24398APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PEMITNQ,
Build Ing Address:
4
4398
a T" J 7
PERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
.
BUILDING-ELECIRICAIPLUMBiNC-MECHAMCAL
APPLICAILONSUBMijiALDAiIi
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CATEGORY
CONTROL It
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QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addresa:3410
PERMITISSUANCE
❑ ED ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ufChapter 9(commenc
Ingwlth Setion7000of Mt slon3ofthe Business dProfee ons Code, and my
Ilceme b m full a effeR. /
APPLIANCES -RESIDENTIAL
JOB OF 1411'1 ION
PANELS
Llsnx Cy ,rotr { O
Da(e ontrator
.►/��.%.^.
2
/ TECTSCIARATION
I understand my m shall be used as public records
201 -IOW AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
E/SQ. FE
SIGNS ELECTRICAL
Licensed Profesloml
OWNER -BUILDER DECLARATION
I hereby affirmthat l am exempt fromthe Contractor's Licens:Lawforthe
following reason. (Section 7031.5, Business and Profession. Cade: Any city or
caantywhichmquiresaper tWcomtmd,altegimpmve,de=tbh,orrepalr
IN
SPECIALCIRCUIT/M15C I n
- '�f
TEMP. METER OR POLE INST.
anystructure priorm its issuance, also requlresthe applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 700D) of Divi-
slon 3 of si
he Bu and Profession. Code) or that he b exempt therefrom and
the basis for the alleged exemption, Any violation of Section 7031.5 by any
applicant fora permit subjectsthe applicant to a civil penalty of not more than
)EWER DEVICES
gWp,{hg NC li]OL ELCCIRIC
ff! EA
0IITLETSSWITCHESFIX7VAF5
L TIO
NEW READENTIAL ELECTR dT.
five hundred dollars ($500).
n I, as owner of the property, or my employees with wages as their sole
W -
E CONSTRUCTION
compensation, will dothe work and thestmture b not intended or offered for
sale (sec. 7074, Business and Profeseom Code: The Contractors License Law
does not apply to an owner of property who Wilda or improves thereon.and
whodoessuchworkhbrself orthrough hiownemployees, providedthatwch
OCC.GROUIa
RES.IIIVRS
Improvements are not intended or offered for sale. If, however, the building or
Improvement is sold with In one year ofcompitfon, the owner-bullderwili have
tIJljZU rd en of proving that he did not build or improve for purpose of sale.).
4 as owner of the property, am exclusively contracting with licensed
ca•Snctrna to construct the projet(Sec 70KBuslnes ami Profesiom Code:
TOTAL:
qryPLUMBING PERMIT FEE
PERMITISSUANCE
FLOOD TONE
APN
The Contntors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such projects with a
c atorts)licensed pursuant to the Contactors License Law.
LJ 1 am exempt under Sec B k P C for this reason
ALTER-DRAINk VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSI DE IT
OwnerKDate
DRAINS FLOOR ROOF, AREA, COND.
�
F�ES- PER TRAP ��
SANITARY Y N
R ECD p
WORMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a certificate of consent to self-Inmre, or
mrtl0mte of Worken'Compere tton Imunnmara certified ropy thereof (Sec.
3500, Lab C.)
Poli N
SCHOOL TAX Y N
RECER'T If
GAS EA. SYSTEM -1 INC.4 OUTLETS
—
PARK FEE Y N
RMEIPT _
Coany
m
Certifted copy b hereby famished.
9"
Certified ropy b filed with the city inspection division.
GAS. EA. SYSTEM -OVER
GREASE/WDUSTRL WASTE INTERCEPTOR
BUILDING VISION FEES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhlssetlan need not Wcomplted lfthepermR bforooehundreddollan
PAID
Date Recei [M
SEWER -SANITARY -STORM EA. 200FT.
($1 W)orfyth the b Naomi
Imnot
Inoy mannere work fa
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
emplat
person an
1 shall not employ any person in any manner at m to become subject to the
as to become the
Workcn'Compenxtion Gwa of CalifDate
Applicant
ETO MPLTCt mteof Exemptionyou
—
PAID
Date RCCCI [i7
WATER SYSTEM/TREATING
/ EATING
'VEV RESIDENTIAL PLMB. �,FT,
shouldNOTI
to the orlerukingthusation
shouldbecame,ms subjecttothe Workers'Comprovisins orthiomofthe Labor
Codgyounwat forthwith comply with such provision orthb permit shall
deenpd revoked.
TOTAL:
BUIL ING -
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there ba construction lending agency for the perform
ance of the work for which this permit is blued (Sec. 3097, Cee. CJ
1<naera Name
Lenders Addnm
I certlfythat I have read thisapp8mtion and sate thatthe above information
SEISMIC FEE
TRIC FEE
QTY. MECHANICAL PERMIT FEE
BING FEE
HANICAL FEE
!FEES
Is correct. l agree to comply with all city and county ordlnanms and nate laws
relating to building comtmction, and heeby authorize representatives ofthiscity to enter upon the abovementioned property for lmpmoo purposes.
agreetave,indemnifyand keep rolestheC' ofCupertio
ag rut bi tlea,V menta, cosaand expo which may anywayac
ago t i City meq ce of g of t pe e
O Z_
PERMIT ISSUANCE
ALTFRORADDTOMECH.
AIR HANDLING UNIT (To lo,WOCFM)
PAID:
ate R2Ce1i tis
SUBTOTAL:
DUNG UNIr (ovER IO,Ino cFM)
CONSTRUCTION TAX
Applicant ontractor Date
HAZARDOUS MATERIALS DISCL URE
Will the applicant ortuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)i
F-1YesII No
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,W0 BTU)
_
Date Reef k
HEATING UNIT (OVER I000 BTU)
TO
Will the applicant or fare m Wilding occupant use equipment or devices
which emit hazardous air eonlm
tamnts as defined by the Bay Area Air
Quality Management District?
4Yes V;°
have read the materials requirements 25505,2553aChapter,1 of
theerstandt Health building
Code, Socia 7x50.5,ve a tenant,
resp,
res erstandthaifthebtheocgdoes not erequir havea hick that ft me,
euste.f ofthemquvemeniswhich must be rrct
VEN'DLATION FAN (SINGLE RFSID)
ISSUANCE DATE
��a9®
OCT 2 t4,
A 'IpOr�
BOILFR-COMP OHP OR IW,OW BTU)
BOILER -COMP
NEW RESfDEIJ]IAL MECH. SQ.Ff
to issitytonf.Ce
prior to Issuance u! a Corti&ate of Ocavpanry.
IJ.
6!I
ISSUED 8Y:
Owner, or authorized agent Dae
TOTAL:
OFFICE COPY