24288 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PI9N11TNQ 4 2 8 8
Bullding Add mss: Z
ncrs Samehone: A AL DAI�
E Q 9 CITY OF CUPERTTN66UILDING DIVISION Q�116�(�` 'L
eanmacta„Name: Lic.N.: APPLICATION / PERMIT t !- 1•
BUILDINr—MECTRICA4PL BIND-UMHAMCAL CATEGORY CO.
t \nchitect/Engineer. LIB Na. - _
R BUILDING PERMIT.INFO .
QTY;a;. •�., ELECTRIC PERMIT, +'. FEE '
Address: PERMIT ISSUANCE
LICENSED CONsed under
pr DECLARATION APPLIANCESRESIDENfIAL / '/
]hereby affirnthat lam licensed ander provision,of Cha)s1er9(rommenc JOB DC5CRI1PIlON
ingwith Sectlor7W0)of Dl eo.3ofthe Buslnessand Profession Code,and my � 0 �
it...Is In fuD form and effect. PANELS "Vi
License Class LIe.N
Date ContractorUP TO 2DGAMPS
ARCHITECPS DECLARATION MI-1000AMI”'
,m0z I understand my plans shall b,used as public records. OVERIODOAMPS �SQ.FT.FLOOR AREA S/SQ.Fr.
u+C
Limned SIGNS ELECTRICAL `4 V
U O Professlovl ( •/ TT
'Zw OWNER-BUILDER DECLARATION
f`n SPECIALCItCUIT/MLSC C
. 3 I hereby ason. that I ,7 exempt fromthe Contractor's License Law for the
county
greawgires a permit to Business and pcoprow,Code:Any dry or TEMP.METER ORIOLE INST.
�rmuntywhich requirnaperNttomnstrud,alter,impmve,damo8sh,orrepair
g< any,truetum prlorto its Luvance,aiso requires the appBwlt forsuch permitm ROWER DEVICES
file a signed statement that he Is limned pursuant to the provisions of the
O
eContractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWASMING IDOL ELECTRIC p'11p
-05 sion3oftheBusineaand ProfesslonsCode)orthathe6exempt therefromand � V at>.
j the barb for the alleged exemption. Any violation of Socti m 7¢115 by any UILETSSNITCFiESFlXIVR6 l M{. s-.�N
;m appBcant(ora permit aubjeostheapp8canttoadvli pavlty of rad morethan
o five hundred dollars($500). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
n 1,as owner of the property,or my employees with wages as their sole
,Z< compensation,will do the work,and the structure is not Intended or offered for
p sale(See 7010 Bualnev and Professlons Code:The Contractors License Law
:�F does not apply to an owner of property who builds or improves thereen,and OCC.CROUP RFS.UNITS
whodo ssuchwork Mmselforthrough hisown employees,provided that such
Improvements are not intended oroffered forsale.If,howe t,thebuilding or
Improvementbwld Mthinoneyearofcompleio0.theowner.Wflderwl tl w _ r .
t enofpnwl Sthat he did not build or improve forpurpose ofsale.). QTY. . ;,x,,/PPE
LUMBING RMIT : T •;'FEE FLOOD ZONE APN
a owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /
Mractma to construct the project(Sec 70K Business and professions Code:
Contractor's License law does not apply to an owner of property who ALIFR-DRAIN&VENT-WATER(EA) _
builds or Improve,thereon,and who contracts for such poojecb with a ,:tx
cgW7+clor(s)limned pursuant to the Contractor's License Law. _ AIX FLOW pct .DEVICE 'r ,--., .-'FEE-$UMMARY;-
U I am exempt under Sec B k P C for this reason OUTSIDE FEES
R ROOF,AREA,COND. SANITARY Y N
�. Owner Date RECEIPT N
WORRMAh1 COMPENSATION DECLARATION FD(NRESPERTRAPSCHOOLTAK Y N_
[11 hereby a firm that I have a certificate of consent to self-Inmre,or a �� RECEIPT N
mnlfiateofW.rkeri Compensation Insurance ora certified copy thereof(Sec. GAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N_
38001Lab CJ RECEIPT N
Policy# GAS EA.5YSTEM.OVER4 MA) BUILDING DMS FEES
Co any
ECertlned copy b hereby furnished. PLANCHECK PSE
❑Certified copy b filed with the city Inspection di n� A / /E CREASE/INDUSTRL WASTE INTERCEPTOR �rn �1
CERTIFICATE OF EXEMPTION FROM RKE S' `� G PAID {w/1 �
COMPENSATION D:SURAN(E I /') (- -M EA-pOFT ate' R it
(TMs section need not be compirted Bthe permit Is MJiunAra� 1.
(SI00)or less) WA /V /ELECTR ENE YFEE _
ImrtifythatinthepedormunmoftheworkforwMcb 1 tis issued,
I shall not employ any person N any manner w a to bY/tN�' to the /.R NG e
Worker:Compensation laws of CalBomb.one. PAID Js C
Z ApplIant RFSID B. SQF7.' Date R i t
NOTICETO APPLICANT:U,.her making thio CehUtate of Exemption,you
0 should become subject to the Workers Compereaaon provbmroof the Labor TO AL:
W Code,you swat forthwith comply with such provisions urthis permit shall be U 'E �
aeemad revoked' SEISMIC FEE O
J
C
CONSTRUCTION LENDING AGENCY
I hereby afBrnthat there b a construction lendingagency for the perform- ELECTRIC FEE
> Z ante of the work for which this permit b Issued(See.3097,Civ.C.) ( [FE
MB]
Indere Na rre '4
1— lenders Adams Q'J'Y. . .J1IECHAMCALPERMIT -." `'.-FEE H LFE
U Imrtifythat]have read this applimtionand state Nat theabove information x AEU bcnrrect.l agree to comply with all city and county ordinance and state laws PFRMIT ISSUANCErelating to Wilding construction,and hereby authorise representatives of this
N ALTERORADDTOMECH.Zcity toenteree to stheaw,inve-mentianed pmperry for Wpe Cit purposes. ate(We)agree to ave,I.%,m y an d keep h it h the City of CupenbwagaWtWbNties,' d menta,mstsa dexperseswhichmayInenywayaccrue AIR HANDllNC UNIT CTO 10,1100 CFM) $U TOTAL:
ago Iry nro e granting of this permit STRUCTION X
AIR t-wnouNc ursr(ovER lo,00)cFangvtu a p co actorDam }II IAUSTFiooD(w/D11C'DSTRUCTION T PAID:
ZARDOUS MATERIALS DISCLOSURE
lllthea rat ,,future building occupant store or handle haurdous HEATING UNIT(TO 100,ODD BTU) DatC RC 1 tN
instar , elinedby the Cupertino Municipal Code,Chapter 9.1 7,and the HEATING UNIT(OVER 100,0008T1A TO
Health and Safety Code Seoioo 25531(a).
❑ Yes �]No
Wllltheapplleant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DIVE
which emit havrdous air contaminants as defined by the Bay Area Air
' Quality Management District? DOMER-COMP OHPOR 100,000 BTU) I
l Yca No
]have read the hada our materials requirements under Chapter 6.95 of BOILER COMP(OVER 100,000 BTU)
10 the Glifomla Health k Safety Code,Stolons 255115,25533 and ISIM. 1 -
understand that ifthebullding does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.Ff.
responsibility to edify the p..t of the requlmmem,which most be met
prior to issuance of a Certificate ofOaupancy. aC14 >
71
Owner or authorized agent Date ` ISSUEDBY:
OFFICE COPY