24390APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
' o Building Pealed Identification
Building Add.,,:
PERMIT NQ, 3 9 fJ
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.ere one:
—
CITY OF CUPERTINO�BUILDING DIVISION
APPLICATION / PERMIT
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Contnd°:•Name: Lic.No:
BUILDINGELECTWCAL-PLUMBINGMECHAMCAL
CATEGORY
CONTROL#
Architect/Engimer. Lk. No:
QTY ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Address: -
PERMITISSUANCE
►�1 ❑ El El
LTJ
CONTRACTOR'S DECLARATION
I)ahSyoi.affirm that f imlicensed i.1.3.fthd..i.provisions of Chapler9(mmmenc-
7000)of it cited. o(lhe Buelnessand Pm(eseloneC.de,and my
inerse 1. In
rs is in fun force and effect.
APPLIANCESRFSIDEM7AL
09 DES
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N
PANELS
Lice
License Clam LICK
/l/��i/a—
I
Date ContactorUP
TO 2DO AbMS
201-1000 AMPS
ARCHITECTS DECLARATION
Iundent.M.yplanaehall4.sdupublicrccmds.
OVERIMAMPS
SQ. ET. FLOOR AREA
E/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm (hat I am exempt from the Contractor's License Law for the
SPFCIALCIRCUIT/MLSC
(�y,P,MET020RPOLE INST.
following remora. 6ection 7031.5, Business and Profession Code: Anyctyor
countywhich requlm a permit to construct, alter, improve, demolish,., repair
anystructure prior to its Luuance,alsorequlreslhe appllcantfor such permit to
file a signed statement that he ls licensed pungent to the provisions of the
Contndor'e License law (Chapter 9 (mmmendng with Section 7000).f Diet.
slon3ofthe BYeinessa.dProfcgI..Cods)mthat he isexempitherefromand
the basis for the alleged exemption. Any, violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not rearethan
POWER DEVICES .
N C
O •.�
VALUAjgQ;,
(S .!T'J�f...
IIV�jnA
NE
nvc oared dollam (55001.
s owner of the property, or my employees with wages es their sole
STORIES
TYPE CONSTRICTION
co peneation,willdothework, endthestmeture larm intended or offered for
m (Sec 7044, Business and Professions Code: The Contractors Limina Law
does not apply to an owner of property who Wilde or Improves thereon,and1
wb0 doeseuch work himself or through hlsown employees, provided that such
DAT
OCC. GROUP
RES. LIVES
improvements are not Intended oroffered forsale. If, however, thebuilding or
Improvement iesnid within oneyearofcmnpleliogtheowner-budderwlll have
TOTAL:
-
the- burden of proving that he did not bund or improve for purpose ofsateh
LI L as owner tr the property, am. 7044, Business
mntnetn roruUenseuct ess noting with licensed
ne Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FAD ZONNR
APN -
eco
The Connector's es thea law dose h apply to an owner of property, who
La does apply to wne
WOda or Improve thereua sed who motto's far such ptajecb with a
C1Bj!'actor(eexempt under Sm to the Contractors License Law.
1 I em exempt under Sec B & P C for this reason
ALIIILDRAIN & VENT- WATER (Fs)
BACK FLOW PROTECT DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIXTURE&PER TRAP
SANITARY Y N_
RECEBR N
OwnerDate
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have of consent m self-Ineurc, ora
S IUOLTAX Y N
o lmunne
moi,LabC(Worken'CompenseHonlnsurance ora rertifled ropy thereo((Sec.
Lab CJ
RwEur tl
GAS EA. SYSTEM -1 WC.4 OU1LE15
PARK I'EE Y_ N_
Polis
Polley p
X
ING
GAS EA. SYSTEM OVER d (EA)
Com any
DI
BUILDING DIVISION PIiES
[PCenlfied copy is helehed.
❑Cenlfled ropy is filed with with the sly inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
-
GRF-ASETRAP
CERTIFICATE OF EXEM PTION FROM WOR KERS'
COMPENSATIONINSURANCE -
(Thiauctlon need not be complaed I/the perNt 4 (Drone hundred dollars
PAID
Date Rcmi l#
SEWER -SANITARY -STORM EA 200FT
($100) .' less.)
I certify that In the performance ofthe work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
Workera'Compensatlon Lawsof CalBomia. Date
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICEould ca esubjettothealtermakingthissation profscate of Exemption, you
shde,you became hwith co Worken' Compensationprovisions of the Lob be
dremedr Det f.rthwlth comply with such provhlonsorthb permit hall be
deemed revoked.
Dale Remi 1#
NEW RESIDENTIAL PLMB.__SQFI'.
TOTAL.
BUIL ING '
-
TOTAL:
SEISMIC ITE
ELECTRIC FEE
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a mnitruction lending agency for the perforce,
anw of the w.rk for which this permit b issuedec (S 31197, Civ. C.)
Lender's Name
Lenaer'a Address
' 1mnifythatl havereadthts application and gate (hattheabovelnfermatlon
QTY. MECHANICAL PERMIT. ,
PLUMBING FEE
MECHANICAL FEB
FEES PAID:
V correct. I agree to comply with a0 city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
PERMIT ISSUANCE
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, Pilgmenb,rest sand expenses which may In any way accrue
age Inst Bald City In consequence of the granting Of this permit.
ALTER OR ADD TO MOCK
AIR HANDLING UNIT (TO 10,000 CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT(OVER 10," CFM)
CONSTRUCTION TAX
S rumre of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applica ntorfolium building occupant afore or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Dale Recei t#
HEATING UNIT (OVER 100,000 BTUI
TOT
Health and Safety Cade Section 25532(a)2
❑ YesLINo
VENTILATION FAN( SINGLE REBID)
ISSUANCE DATE
Will the applicant orfuture building occupant gee equipment or devices
which emit hazardous air c.ntamicants as defined by the Bay Area Air
BOILER -COMP OHP OR 100,000 BTU)
Quality Management District?
qYes N No
have readthehaza nus materials requirements under Chapter 6.95 of
f� p
BOILER-COMP(OVER 100,000 BN)
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
E
NEW RESIDENTIALMECH. SQ.FT
understand that If the Wilding does not currently have. te... tthatitb my
res nsl lutytonctifytheoccupantoftherequirementswhichmustbemet
pr ammo/ ert roof Occupancy.
®� T '
IF+,KjJii'q/�j1gag�
neroraulori
heed agent Dat
CNV.
)r�Vr�IYIIN!)
TOTAL:
ISSUED BY:
OFFICE COPY