24023 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
— Building Protect Identification PFILMIT NO.
Building Address: 24023
100 414 S /11 O/t —,
nersame: one: p A A
gcroon $_j7bZ CITY OF CUPERTINO-BUILDING DIVISION t�
C°"tragolaName: Lie.No: APPLICATION / PERMIT
r/SG Ls'Q e- loes3356/ BUTLDINGELECTRICALPLIIMBINGMECHANICALCATEGORY CONTROL#
ArchitevS/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby:fit.thatiamlicensedunderprovbions of Cha 9(mmmena APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Se"3on7000)of Dnvision3 ofthe B. 0=f nsC°de,and my
licenulslnfullfoa+rLdeffe<. a PANELS
LlronscCbse -IC 7F3c.tl E+�
Date 7,22= Coittacior :V —UPTO2D0AMPS
ARCHITECTS E LARATIO 201-10DOA.MPS
OZO Iunderstandot Iaosshallbeuseclas ublicrccorels. OVERI000AMPS F7.FLOOR AREA
CC YP P SQ. E/�.FT.
U Licensed Professional SIGNS ELECTRICAL
Q r� OWNER-BUILDER DECLARATION
f, Zi Iherebyaffirm that lam exempt from the Contractor.License Law for the SPECIALCIRCUIT/MLSC
following...(Section7031S,Businessand Pmfensloos Code:Mycityor�.t ms
r4f ' cwntywhichmqulaper tW.®tm",alteglmprov de=]Lsh,orrepalr TEMP MEIPR OR POLE INST.
anystmdumpMrtottslawanceatsorequbestheappgantforsuchper tto
O+ file a signed statement that he b licensed pursuant to the provblons of the POWER DEVICES
3w
Contractor'.License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC f�. O ion3of the But einem and Professions Code)or that he is exempt therefrom and VALUATION�y,
yl the basis for the alleged exemption. Any violation of Section 70315 by any '61%J
-oot
appliantfora permit subjectsthe applicant toarnilPenalty ofnotmom than OUTLETSSWTTCHE4FIXTURFS 2-2
e five hundred1,28oowndoler
of the pr. NEW RESIDENIIAL ELECTR
I,as owner of the property,or he employees with wages r there sole STORIES TYPE CONSTRUCTION
C < compensation,wWdessand ProfesionsCodc;rehe ottletended Cordiam'o kens Law
$�Osale(Sc.7W4,Business and Professions Code:The Contractols Littre.law
does not apply to an owner of property who builds or improves thereon,and
who does such work himself m through his own employees,provided that such OCC.GROUP RFS.UNITS
Improvearcnb are not intended orot(ered Tarsale.If however,thebuildingor 70TA
Improvement lssold withlnoneyearofcompl"ion,theowner-buflderwill have
thiS.hurden of proving that hedid not build or improve for purpose ofsalo.). QTyFLUM13ING PERMIT FEE FTppp1ANE ppN
I,as owner of the property,am exclusively contracting with licensedPERMIT ISSUANCE
rontracton Lianas to mostruR the pmje"(See 7046,gushes and ProfeabntCode:
The Contncioes Lis Law does no apply to an owner of property who ALTER-DRAIN VENT-
Wilds or improves thereon, and who contracts for such IrWisets with a WATER(G)
%!(a"or(s)licensed pursuant to the Contractor's License Law. soBppg FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under See. B&P C for thin rean
OUTS I Up FF
Owner Dace DRAINS• FLOOR ROOF,ARG,COND. SANITARY Y_ N_
WORKMAN COMPENSATION COMPENSATION DECLARATION RECEIPT#
01 hereby silicon that I have a certificate of consent to salt-Insure,or,a FIXTURES PER TRAP SCIiOOL TAX Y N
certificate of Workers Compensation Insurance ora certifiM ropy thereof(Sec. RECEIPT
3800,Lab CJ GAS G.SYSTEM-1 INCA OUTLETS PARK AEE Y N
Policy RECEIPT#
Com any CAS G.SYS(TM-0VERQ(G) BUILDING DIVISION FEES
�CertlOed ropy b hereby fumbhM.
.5aCertltied ropy b filed with the city inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FL•E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TARP PAID
COMPENSATION INSURANCE
Cfhlsse"ion need net becompleted Rthepermit bforone hundred dollars SEWER-SANITARY-STORM G.200FT. Date Reeei t#
(410()mless) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I°citify that In the performance of the work forwhich fhbpermitLssu
pet la ed,
I shall not employ any person in any uvnner w as to become subject to the
Workeri Compensation Laws of California. Date WATER SYSTEM/TRGTTN'G PAID
O Z Applicant
Z O NOUCETO APPLICANT.If,ofter makingthb Certi(Iateof Exempllon,yuu NEW RESIDENTIAL PLMB._SQ.Ff. Date Recei I#
Fsh°uldberomesubjedtothe Worken'Compewtlon provbimaofthe Labor TOTAL:
N Code,you must forthwith comply with such provisiora orthis perMt shall he
LU > deemed ravoked. BUI ING FEE
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a roratm"ion lending agency for the perform- AL ` ELECTRIC FEE
O ante ofthe work(orwhichthis perm.is Owed(Sec 3097,CIv.C.)
LL 1<ndcr.Name PLUMBING FEE
ly F ner.Addreas QTY. MECHANICAL PERM IT FEE
O LU Icertify(hatl have read thbapphationand statethat theabove information MECHANICALPEE
4 is corm.I agree to comply with all city and county ordinances and state laws PFRMITISSUANCE FEES PAID:
} W misting to building construction,and hereby authorlu mpresidatives of this
FZ city to enter upon the aWvam7 ton Property fee inspection pu rpmes. ALTER OR ADDTO MELH.
— (Wa)agree to save.IndemNry d keep harmless the City of Cupertino Date Receipt#
agairat liabilities,ladgmcOn,coat ndexpe..,which mayin anywayacerue AIR HANDLING UNIT CIO I0,0D0 CFM)
ag nataid City/lot - egce fthe granting of this permit SUBTOTAL:
AIR HANDLING UNIT(OVER I0,000CF.N) CONSTRUCTION TAX
Sig azure ml Ap cant/ not "or /
HAZARDOUS MATERIALS DISCLOSURE Data IXHAU5r HOOD(W/DUCO CONSTRUCTION TAX PAID:
Will the applicant or future building Occupant store or handle havarcious HEATING UNIT(TO 103,0000
material as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the Date
Receipt
Iir❑Yes alth and Safety C°dc, N°
Sn1on 25534(a)t HGTING UMT(OVER 100,000 BTI-0 'IOTA
Will the ❑applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haeanlous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PIU'OR 100,000 BTU)
' Yes ❑No
have read the baaa4ousmaleriatsr Iremrnts under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code, ns 75505,25533 and 25534. 1 ? AID
understand that ifthebuildingdoes cu nently have:tenant,that it b my NEWRFSIDFNTIALMECH. SQ-FT
responsibilitytonatl t eompan the queens, which mustbetret
primto c matcof mpanry. JUL 27 1"�
i
Owner or auth agent pate 1111VV
TOTAL: ISSUED BY: y
OFFICE COPY