24199APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO
24199
0 �o vR -
n one:
A AL DA
/ /
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECTMCALnUMBING-MECHAMCAL
/)�)f /yA
�l �\ f/
cnntraanraNam: n J LIc.No:
CATEGORY
CONTROL 0
Archn./Fagirm. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PFRM(ITISSUANCE
Address:
N soLam' %1
C
LICENSED CONTRADECLARATION
wblons of Chapter9(commenc
Thereby a((imn that lam BcrnsM underder provisions
MPI]ANCESRESIDENTIAL
- JOB DESCRIPTION
PANELS
tngwlth Scoum7XD)of Dwision3.fthe Bmaressand Profirsom sCedgand my
licenseisint fgrtca_n effect, a
LI¢ns�Ch ren .p
Date'1—Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used at public records.
201-100a AMPS
OVFRI000AMPS _ _
Snip.. �Fqr. FLOORAREA
7
I
5/SQ. F[.
Licensed Professional
SIGNS ELECTRICAL I
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that l amexempt tram the Contractor's License law for the
ppla�y
r N.e�
[i I ll
�p METER OR POLE INS,.
)OWER DEVICES
following reason. (Section 7071.5, Business and Professions Code: My city or
county which requlresa perMtto construct, esth Improve, applicant forsu.h,or repair
any atsucture priorto statement thathe Is also sed PursuantttheEorsuch permit t e
file a signed statement that he b licensed pursuant to the proNslons of the
y/'1
SWIMMING POOL ELECTRIC
r�
Contractor's License Law (Chapter9(rom ening with Section 7000) of Divi.
sion 3 ofthe Businnsand Prv(esim sCode) mthst he is exempt therefromand
the basis for the alleged exemption. Any violation of Sectlon 70312 by anyWAUMETSSWITCHES-FIK17URES
applicant fees permit subjects the applicant to a civil penalty of not mare than
VALUATIO.x
five hundred dollars (¢500).
❑I, as owner of the property;.rmyemployees with wages astheir sok
NEW RESIDENTIALELECTR �hT'
STORIES
TYPECONSTRICTION
compenatlon,wlildo the weak andthestmarme b not Intended or offe dfor
'
vie (Sec 7014, B..mess and Profcalona Code: The Contractors Licerme law
does not apply to an owner of property who builds or Improves thereon, and
who doessuch work himselforthrough his own employees, provided that such
OCC.GRON'
RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building or
improvement bsuld withinormyearofcompleiomtheowner-bunderwiil have
thchurdenotprovmgthathedw no bund or improve for purpose ofsala).
R 1, as net of the property, am exclusively contracting with licensed
to construct the project (Sec. 7Wk Business and Professions Code:
QTY. PLUMBING PERMIT FGE
LT,OODZONE
APN
PERMIT ISSUANCE secontractors
The Contractor's License law don not apply to an owner of property who
bunds or Improves thereon, and who madmen, fm such ptojeas with a
yyllTTactm(id11...d pursuant to the Contractors License Law.
c L11 am exempt under Sec. B & P C for this reason
ALTER -DRAW & VENr- WATFR (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY V N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
F11 hereby affirm that I have a certificate of consent to self -Insure, or a
rediflcateofWorkers'Compensation ImumnmoracertBiedropythereof(Sec.
3800, lab C.)
FIXTURESS PER TRAP �•
SCHOOLTAX Y_ N_
RECEBT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFEE Y N
RE p
Policy p
Co�mpany
GAS M. SYSTEM -OVER 4 (IA)
BUILDING DI VIRION FEES
I ICertlfied copy b hereby th the cid.
copy is filed hereby
inspection dlWaloa
CREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE7RAP
!`1�ertiled
CERTIFICATE OF I:XEMPFION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 200FI'
COMPENSATION INSURANCE
IThlssectlon need not be completed 9 the permit later ane hundred dollars
(SI00 erica.)WATER
I certify that in the performanceof the work fo,whlch this permit Is Issued,
Date Remi IN
_
HEATER w/vpxr/eI.ECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
I shall not employ any person In any manner m a to become subject to the
Workers Compensation law. of California. Date
PAID
NEW RESIDENTIAL PLMB. SQFr.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the WorkersCompereatlon provisions of the Labor
Date Remi t#
TOTAL:
BUILDING FEE
Cade, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
CONS ON LENDING AGENCY
SEISMIC FEE
em is a
hereby lending agency for the perform-�
ance of the work for which this permit is Issued (Sec. 3097, Clv. C.)
lender's Name
Lenders Address
IcertifythatIlove headiR appliatlonand datethatthe above Informationor.
is correct.I agree to comply with all city and county ordinances and state laws
ELECTRIC FEE
PLUMBING FEE
Q 7Y. MECHANICAL PERMIT FEE_
MECHANICAL MGH
FEES PAID:
PERMIT ISSUANCE l ��
relating to building ronstructiaa, and hereby authorive representativesof thio
city to enter upon the above-mentioned property for impMlon purposes.
(We) agree to save, Indemnify and ep harmless the City of Cupertino
d In,ou : ex case. which may Inan accrue
against habilitle gnr•n ex y yway
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT U010," CFM)
SUBTOTAL:
against old Cittyy In ro Oce of granting of this permit.
/7r`/
AIR HANDLING I1NTr (OVER 10,000 CEN)
CONSTRUCTION TAX
Signaturam Ap/pliant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building compam store or handle haaardous
HEATING UNIT (TO 100," BTU)
-
Date RcCeinfAl
material as defined by the Cupertino Municipal Cade, Chapter 9.12, and the
Ilealthand Safety Cod er�Section 25532(a)?
nYes u No
Will the applicant orfuturc building occupant useequlpmen[.,devices
HEATING UNIT (OVER 100,000 BTU)
TOT L.
VENTILATION FAN (SINGLE RESID) &F C6
ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Ab
Quality Management District?
Yes ��i1 Na
Tbveread the haramousmaterials requirements underChapter6.95of
�i
P A S
BOILFR-COMP OHPOR 100,000 BTU)
BOILER -COMP (OVER l00," BTU)
the California Health&Safety Code, Sediom 25505,25533 and 25534.1
understand that tithe building does not currently have a tenant, that it b my
mu
maponsibility to notify the occupant of the requirements which =at be met
'I 'I
SE P dy 190
NEW RESIDENTIAL MECH. SQ.17.
prior to Issuance of a Certificate of Occupancy.
ISSUED BY: p�
Owner or authMud agent Date
—
OFFICE COPY