24270 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE.BALL POINT PEN ONLY
Building Prr'en tdenmi(kaeonPERM" NQ, 4 2,7 O
'\ Building Addmss: � � Z
1�1/069 o&k -
/h7 one: AiL
CITY OF CUPERTINO-BUILDING DIVISION
( Contract •.Name: LIc.No: APPLICATION / PERMIT —� Z
—
( 6 'O BUILDING-ELFCTRICALPLUMBING-MECFMMCAL CAgT-GARY CONTROLp
S rcLitee/ Blesser. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmss - PERMITISSUANCE 1:1 ElO
LICENSED CONTRACTOR'S DECLARATION
I hereby
ereb affbm that l am llcmud under rivigoaof Cha erg mmmene APPLIANCES-RESIDENTIAL
y p p ( JOB DESCRIPTION
Ingwlth I tion,000)o(Divlsion3o(theguslr�es+and Pm(esslomCode,and my
license is in fou f and effect. PANELS w, e C
Llrnnse Clam a Llc.R !J
DateContractor
ARCHITECTS DECLARATION 701-1000 AMPS
7 I understand my plans shall be used u public monis. OVERIODOAMPS SQ.FT.FLOOR AREA VSQ.Fr.
WLicensed Professbwl SIGNS ELECTRICAL /
<Z. OWNER-BUILDER DECLARATION s.. ® I
Ci] 5!'ECLIL CIRCUIT/MISC illi_.
'Ihcrcaffirm exempt from the Contractor's License Law for the _
o9F�
following reason.(Section 7031.5,Business and professions Code:Any city or TEMP.METER OR POLE INST.
V �� ^�
countywhich requires a permit to contact,alter,bnpe ve,demollsh,orrepair
'q p'� anystructure prior to Its Wuancere
,also qulrestheappIcant for such permit to POWER DEVICES - 3
6 O il
ilk a signed statement that he,Is licensed pursuant to the provisions of the
g3u,� Contractors License Lw(Chapter9(rommencing with Seniors 7000)of Divi- SWIMMING POOL ELECTRIC D ALUATION
F,E, sIonlolllolugnnsand Profe.Wn CWelorthat helsexempt thcrefromand
O 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUD.ETS SWITCHES-H%TURES
G' appllmntfar a permit subjects the applicant to a civil penalty of net more than
w five hundred dollars 1$500). SQ STORIES TYPE CONSTRUCTION
s NEW RESIDENTIAL ELECTR FT.
C f< ❑e s owner of the property,or my employees with wages r their sole
compensation Busdo the work and the structure V not Intended or offend for
O sale(Sec.7014,Businnsand Profession Code:TM Contranofa Liremse law
whodotsuclytork imserofthroug hisonemptrimpravnted thatand OCC.GROUP RFS.UNITS
whodonmas acorn hlmuBortomugh hisownemp,however,
provided that such
improvements are not Intended earofo d for sale.theo w er-b theerildingve TOTAL: .
improvement ksold withinonyearo(compinloM theownei-bullderwlll have
t1ig.I,iurden of praying that he did not bund or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
)q-OOD7ANE MIN
Lj L as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Conteono
ts License Law does t apply to an owner of property who
nALTER-DRAIN k VENT-WATER IEA)
Wilds or Improves thereon, and who contracts for such p,jmts with a
dials)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
151 am
SUMMARY
am exempt under Sec this h P C for reasons
OwnerDate DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECEIPT
WORKMAN COMPENSATION DECLARATION� �.N��.�a SCIR)OLTAX Y_ N_1 hereby affirm that I have a certificate of consent to self-Insure or S. RECEErf p
rnr9(Icate ofWorkera Compensation lnurance or a certified copy themof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y tN
38 W,lab C.) _p.• RECEIPT p
Pollry Y / GAS EA.SYSTEM-0VER 4(EAI
Com any ! BUILDING DIVISION FT:ES
[]pCertlf�copyla filed
the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
�j(Cenlfied copyb(Iled with the city Inspection division.
CERTIRCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.700FT Date Recei t#
Rhlsaectbn need not be completod II the permit Is foram hundred dollars
(f1000orlc".) WATER HEATER W/VEM/ELECTR . 50 ENERGY FEE Y_ N_ ,
I certify that In the performance of the work forwhich this permit Is begad,
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/MRGTING
Workers Compensation Laws of California. Date PAID
O Applicant Date Recei tW a
Z NEW R[SIDLN77AL PLMB. 5Q}T.
Z0 NOTICE TON'PLIet to
L ahermixing
ompothis
sationlproof Exemption,you
sowed oem us subject to the Workers'Com provisions
n provisions of the Labor TOTAL:
W Cade,you must forthwith comply with such provbloa or this permit shall be BUIL ING FEE
W > deemed revoked.
lL! — CONSTRUCTION LENDING AGENCY SEISMIC FEE
C Ihereby affirm that them is a construction lending p
agency for the erform
a TOTAL: ELECTRIC FEE
.(the work for which tots permit b Lease
Z once Leased(Sec.3097,Clv.C.)
.Z.. 8
02 Leraef.Name PLUMBING FEE
LL F Lender':Addmss: - QTY. MECHANICAL PERMIT FEE
Ow ImAilythatIhave read thi application and gate thatthe above information MECHANICAL FEE
S - bcorren.l agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>- 0. to Wilding acnstmction,and hereby authorize reprnantallvesaftha
(_ N city to enter upon the above-mentioned property for Nspeadlon purposes. ALTER OR ADDTD MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V ag ll.billtles,jud,nent.,rags dexpenses whi<hmayinarywayacerim AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
i .rad City in ronequence o e gr ung of mi.permit. CONSTRUCTION TAX
D�` AIR HANDWNG[ATT(OVER tO,WOCFM)
tore of Appli..t/C.nt.cT.r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appilca In or future building occupant store or handle hanrdous - HEATING UNIT(TO 100,000 BTU) Date Recel tit
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
!unhand Safely Codr ion75S37(a)7 HEATING UNIT(OVER IM"BTU) TOTAL:
❑Yes . Mix.
Will the applies est orfutum building occupant use equipment or d evicts VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdoua air contaManls as defined by the Bay Area Air
Quality Management Dlgrat7 BOILER-COMP QHP OR 100,000 B'17-0 At
n YesVj No
Thsvcread the ha> smaterialsrequirements underChapter6.95of BOILER COMP(OVER 100,000 BTU) OCT p �s�7A(]�
\ the California health k Safely Code,Section 75$05,75533 and 75534. I
understand that it the building does not obi ently have a tenant,that it is my NEW RESIDENTIAL MECFI. SQ.FT -
U
responsibility to notify the occupant of the req,ummente which must be met I AW
wigu..m&.Certiucatypto parry. - CII Y Ur I,UF'tn
�J+nor or authorized agent Date TOTAL: 1_ ISSUED BY: V.ITYA IV CL
OFFICE COPY