24028 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project ldentltiunC)Q PERMIT NQ, �O ��
Building Address: Z
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wrmra one:
�cL _25;� `1,;)q7 CITY OF CUPERTINO-BUILDING APPLICATION /PERMIT SION 2
Co actor's Name: e,No:
Ahk
�� LWF3V BUILDING-ELECTRICAL-PLUMBINC-MECHAMCAL CATEGORY CONTROL N
JW'Aochfiect/lugirser. Lie.No;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCII fall 1:1 [:1LICENSED CONTRACTOR'S DECLARATION L��
I hereby affirm that l am Heensed under provisions of Chapter 9 fixmorenc APPLIANCES-RESIDENTIAL JOB DESCKI'ITDN
Ing with Sedian700D)and effeon3 ofthe Budneeaand ProfeasLnsCadcmdm ���saaMr
I We. b In fuLL f end died. ?> PANELS [V\
Llanse CV LION - V'r
Dale T -ConradoUP TO 2DO AMPS
ARCHITECT OECLARA IOj 241.1000 AMPS -
µppµ��9 ZO I understand my pla na.hell be used as public rcoords OVER 1000 AMPS SQ.FT.MOOR AREA $/SQ.FT.
E LicensedPro(esslaoal SIGNSELFCTRICAL g L E D I N
<< OWNER-BUILDER DECLARATION
SPECIAL CB2CUIT/M15C E R
thereby a(Orthat lam exempt from the Contractor's License raw for the Zp1., n m following reason.l5ection 7031.5,Business and ProfemWns Code:Any city or 1 t
02 TEMP.METER OR POLE INST. V
�� caantywhich require..pemNtmconstmct,alter,improve,derroWh,orrcpsir
anystmmmprtorntoiu Wuame,al.on<prlrc.theappha tfaauchpermitto POWER DEVICES mer e
O file a signed statement that he is licensed pursuant to the provisions of the IdbICIIJ Z [�
Contrao'sLlcetueLW(ChaFire9(commencingwithSection7000)ofDlvl- SWIMMING D T
30J slun3 ofthe Buslneasand PmofeselonsCode)orthat he bexempt therefromand ALUA7I0
the basis for the alleged exemption. Any violation of Section 7031.5 by anyOUILETSSWITCHFSFIKTURFS ,1
ePpu,.nt fora permit o.bjed.the applicant to a dvll penaltyof not mmthan r
fivehundredL.$red solos($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRICTION
�n ❑I,as owner of the property,or my employes with wages r thele dole
rompanartlon,waldothe work,and i.m C dere b not intended or offered for
C1 vie(Sec.7at4,Bueb�eas end Profwloru Code:The Contradore License law
p/ F does nm apply to an owner of properly who builds or Improves theme,and OCC.CRDIIIP RES.UNITS
0.0. who does such work himselforthrodgh his own employees,provided that such
Improvements arc not Intended oroffered forale.If,hmveveq thebuilding or T
Improvementtsaoldwlthln omyearafcanpldlorytheowner-buuderwul have
tryLlt udenof provingthat he did caw build crlmprove for purpose ofdale.). QTY. PLUMBING PERMIT FEE FI.ODDIONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to ocruWd the project(Sec.7044,Business and Professions Cade:
The C.otra tor.License Law don not apply to an owner of Property who ALTER-DRAIN&VENT-WATER(EA)
W Ilds or Improves thereon,and who contracts fa such pta)eda with e
Mdor(s)licensed pursuant to the Contractor.License Law. FEE SUMMARY
am exempt under Sec B 4 PerC for this reason BACK FLOW PROTFLT.DEVICE
OUTSIDE FEES
DRAINSFLOOR,ROOF,AREA,OOND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
[-]ISCI100L TA% Y N
I hereby affirm consent to I have a certificate of conseto self-InsureorFIXTURES.,
a PER TRAP RECEIPT_ N
artioatoo(Workers'ComperuatlonlrounnmoramAifledmpythenrof(Sec.
3800lab C.7 CAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
Policy N RECEIPT N
C,o�mPanv GAS EA.SYSTEM-OVER4 BEA) BUILDING DIVISION FEES
u Ceifed ropy 1.hereby
dc
ltled copy V(fled withh the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
city
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANEEAAY-STORM EA 2WF1. Date Recel tic
(Thlesedbn need not he camplcted lithe permit b(.rona hundred dollen
a1007arfeaa WAT1RHEATERW/VENT./ELECTR ENERGYFEE Y N
!certify that o any pehe rson
any annex so as to h this brooms subject
blued,
I shall not employ any person th any manner at ns to 6erome aubjM to the WATER SYSTEM/TREATING
Worken'Compewtion laws ofGMoaO.Date PAID
Cl Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQbT. Date Recei tR
Z Z NOTICE 70 APPLICANT:]!,after making this Certificate o(Exemptlan,you
Fshould become subject to the WorkersCompensation provisions of the Labor TOTAL:
(/) Code,you must forthwith comply With such provisions or this permit shall be DI �
W > deerrad revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE 't erlae]L
CL I herebyafarmthat there is a conatmdi.n lending agency for the perform ELECTRIC FEE
permit Z arm ofthe Work for which this peolt is Issued(Sec.3097,Civ,C.) TOTAL:
U O Lender.Name PLUMBING FEE
1L H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I ornlfythat l have read thisapplicationand Yatethal theabovelnformation
Iscorred:I agrerocomplywlthall rityand countyatdinancesand statelaw. PFRMITISSUANCE FEES PAID:
>- O- relating to building comimdlon,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for impttsion purposes. ALTERORADDTOMECH.
(We)agree to save,ind,nul an d keep .Phases the City of Cupertino _ Date Reeei t#
V against llabill ,jadgmenb,caeband ex awhlchmaylnanywayaame AIR HANDLING UNIT(TO 10,000 CFM) Lt
a irstda I n sit ting of thl molt AIR HANDLING UNIT IO,ODDCFM) CO CTION X
Ignaluro of Applicant CprtJ dor Date IXF1A1157 HOOD(W/DICT) ON P
HAZ"rpOUS MATERIALS DISCLOSU E
Wllltheappllanl oc(uture building occupant storeor handle hoard... HEATING UNIT CID 100,ODD BTU) ate ace'
material as defined by(he Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TO ,
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) F d'44LUNCE DATE
Which emit hazardous air contaminant.ad defined by the Bay Area Air
•
Quality Management Mind? BOILER-COMP OHP OR 100,000 BTTI) JUL ��
❑yea ((''J�No .Jaaaa�
Ihave mad the hnar`douemateriels requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 11199{92
the California Health k Safety Code,Stolons 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. iITY Ur (,UNtn I HTv
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Occupa nry,
Owner or aulhmired agent Date ISSUED
BY a
TOTAL:
OFFICE COPY
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