24120 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pto"ert Identification PERMIT N¢ 412 0
Building Address: //++ Z
TG
Phone: A p
2 - CITY OF CUPERTINO-BUILDING DIVISION `r 7 ,Z—
cnnnanor'sName: un.No: APPLICATION I PERMIT
Z BU[LDING-ELECTRICAL PLUMBING-MEC LAICAL CATEGORY CONTROL N
Arc Itea/Englneen Lk.No:
Qrr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PLUME
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S pr DECLARATION
Ihereby mhScch..70thatl iv Bcensed 3ofthederpunsian Profen apter9(e,andm APPLIANCES-RESIDENTIAL JOB DESC ON
Ing sci infon7000)o(d died 3ofthe Bupvsaand lhc(nsiovCode,and my /fit /JET
license "n fun res and erten. PANES • t�9/� C //h
LicenseClam Lle N Z 3Z/ d /)�G/'l �Vd/
Dale r Contractor son a iii.-.. 7
ARCHITECT'S DECLARATION 201-1000AMPS
ZO I understand my plans shall he used az public records. OVER 1000 AMPS e-Q.FT.FLOOR AREA T.,., s75(I`
r. 1
SIGNS ELECTRICAL n. `1•'`
x�� Licensed Professional � ^ n �• j171�iJ•
OWNER-BUILDER DECLARATION SPECIALCItCUIT/MLSC
7 � herebyaffirm thatlamexempt frorethe Contractor'sLlcenselawfor Me )
p following a sson.(Section C 7R11S,Business and ProfessionsY Code:An city or
ceuntywM .
� ch requiresa permitmru
rovtct,alter,improve,dennl'h,or repair TEMPMETER OR POLE INST.
m�a anypructure prlorto its Issuance,also requlresthe applicant for such permit to POWER DEVICES p�lE y
CO O file a signed statement that he la licensed pursuant to the prov'lov of the
3 w Contractor§License law(Chapter 9(commencing with Section 7000)of Divi- SWWMING POOL ELECTRIC Uis t
F�Oa sicn3o(the Bvrd
uslneand Pesslov Code)orthat he'exemptthere(romand VALUATION
the basis for the alleged exemption. Any violation of Section 7MIS by any
applicant fees permit subjects theapplicant too civil penalty of not more than OUTLETS-SWITCHES
five 1,as
owndoler
of thepr. NEW RESIDENTIAL ELECLR SQFr. II6 U TYPE CONSTRUCTION
'4. ❑I,as ower of of property,or my employees with wage as thele sole
CC &c.7ion,B.ninuthewor eandthe ecionstmcture'utintended orofferedLw
5�0 sale(&c.7044,Buslvssand Pmfesslons Code:The Contranofs Lirerue law
$ does not apply to an owner of preperty who builds or improves thereon,and FS.UMTS
OCC.GROUP R
who docs such work himself or thwgh his own empleyea,provided that sech
Improvements are not Intended oroffeerd for sale.If,howevcp the building or TOTAL:
Improvement'sold within oneyearofcomplellon,the owner-builderwlll have
the rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE pLOpDpONE TpN
[as owner of the property,am exclusively runt.. c Ing with Ikensed PERMIT ISSUANCE
contractors to constmn the project(Sec.7044,Business and Professions Code:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves ects thereon,and who contracts for such ptpjwith a
,,RR11((actor(s)Ilunsed punuanttothe Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
on
I am exempt under Sec B h P C for this reason
Date DRAINS FLOOR ROOF,AREA COND. SANITARY Y_ N—:
. Owner RECEIPT N
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self-losers,or a FIXTURES PER TRA' SCHOOL TAX Y N—
evnifiate of Workers Compensation Insuranceora certified copy thereof(Sec. RECEIPT'N
Poli Nb C.)N` �)IOS 9
GAS EA.SYSTEM-t WC.6OUTLETS PARK FEE Y_ N_
GAS EA.SYSTEM-OVER BUILD WCGDRECEIPIVIgIONFEFs
ECertifed copy ed with tnb
❑Certified copy'(i'd with the city inspection division. CR[ASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(This section need not be completed if the permit'for one bund red doliare SEWER-SANITARY-STORM EA.2WF1'. Date Recei o
(41(t)mfesv) WATER HEATER W/VENTRENERGY FEE Y N
(certify that In the performance of the work forwhk / LECTR
hthis permit is Issued, —
I shall not employ any person In any number so as to became subject to the WATERSYSfEM/TREATING
Workera Compensation Lawso(Califomia. Date PAID
0 Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recel Ik
Hshould becomewbject to the Workers''Compensat ion provisions of the Labor TOTAL:
N Code,you rust forthwith comply with such proxialov or this permit shall be
W > deemed revoked. BUILDING FEE _J O
a O CONSTRUCTION LENDING AGENCY SEISMIC FEEa
I hereby affirm that there Is a construction lending agency for the penorrry ELECTRIC FEE
7 ZO anmoftheworkforwhlchthbpermit bisprN(Sec.3097,Civ.C.) TOTAL:
U lenders Nasse PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythatl haveread this application and patethat theabovelnformation
C 'correct.I agreeto complywith all city and county ordinances and pate laws PELMITISSUANCE FEES PAID
U) relating tobuildingeonstrunton,and herebyamhoriaerepersentativnsorthis
H Z city to enter upon the above-mentioned property for Wpection purposes. ALTERORADDTOMECH.
— (We)agme Weave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
aga1vnt11abliti ydgmnts, o andexpnswhichnylnanywyaue AR HANDLING I010,0CFM)
.211 a�nenes of the Babtin of this pertni
SUBTOTAL:
I AR HANDLING UNIT(OVER IO,OJOCFM) CONSTRUCTION TAX
Signau Tp fApplicant/Contractor �p/ate� EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
V HAZARDOUS MATERIALS DISCLOSURE
Willtheappllca of orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
macrialas defied bythe Cupertino Municipal Code,Chapter 9.12 and the Date Recej t# l
Ikalthand Safcty Cod ct1on25532(a)7 HEATING UNIT(OVER 100,000 BTU) l
❑ Yes `O No TOTAL: ie
Will the applicant orfutumbuilding occupant use equipment or devices VGN,MATION FAN(SINGLE RFSID)
which emit hazardous air contaminants as defined by the Bay Area Ab ISSUANCE DATE
JI rye
Quality Management District? BOILER-COMP QHP OR IMO(O BTU) lY
Yes o
have read ealth a�matcria'tions 2m05,2553andnts under 2554. 1 of BOILER-COMP(OVER100,000 BTU) AUG 171992
thehv.c California the ha
hSafetyCode,Seniors25505,25533andapter I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be rent
priortrouser a Certifiateof Occupancy. CIIY Ur vor'c (INV
o
�i wR• u onud agent Dale TOTAL: ISSUEDBY:-,{ 7T Vt\Q_�_�CC.r
_�
OFFICE COPY