24067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proert Identification MI
baa PERT NO.
Building Address:o G./1 ZZ Ca�r t 24067
KAztmz ss,;-469MX A]ON41119
CITY OF CUPERTINO-BUILDING DIVISION
C7web.Inw
Lic.Nm APPLICATION /PERMIT l••
_ BU DINGELECTRICAL PLUMBING-MECH LAICAL CATEGORY CONTROL tl
1
6 Architect/ gineer. LG7 1 Noyes ...
L QTY ELECTRIC PERMIT., FEE BUILDING PERMIT INFO
PLUMB
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSEDCONTRACEOR'SDECLAR ON
T hereby dfirmthatlamlleertm, under provblonsa hapter9(mmmene APPLIANCES-RESIDENTIAL )OB DISCRI'IION
ingwith Sectlon7 )ofDivision3ofthe Busin sand fesdon.Cml,xrd my .
license is In full force and effect. PANELS
License Class Lk.Is
Date Contractor
ARCHITECPS DECLARATION XII-IOW AMPS
pZ I understand my plans shall be used as public record& OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FI'.
O
Licensed Professional SIGNS ELECTRICAL
OWNER-HUILDER DECLARATION I A
t;:5 SPECIAL GIRGUIT/MISC In1 'V
I..,�� Ihereby alOrmthatfamexempt fromthe Comrator'dLicenm Law fee the A
1raitZwhichmutmaetioimpmit�, ppppppmuntywhichrcqulreaapermi[Iomrutruct,alter,impmvedemolbh,orrepalr �P.ME[iR OR['OLEINSI'. R
� anyatructme primufta lssuancqalsorequires theappliantfor such perrmtte, l � TEfib a signed statement that he Is Ikensed pursuant to the provisions of the P OWERDEVICESContractor.License law(Chapter 9(commencing with Section MOB)of Divi-
Men3ofthe Budneasand PmfemonsCode)mthae he b exempt therefrom and SWIMMING POOL ELECTRIC TC L
yd the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora pemut subjectstheapplicanttoa civil peratyd net nnrethan 0[Tpl.E7SSWITCHESFLYI'URFS
five Nuns ed owner of
ro NEW RESIDENTIAL ELECTR SQFC; STORIES TYPECONSIRUCTION
�n ❑I,asownerof theproperty,or my eachum Is withwagesa their sole
compensation,will do Business work,and to.he Codurebnot Intended oroffered for
p sale(Ser.7044,to Busan iness property who builTheds
Contractors License law
3$
does not applytorkhmearorth=gy sonmemporlmproves thereon,ovidedthatsud OCC.GROUP RES.UNITS
EEE whodoementsaonot intelfedoroughhhowne.If,hoes,er,thadthatuor
Improvements arenotintendedo.rofco pIMia If,however, older ldingve TOTAL:
Improvement bsoldwithlnone)earolcompletion,the owner-bullderwill have
tliLlIurden of proving that he did notbuddorimproveforpurpmeofnkJ. QTY, PLUMBING PERMIT ', 'FEE ,
IJ FLOOD ZONE APN
Lad courser tr the properly,am exclusively rax and Ing with s,Codd PERMIT ISSUANCE
The Contractcorotrocttheproject not ec.7044,
Budnesaand of pre,lona Code:
Wil Contractor's impea es Chernse Law does not apply to an owner d property who ALTER-DRAIN VENT-WATER(EA)
. t or Improvm thereon,and who contracts (m such plojects with a
fl'o exempt
amtotheConeraRor'e License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
EFEE%
LJ 3 am exempt under gen B &P C for thio reasonOUTSI
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATIONFIXTURES PER TRAP SCHOOLTAX Y N_
01 hereby affirrn that I have a mrtifiate of consent to self-inm re,ora AECEIxf M
mdi0amo(Workeri Comper tioil mnceoramAifiedcopythereof(Se. GAS EA. INC.40UILElS
3800,46C.) PARKFEE Y_ N_
Policy tl GAS EA.SVEI'Gf-OVER d(FA) RECEIPT M
a^Y BUILDING OI VISION IF IS
rtiBM cop"hereby furnished. GREASE/WDDSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy b filed with the city Irepecilan division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 2WFr, Date Recei tic
(fhb section need not becompleted lithe permit b(sone hundred dollars
(S100) 3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertrtifylfy that In the performance,of the work for which this permit is issued,
I shall not employ,any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worken'Compenation Laws of California. Date PAID
-
zZ Applicant NEW RESIDENTIALPLMB.__SQF7. Date Reeei tN
Z O NOTICE TO APPLICANT-.If,after nuking this Ccrtllateof Exemption,you
should become mb)mt to the Workers'Compensation provisions of the Labor TOTAL:
4) Code,you must forthwith comply with such provisions arthb permit shall be
j deemed revoked. BU
WILDING CONSTRUCTION LENDING AGENCYSEISMIC FEE
O. I hereby afflrmthat there b a corstrvtion lending agency for the perform- ELECTRIC FEE
Z) Z anceoftheworkforwhichthb pe rmtbbwed(Sec.3097,CIv.C.) TOT
O O I<nder.Name PLUMBING FEE r'
LL I- Iender.Address QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE
O W ,Fred ify that l have read this application and orate that the above information
f1 ismrret.I agrceto comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
(IT relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the abou&mentionei properly for inspection pu rposes. ALTERORADDTOMFCH. Dale Recel til
— (We)agree to save,Indemnify an d keep harmless the City of Cu Fermin P
against liabilities,judgments,costs and expenses which may in any way some AIR HANDLING UNIT OD,10,000 GEM) SUBTOTAL:
against said City In consequence of the granting of this permit ATR HANDLING UNIT(OVER I BODO CFM) CONSTRUCTION TAX
guature of Applicant/Contractor Dale E(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappbant orfuWm building occupant store or handle haxandous HEATING UNIT(TO 100,000 BTI)
materialasde0ned bytMCupedlno M.MdpalCWd,Chapter9.lZ and the Date Recei tq
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU TOT
❑Yea MN.
Will the applicant or future building occupant use equlpmeol or devices VFWTILATIONPAN(SINGLE RE SID) ISSUANCE DA E
which emit harardous air contamicants as cieflned by the Bay Area Air
Quality Management District? BOILER-COMP(3H P OR I00,000 BTU
ye'
O No
have read the harazus materiab requlrcmenb under Chapter 6.95 a( BOILER-COMP(OVIE 100,000 BTU) ��11
the California Health&Safety Code,Set lona 25505,25533 and 25534.1 y— V q
understa rad that if the building does not currently have a tenant,that It b my NEW RESIDEN77AL MECH. SQ,FT I Y
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occv pa ncy. AUG
Ownerorauthodudagent Date ISSUED BY: ,1 l� [�
TOTAL:
OFFICE COPY