24252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project IdentificationPERMITN
Ball:a'5-1
Addmes: sT 4252
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�veyratta`creI: one:
�J I �L,y QQ1'lf y 'a�. I' � CITY OF CUPERTIN0.8UILDINC DIVISION 11 �y,�
C°nirador's Name: Tic. o: APPLICATION / PERMIT `✓'R
OL�V BUILDINGELECTRICAI PLUMBINGMECHAMCAL
CATEGORY CONTROLY
Archltttt/Enginer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DE ces ofC ION
I herebyafbmthatlamlcen3aftheerprouandofCedoes9de,and APPLIANCFSREEDENI7AL - JOB DFSCRB'770N
Ingwtrb5eetlon force and
the BuYnessandl'ro(esslanaCade,andm
l icense ie full force and c'0 PANES
Date Clam LIC.N
Datemanemr
ARCHITECTS DECLARATION 201-1000 AMPS
9
0 O I understand my planes @hall be used as public remrds. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
5 Limned Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
p, 4 1 himby.M.that I am exempt from the ContndoriLlcense Law for the
V.o qqqq following reason.(Section 7031.5,Business and Professions Code:And or
�-g county which mquirsapermit tommtmct,alter,Improve,demolish,orrepair TEMP.ME=OR POLEINSI.
any structure prior to Its Issuance,also requlm the applicant for uch pertrdt to POWER DLV ICES
rNL 5 file a signed statement that he Is Recessed pursuant to the provision of the
3 u.� Contractor's License Law(Chapter9(mmmendng with Section 7000)of Divi- SWI HUNG POOL ELECTRIC
EOS sion 3ofthe Businenaand Profession Code)orthat he Isexempttherefrocrand VALUATION
the beat@ for the alleged exemption. Any violation of Section 70315 by any
65
applicant(Ora permitmbjedatheappllcanttoadWipenRy ofnat norcthan OVILETSSWITCHESEXNRES
O five ndred dollars($500).
asowner of the property, NEW RESIDENTIAL ELECTR SQd'f. ECONSIRIKTION
too�n p party,or my employees with wage as thele rule
pen.7044,soul Bothework,and thertruduroh not Ntendedo iofferedfor P
O .1.(Sec.apply
to an owner
df property Code:The Contractor's Limns Law Im TF
�$ don net assuch work lower of property who b llcis employees,
mpl r improves thereory and C Ol1Ia R
who
provementsam kldmeededorough his man Is.If, owaprovidedthatsuch
improvementsarcnot intend¢doroffered for fc.ple e,theh neebuilderwilIngw
ImprovementIsovi within hedid net
plr improve
mproe for purpose
ofule.).
have
tflv�urd s o neer of theng pr wild na exclorimprovefacting license QTy, PLUMBING PERMIT FEE FLOOD aD p
M I,as owner tr the property,am exclusively Busy mntnding with licensed
contractorsContra
oconlrunsect Law jM;not7 apply town owner
Profession Code: PERMIT ISSUANCE
The Contndors License Lew don rad apply to an owner i property who ALTER-DRAIN&VENT-WATER(FA)
Wild, or Improve thereon,and who contracts(or such ptojem with a FEE SUMMARY
cjR lfd exempt
Pursuant to the Conlndors Cleans Law. BACK FLAW PROTECT.DEVICE
L..�1 am exempt under Sec. B&r C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION FD('NRF_S PER TRAP SCHOOL TAX Y_ N_
j2==.
QI hereby affirm that I have•coniBrate of caveat re self-Insure,or. R_ N
cortNnteofWorken'Compensation insurance ora codified copy thereof(Sm.
3800,Lab C.) GAS FA.SYSfFM•11NC4OUTLETS PARK FEE Y N
Policy N RECEIPT Y
Com GAS PA.SYSTEM-OVER 4(EA)
y BUILDING DIVISION FEES
Certified copy Is hercbyth the cid. CREASE/INDUS'ML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is(Ikd with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY.97ORM EA XpFf Date Recei>t#
(This aedion need rad becompleted If the permit Is Forane hundred dollen
($10crifWATER HEATER W/VENTIR Fr•TR ENERGY FEE Y N
Icertify
that performance of the work(orwhlch lMper
out leluued,
I shall not employ any person In any manner se as to become subjeek to the WATER SYSTEM/TREATING PAID
Wmk.WCompensation Taws O(CahfmnIs.Date
licant
Z 0 NOITCETO APPLICANT.If,after creking this Certificate of Eaemptlan,you NEW RESID[NTIAL PCMB. SQRf. Date Remi tN
m
should becue subject le the Workers'Compensation provishm, the Labor TOTAL:
W Code,you at fart hwilh comply with such provislon or this pertNt&hall be
> deemed revoked. I N
ILC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afRrmthat there Is a construction lending agency(cribs pedorm� ELECTRIC FEE
7 Z mice of the work for which thin permit Is tested(Sec.3097,Civ.C.) TOTAL:
C) Q Lander'•Name PLUMBING FEE
LL F Lc"der'@Addreea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mdifythatl have read thisapplintion&nd Yatethat the above information
S Iscomi ws
rl agresto comply with all dty and county ordinances and Yate laPERMIT ISSUANCE- FEES PAID:
>. N mlatingto building construction,and hereby authomm representatives ofthIs
F Z city to enter upon the above-mentioned property for inspection purpons ALTERORADDTOMECFL Dale Reeei tk
Z (We)agree to save,IndemNfy an d keep harmless the City of Cupertino
against liabilities,judgmenb,m bandes nee@whichmaylnanywayamroe AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
SIg�a int uld I In mnseque c ofthe atingafthl permit AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUC170N TAX
`Ap rat/ ontrador "rel Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL DISCLOSURE
Will the applicant ce future building occupant store or handle havardeus HEATING UNIT(TO 100,000 BTU) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I'Iealth and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yes [j No
Will theapplimnt orfutunbuilding occupant usesqulpment ordevicn VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanardous air contaminants as defined by the Bay Area Air 1 N
Quality Mangencnt District? BOILER-COMP(3HP OR 100,000 BTU)
Yea he F-I No
have read Health
ous Code,Sect
25505,25533
5 enbunder ndCha 2554.1 of BOILER-COMP(OVER 100,000 BTU) ��� �� 100
understand t Heahh&Safety Code,Stolon 25505,have
a tenant,and 25534.1 sa77s7
understandthat if the ntify the ing occuoes note requirmnts whcthat it is my NEW RESIDENTIAL MECH. SQ.Ff.
rmponiledityL%ua to mreifytheo to oftoftherequirement•which met be fret 1HTV
Edon to Lmuanm ofaCertlflnte ofOcmpanry. C1IY ur l9Ur Gf4.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE COPY