24163 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT'424163
Bufldilg.'t5_,: Z 416 3
Zwne a aces: ,r^ one: p
E,eT C• �. '(-f��� CITY OF CUPERTINO-BUILDING DIVISION n
Ge/njjr�'(araNWe No APPLICATION / PERMIT ^ !/
— J'�! BUTLDINGELECTRICALPLUMBING-MECF)ANICAL CATEGORY CONTROL N
Archlte t/Fsgineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTR under rDECLARATION
thereby hSeeti i.n700( oOnvit I am icensedhellus sessaonsef Chapter9(mmmenc APPLIANCESRESIDENTIAL JOB DGSCRU'ffON
fngwe fisin1on7onvii.Dlvfect. fthe0ueineaeand ldrv(eslonWCoda,and my
license le In s-!oraeand ic.# PANELS
Llanx Clan LIaN
Date Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
19
0zp l understand my plans shall be used as public mcorda OVFR 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
b Licensed Professional SIGNS ELECTRICAL
I.,�� OWNBR-BUILDER DECLARATION SI'ECIALCIRCUfT/MISC
z` a Ihereby affirm that am exempt from the Contractor's Lkense Law for the
Q fo0owing reason.(Scala.70315,Business and Penfession.Code:An tl or
Kcountywhlch requires a permit teconstruct,alter,Improve,demolish,orrepair TEMP.METER OR POLE INST.
'� a aey,trucNre pdorwits l,suance,also requlrestheapplicantforsuch permit to
U file a signed statement that he Is licensed pursuant to the provblom of the POWER DEVICES
3 O Contactor.License law(Chapter9(commenting;with Section 7000)of Divi. SWIMMING POOL ELECTRIC
etoo3aflhe Businesand Pmfenimu Code)mthb
at he ..mpttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any
fB 6 OUTLETS-SWITCfffBFD(TURES
eppBcant(ora permit subjects the applicant to penalty of not moreShan '100 sa—t
ve una od owns of the500). NEW RESIDENTIAL ELECTR SQYr. STORIES TYPECONSTRUCTION
�n s owner of she Property,or my employee with wages as their sole G c oration,will do the work and the structure la not intended or offered for
O sale c.7064,Business and Prefenimu Code:The Contractors License Law
S$ does not apply to an owner of property who build.or Improves thereon,and OCC GROUT' RES.UNITS
suchworkhi.1fo through Msownemployces,p.Wedshatsuch
Improvement,are nal intended...fferod for safe.If,however,the building or TOTAL
Improvement is sold within aneyearofcomplesion,the owner-bulkier will have
tmen of provirg that he did not build or improve fee purpose of to.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
oL1,as owner of the property,am exclusively centra ting with licensed
mntncoPERMH ISSUANCE
ctors to construct the pmjed(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wild, or Improves thereon, and who contracts fa such Enwicts with a ALTER-DRAIN&VENT-WA
e�[actor(,)Ilanxd pursuant to the Contractors License Law. BAIX FLAW T. FEE SUMMARY
LJ I am exempt under See B&P C for this reason
DRAINS.FIAOgenBY Y N
Owner Dale RECEIPT s
WORKMAN COMPENSATION DECLARATION FIME
IT(T1IRES PER {OOL 'AK Y N
❑I hereby affirm that I have a certificate of consent m set(-Ware,or a
mMfiateo(Worers Compematimlnsnnmoraadifked copythermof(See.
RECERT
3800,LbC) GAS EA SYSIFM �T M
ARK Y— N_
Policy If
GAS EA.SYSTEM-OVER 4 MA) BUILDING GDIV]SION FEES
[Certified copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
!Certified copy k flied with the city inspection division.
CERTIFICATE OF MEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE PAID
S(OBM EA:zoBFr Date Recei t#
(rhiss tonnaednaebecompletedifthepermithfaonehundreddollars
(Yt
I cemlea.) N
certifythat the performance of the work forwhlch this permit Is unci WATER HEATER W/VFNT/ELECTR ENERGY FEE Y
, N_
1 W not employ any person any manner n as to become abject to the WATERWATERSYSTEM/TRFATIN'G PAID
Workers Compensation laws off California.Data O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,FT, Date Recei t#
Fshould become subject to the Worken'Compensation provisions of the Labor TOTA
f/2 Code,you must forthwith comply,with such mpW. provisions orthb permit shall be BUILDING
ll.I 1 deemed
ll G C1yNSTRUCTION LENDING AGENCY SEISMIC FEE
the ya(firm tXas Nerei,amnstructlon lendingagency for the perform. TOTAL: ELECTRIC FEE
7 O ecce.( .work forwhkhthis permit b issuei(Sec.3097,Civ.C.) .
(> Iander'd Name `. ' PLUMBING FEE
LL 1- lanaera Aaama, QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertltythall have read hieappbotionand stale shatthe above information
IL bmrretl.]agree lacompi Idty.ndmuntyaminanasand wtelasva PERMTTISSUANCE r•EESPAID:
} N relating to building construction, hereby aulhorize reprexnta0vn o(lhb
Z aty to enter upon she abovorcenthowd property for Inspection purpose,. ALTER OR ADD TO MECH.
V _ (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Receipt#
.,.Inst liabilities,judgments,costs and expensed which may In any way accrue AIR HANDLING UNITED 10,000 CFM) SUBTOTAL:
against sal Cil Wconseque of/ nit ga his permit.
4,g AIR CONSTRUCTION TAX
fraidus,of Applicant/Contractor Date EKHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or intone building occupant store or handle hazardous HFATING UNIT(TO IW,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the Date Revel t
I lealth and Safety Code Section25532(a)? HEATING UNIT(OVER lOQ000 BTU) TOTA
E] Yes M No
Will the applicant car future building octstpanl use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hsramou,air contaminants as defined by the Bay Area Air ItOILER CAMP IXp
Quality Management Distrfet QHP OR 100, BTU)
q Yea No
have read the hen outmaterials requirements under Chapter 6.95 of BOILER-COMP(OVEt10Q00BBTU)
the California Health&Safety Code,Sections 25505,25533d 25534. 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECN. SQ.Fr
responslbWty to notify the occupant of she requirement,which must be met
0q pp
prior to Issuance of a Certificate of Om panty. P A Q D
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE COPY CITY Ur VUernuwv