24308APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Prom Identification
Building Addres �
P`l"TN24308
ere sure: - One:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBINGMECHAMCAL
�e`a�.��
J
tmcmr'e Na ']'Lic.No
�
CATEGORY
CONTROL X
Architect/Engineer: Lic. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Adduces
• PERhITISSIIANCE
❑ ❑ tY ❑
LICENSED CONTRACTOR'S DECLARATION,
I behSxctk6m'hat l istg 3.fthaderprovanclPrf Chapter 9(commrn
irgwItBeer.h 1. fullforce ofdciteon3 ofthe Buelnessand ProfesslonaCode, and my
is InfuBforceandeffect.
APPLIANCES -RESIDENTIAL
JOB DESCI(I'TION
/a
PANELS
L'oen
License C}aa�Lk. p
Date( �a tractorUP
TO 2DO AhUS
MPS
ARCNIIECPSDECLARATION
I understand my plana shots be used as public records.
CJV
OVER
OVER 1000 AMT'S
0AM
SQ, FT. FLOOR AREA
5/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. METER OR POLE INST,
following reason. (Section 7031.5, Business and Prolamines Code: Any city or
county which requires a Nrmlttomectrutt, alter,impmee, dennllah, orrepair
anystru ure prior to its Wuance,also requirmtheappiiant forsuch permit to
ilk a aligned statement that he is Ilrenaed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Dist.
sion3 ofthe Business and I'mfeaslowpods) arthat he isexempt therefromand
LOWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of no exam than
OIITLETSSWITC1iESFTXTURES
NEW RESIDENTIAL ELECTR SQ.FT.
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compereadon,wW clothe work andthestructure is not intended or offered for
sale (Sec. 7W4L Business and Pmfessimu Code: The Contractors License I.
does not apply to an owner of property who Wilds or Improves t hereon,and
who doessuch work himself or through his own employees, provided that such
__RES
Improvements are not Intended or offered for sale. If, however, the building or
Improvement issold within one ycarofcompletion, the Owner-builderwW have
TOTAL:
t rdea of proving that he did not build or Improve for purpose of sale.).
e L as owner of the property, am exclusively contracting with Ilrenaed
contractors to construct the project (Sec. 70K Business and Professions Code:
The Contractors License Iaw does not apply to an owner of property who
Wor improves themor, and who contracts for such plojecb with a
gp(9acr(s) limned pursuant to the Contractor's Law.
cgp((I
um
am exempt under Sec B k P C for this mown
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE _e
ALTER -DRAIN & VENT (EA)
FLOOD ZONE
APN
-
BACK FLOW PROTECT D8VIC B
FEE SUMMARY
OUTSIDEFFTS
SA T I RECEIPT p
A Y N
DRAINSFIAOR ROO , NU. I/t.�= '^ .+
I- i
FTXTIRiES E'ER TRM -1�.� J
Owner Date
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that I have mrtl(Icate of consent to
opythemof ora
mrtitlab ofWorkers'Compevatlonlvunncemacenllkd copytAereo/(Sec.
o
3800, Lab CJ
RICE N
IP Y N_
'
CAS EA.SYSTEM-1 INCA-IITLEIS J i
Policy B
GAS EA. sY �VER 4ry��
RECEIPT p
Company1,9%rT
BU LDINC DIVISION FEES
crtificd copy k herebyfurnished.the city
CerlUied copy V filed with the city Inspection division.
GREASE/INDUSIRL WASTEIM'F:RCE'TOR
HECR�FEE
CREASETRAP
CERTIFICATEOFE(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars
($1 I many that
in
[certify thatoy an person
7 shall not employ any perws In any manner w as to become subject to the
aInan the work foras to whichthispertbjmitect to the
s'CompenwtlonLws of California. Date
PAID
Date Recei [N
SEWER -SANITARY -STORM EA 700Fr.
WATER HEATER W/VENT/ELECTR �
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
Applicant
Nould hoOMPLICt tothe afternukingstela ation, pre ulonso theof Labor
shouldbecome forth to the ply wit'Compeva0onprovbiomofthe Lab or
Code, you must forthwith comply with such Provisions or this pertNt shall be
deermi revoked. -
Date Recel til
NEW RESIDENTIALPLMB. SQ.FT.
TOTAL:
BUILDING FE
T
SEISMIC ITE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I hereby atOrce that there Is a commaction lending agency for the perform
ofthe work forwhlch thin permit saed3097OITL
Lmb b (Sec. , Civ.C.)
reder'e Name
Leech,'. Address
I cedifythread atI have this appl ationand nate that theabove Infpmutlon
QTY. MECHANICAL PERMITFEE'
PLUMBING FEE
MECHANICAL FEE
FEES PAID: ,
is correct l agreeto complywlth all city and county ordinances and elate laws
elating to building construction, and eeley iuthodze representatives oflhls
PERMIT ISSUANCE
city to enter upon the above-rrcntb property (or Wptttlon purpose.
(We) a e to eve, indemnify n keep heard. the City of Cupertino
ALTER% ADD TO MECH.
Date Recei [p
.,at Is te, cosingba rfcxperjwbkh may In any wayacaue
agai c sequenm ( egrentin oftMspenrut
�s
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,0D0 CIM)
CONSTRUCTION TAX
Sign plmnt/ ontr o Date
EXHAUS'17HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future building occupant atom or handle hazardous
lienal as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Coder �Section 75531(x)?
❑ Y. L_I No ��
Dale RCCCI [N
HEATING UNIT (OVER I00,W0 BTU)
TOTA
VENTILATION PAN (SINGLE READ)
ISSUANCE DATE
Wllltheapplicant or future building occupant use equipment ordevices
which emit hazardous air comandeants as dented by the Bay Area Air
BOILER -COMP p1 U' OR 300," BTU)
Quality Management District? -
4 Y. No
have read the haza ous materials requirements under Chapter 6.95 of
p
A
BOILER.00MP(OVIR 100,000 BTU)
the California Health k Se fay Code, Sen lona 25505, 75533 and 7:539. I
understand that if the building does not mrrently have a meant, that itis my
responsibility to notify the occupant of the requirements which must be met
O CT �Q(�A
%2
NEW RESIDENTIAL MECH. SQ.Fr.
prior to Issuance of a Certificate of Occupancy.
_
V 1 c
CITY Uf
ISSUED 6Y: D451t
Owner or autharlud agent Date
TOTAL:
OFFICE COPY