24177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
' Building Protect Identification - PERhRTNO.
Building Address: n 1
alai 0,0 _ `T11� c Lf I
mer77
am: A A A
a _ " yrs 065-7318 CITY OF CUPERTINO-BUILDING DIVISION q^ eZ7a� r
cwmato a ante: ua.Nt APPLICATION I PERMIT
BUILDINGII.ECTRICALPLIIMBINGMLCHAMCAL CATEGORY COo•A--•NTROLLa N
Architect/Engineer: Lic.No:
`a QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address IIYC./� �IP'�� PERMITISSUANCE ❑ ❑ ❑
��
LICENSED CONTRACTOR'S DECLARATIO
I hereby affmm that l am Remand under provisions of Cha pier 9(mmmen APTHANCFSRESIDENTIAL )OB DESCRIPTION
Ingwith Sec1imn7000)of Dlvlecx3 ofthe Betalneaaand Profeslom Code,and my
license Is in full force and effect. , PANELS �)t N��,ak r�
Licenaa Class Oaj_Lic.p 31I��3 ����`II AAS �
Date so-.7-lS Contractor - �s.,J
ARCHITECT'S DECLARATION OYVMZ" Co Nl-10DOAMPS —
q�q�++Om z I understand my plans shall be used as public records. OVER 1000 AMPS `.Q.FT.FLOOR AREA $/SQ.FT.
k Ili`j Licensed Professional SIGNSELECTRICAL -
<6w
1- OWNER-BUILDER DECLARATION
n SPECIALCIICIRT/MLSC I N
Zi,., Iherebyafflrmtlutlam exemptlromthe Cont raises License Law far<he r' -
pp followingreason.(Semon? tw Bmtmd and Professions Code:Anympir
0 TEMP.MLTER OR POLE INST. � ,
aountychare poor
theaprovgdemoLLsh, enoutte
QQ anyawcturc prior to its issuance,aborcqulrca theappRanl forsuch pemdt to )EWER DEVICES t I U R
0.V file a signed statement that he is licensed pursuant to the provisions of the _
31ti� Contractors License Law(Chapter 9(mmmenclng with Section 7f10()of Divl- gWlxlbgNG POOL ELECTRIC LUATION
slon3of the Business and Professions Code)or that he is exempt therefrom and ) C ,O
the basis for Ne alleged exemption. Any violation Of Se tion 703IS by any OUTLETSSWITCHESFIXTURES
appft.t for.pe rrrdbubjets the applicant to a civil penalty of net more than
qq five hundred dollars($SM.
$I8 NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
GGGGGG111III Sn ❑e as owner,will
of property,or he employes et In wages r thele sole
compensation,willdessandwork,fiesso Code: bra ontracded orcemsoffered Law
0 sale(Sec.705y Bushes and Profmlos Code:The Contractor's Licerae Law
� $ does not apply to an owner of property who Wilds or improves thermn,and '
$^ who doessuehworkhmealforthreugh hlsown employees,provided that such OCC.GROUP RFS.UNITS
Improvements are not Intended orafferedforsale.If,however,thebullding or - TOTAL:
Improvement bsold within omrarofmmpteion,theowner-builderwill have -
trysItarden of proving that he did not build or improve for purpose of sale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN -
U L as..or of the property,am exclusively mntrating with licensed PERMIT ISSUANCE ^�
contractors to construct the project(Sec.7056,Business and Professions Code:
The Contractors Lkxnse Law does rat apply to an owner of property who '
Wilds or Improves theram,and who contracts for such pyojects with's ALTER-DRAIN&VENT-
WATER(EN
�q➢STador(s)licensed pursuant to the Contractors License Law. gA0(p(pW PROTECT.DEVICE FEE SUMMARY
I_f Ham exempt under Sec. g &P C for this reason
ovel
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
Owner DateRftFG- N
N
r T a
WOKMAN COMPENSATION DECLARATION
� SCHOOL TAX Y tharcby a(lirtn that I have a certificate of consent to self-insure,or a FIXTlIRFS PER TRAP .RECEIPT N
certificate ofWarkeri Compensation Wurance re a certified copy themof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38100,Iab C) ��11 F �v,Cs I RECEIPT#
GAS FA.SYSTEM-0VER4(EA) BUI LDI:VC DI VISION FEES
Com anv_typil 11 ]NSU�L -
Certifledcopyla filed
it.city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Certitied copy Is filed with the dtyinspectlon division, � '
CERTIFICATE OF EX EMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCCI (#
(This section need net be compited If the permit la for one hundred dollars
(STO(Dor less) - WATER HEATER W/VENT/FI.ECTA ENERGY FEE Y_ N_
I certify that In the petomance of the work for which this permit Is Isxued,
1 shall not employ any person In any manner so as to become subject to the ATER SYS TREATING
worker%COmpensadon Laws of California:Date PAID
C' Z Applicant DEMTALPLMB. SQ.FT Date Recei t#
Z O .OUCETOM7LICANT:ILaftermakingthb Certlfloteof Exemption,you
'shmld became subject to me workers'Compensation prov/alons Orme Labor TOTAL:
H N
Code,you most forthwith comply with such provisions orthis permit shall be
> , deemed rovokea. BUILDING EEE
W — CONSTRUCTION LENDING AGENCYSEISMIC FEE
1 Thereby a(Bmnehat them bamnstmction lending agency for the perform TT-6
T r ELECTRIC FEE
Z once of the work for which this permit is Issued(Sm.3097,Civ,C.) PLUMBING PEE
Q O lender's Name
F LenderSAddmss - QTY. MECHANICAL PERMIT FEE
O O Icertilythatl have read thisappllcationand statethatmeabove Information MECHANICAL FEE
bcorrect.Iagreeto comply wise allttyand muntyordlnanmand nate laws PERMITLSSUANCE FEES PAID:
Y N relating to building construction,and hereby authorize representatives ofthls
oft to entero rat hove-mentioned f W ion sea. ALTIIt OR ADD TO MECH.
Z y P° Peny or pe=t purpO - Date Receipt#
(We)agree to Indemnify and ep harmies the City of Cupertino
V agaustllabilitles,' d mems,matsand x nxs which maylnanywayacaue AIR HANDLING UNIT(TO 111,000 CFM) SUBTOTAL:
againstsald Gtyi c equenca jI h .ming of this pc it.
n _ - ^ AIR HANDWNC UNIT(OVER IO,000CFM) CONSTRUCTION TAX
'igZomof pp rata//CContrador Date G' EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT OC)100,000 BTU) - Date Reuel
material as defined by the Cupertino Murdelpal Code,Chapter 9.12,and the - —
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER I W,000 LOU) TO
0 Ys M No
Willthcapplicant or future building Occupant use equipment ordeviceS VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
r which cert hazardous air mntandeantsas defined by the Ray Area Air -
L Quality Management Dbtrit7 BOILER-COMP OHPOR 100,000 BTU)
( Ys �No PAID
Ph read the hazer sus materials requirements under Chapter 6.95 of BOLER.COMP(OVER 1100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25536.I (�r.,n
undersbndthat lithe the occupant
ant rat currently aveatcich mosUt6my NEW RESIDENTIAL MECH. SQ.Ff �asas
rnponsibsato notifyereiate of oftherequirementswhich most be mM aJy�
prior rolssuanca ofa Certificate ofOmpanry. _
CI
Owner
Owner or authorized agent Date ISSUE -
TOTAL:
OFFICE COPY