or one hundred dollars
($100)marlen.> WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cenot that o any personhe I.anof y
morhe work(o as to
permit c Issued,the
I shall not employ any person In any manner w u to become Sub'd to the
Workeri Com nsaeonlawsof Oli(omk.Date ooh wATTx sysTEM/TREAnNc PAID
0 Z . Applicantd/LL//J/ll l�L
Z 0 NOTICE TO APPLICANT:IL after making thin Certltlote of Exemption,you NEW RESIDENTIAL PLMB. SGET. Dale Recei t#
Fshould become subject to the Workers'Compensation provlslom of the Labor TOTAL:
V)
Code,you=at forthwith comply with such provisions or this pert hall be BUILD -E
> deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Thereby affirm that there V a construction lendlegagency for the perform- TOTAL: ,y/Y ELECTRIC FEE " Q�
ante of the work for which thin permit is Issued(Sec.3097,Civ.C.) UV `
V O Lender's Na PLUMBING FEE60
LL H Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have readthkappliotionand datethatthe aboveinfornuBon
C Is cored.I agreeto comply with all dty and county ordinances andstatelawa PERMIT ISSUANCE .-d FEE$PAID-
} W relating tobullding connotation,and herebyauthodzerepresentmivesofthis
F Z city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MECH.veDate Revel [#
z (We)agree to sa ,indemnify an d keep hamdem the City of Cupertino P -
agaWtllabNtlen,judgments,ewts and expenses which may In anywayaccrue AIRHANDENGUNITII010,00clum) SUBTOTAL:
against mid City in consequence of the granting of thin permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gnature of Ap rat/Contractor Date ' EXHAUST HOOD(V/D[X:7) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Dale RCCei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
E-1Yen �No
Will the applicant orfuture building occupant use equipment or devices VENIILATION FAN(SINGLE RESID) I$$UANDATE
whitK emit hamrdous air contaminants as defined by the Bay Area Air $$'+ `wYfJ
. Quality Management District? BOILER-COMP(3HP OR 100,OM BTU)
Yen
❑No
have read the hazard ouamateriabrequirementsun der Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU) OCT 12 1992
the California Health&Safety Code,Sections 25505,75533 and 25534.1
understand that if the building does ns,currently have a tenant,that it V my NEW RESIDENTIAL MECH, SQ.FT. i
responsibility to notify the occupant of the requirements which must be met rx
prior to issuance of a Certlfimte of Occupa racy. - `TTI t'ur(iUf'Cn FII IQ
Owner or authorized agent Date' - ISSUGD BY: v
TOTAL:
OFFICE COPY