24045 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL-POINT PEN ONLY
Build AddBuildingPr.ca identificationlidentification -
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��amress: s7. v4drxgc 2.4045 .
cora d hone: - ar APPLICArUM, A
CITY OF CUPERTI BUILDING DIVISION ea� w�• 1
o-d ',Name L APPLICATION / PERMIT
S BUILDINGF]ECTMCALML BIND- ECl AMCAL CATEGORY C p
Architect/Figineer. Lie.No:
i DIY 't„ELECTRICPE,16 �J' ' j1FLC I' ''L. -;,rjBU1LR!NGPERM!T'INFO
�t, ",•'
Address PERb1ITISSUANCE t ��' ❑
LICENSEDCONTRACTOR'SDECLARATION _ -
Iherebyaffirm that l am Bceread under pmuEdoes of Chapter 9(commm APPEANCESRFSIDE L JOB DFSCRB'DON
ingwith Sedlon7DM)of Dlvislon3ofthe Bualnemand PmfeaslonsCode,and my'
license la in h or cite t. PANELS -
LIceo.Chi ICM
Date ConmuAm, IRTn'rilama (� IV AA
ARCHITECTS DECLARATION 201-I000 AMPS
,ups rc0 O I understand my plan sbaB be used m public record,. - - OVER 1000 SQ.FL FLOORAREA f/SQ.FT.
Limnsed Professional Nsp”
CAL IO
GGGG�d OWNER-BUILDER DECLARATION - CEtC C - '
1., ki
Thereby alflrm twt]ass exempt lmmthe Contractor's Gimme Law for the - _
... following reason.(Section 7¢01.5,Businem and Professions Code:An cityor
Or t^ muntywh]ch requires a perenttnmotmd,alter,improve,demol]sh,or reair �IEIP.ME (NST. -
anystm=mpdorto]ts]ssuancgab mquimstheappgantf.rm&N,mttto pO
O Ole a signed statement that he V Iluensed pursuant to the provistoo of the
��$?( w�y Contracior'sLicense law(Chapter 9(commencing with Section 7000)of Div]- r
�OUp slon3ofthe Buslnemand PmfemtmuCode)orthathe]sexemptthcmfmmand N LELECTRIC VALUATION
y' the bash for the alleged exemption. Any Aolati.n o(Sccdon 7031.5 by any
¢5. applicant fora permitsubjectstheappitcanttoa civil penalty ofact..than TCHPSEXTURFS afV�
° Bvc hundred dollus(from. OUTL
I as owner of the property,or m employees with wages as their sale N'EW R DENTAL ELECTR SQ.F. E SIkIKTION
❑ P Pert,a y snap o4, g 7
ta-
7a compensation,wtltdot aMPr fmio aCdurel,naIntended orolle Ie w 4
J ° sale(See aptly Bu aloss owner
of property
who builds
orimpraves License law
EI $
does nor apply toanownero!propertywhobuildsorImprovesthereoryand c OCC.G ' "
0.0.
who does entsamrkNmae dedomoghhbowne.11,1. es,er,the dth tsuchmuch D TE /
Improverrcntsare not Intended orof(ercd(orale.IQ howeveq ihebuiltling.r - TOTAL: �7
improvement]ssoldwithinoneyearofcomple ion,the owner-bultderwill have C_.
t benofpmving that Mdid nm bulla orimpmve fdr purpom ofmle.). QTY' 'PLUMBING LPERMIT'. 'E �� H.tX) IDNE
LJ 4 an owner of the property,am exclusively contracting with licenses pply DANCE
contractor,to conalmd the pmj.ct(Sec.7034,Budin and Professions Code:
The Contractor's License Taw does net apply to as owner o!property who
builds or Improves themem, and who contracts for such p(ujeda with a ALTER-DRAIN&VENT-WATER(EA)
co6actor(s)licensed pursuant to the Contractor's L]cenm Law. -FEE SUMMARY,
LJ I am exempt under Sm B& P C for this rcawn BACKFLOW PROTECT.DEVICE OUTSIDFFEES
Owner Date -MR��.
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
R
WORK
AN COMPENSATION DECLARATION
F-11 ((I
I hereby erm that I have a certate lOof consent to del(-InwFpp(IgES,
m,or PER gRAls SCHOOLTAX Y_ NRECEIPT N
moillateofWorkera'Compemat]onlourance oracedified copy therm((Sec.
3BW,Lab CJ S GAEA.SYSTEM-I INPARK FTE C.4 OUTLETS Y N
RME
Comryao - GAS -OVER4(FA) - DING DfN
Y 'BUILDING DTVI ION PIES
Certified copy is heed with the
city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE �/Ya
Certified mpy Vfiled with the city lolsMian division. to w`
JO
'
CERTIFICATE OF ID(EMPI'ION FROM WO KRRS' GREASE TRM PAID
nOMPE SATION�IN UR CE SEWER-SANITARY-STORMEA.200FT. . . Date Recd t#
(This secH n e dM nPlus lft tune hand an
(fl00)orlm WATERHCATERW/VENT/ELECTR - E'NERGYFEE N
Ilcariffylam p man t work/orwhlc this mnitb bsu
Workers' nap sa nine n o at WATER SYSTEM/TRFATNG PAID
O Z Applin NEW RESIDENTIAL PLMB. SQ.FT. ate 'Recei t#
Z O NOTICE? ICANT:IL after mak g ertiflate of emplion,you
Fshould became mbjcct to the Workers''Compewtbgqpprovisioo of the Labor TOTA '
N Code,youmust(oAhw]thmmplywthmchprov lo BA dithiiperrrdtehallbe - -
deemed revoked. L IN
CL G CONSTRUCTION LENDING AGENCY .� MIC FE
(hereby a(lirtla hat there is a mmtrudlon lending agency for the perforn, ELECTR
Z ance ofthe work!m or which this permit issued 6.3097,Civ.CJ TOTAL: IC E
U Q Tender's Name
LL E �—
Iy — der'sndarem Qv. MECHANICAL'IERMIT FEE+' MEC((ANI LFEE �•
O W I cedlfythat l have read thio application and Stan thatthe above information -
Ismrrcd.I agree to complywlth all city and county ordinances and elate taws PERMIT ISSUANCE FEES PAID: -
} N d relatingmm
tomolding ulction,and hereby authorize representatives representatives of this
H citytoente Ponthe An, mentionedpm yfor loped]. urpoaes. ALTERORADDTOMECH..' -
Z (We)a to save,Inde fy and ke erM t ty of Cupertino Date Receipt#
V against b] 'm,' dg a t. amend se. Inanywa a AIR HANDLING UNIT(TO 10,000CFM)
agaim as[ SUBTOTAL:
. AIR HANDLING UNIT(OVER IO,MOCFM) CONSTRU NTAX
Sig to of pliant ontre a EXHAUST HOOD(W/DUCT) CONSTRUCFI TAX PAID:
HAZARDO ATERIALS DISCLOSURE
Will theappitant orfutombullding occupant store or handle hazardous HEATING UNIT(TO H0,000 BTU) Date RCCeI t#
material as defined by the Cupertino Munidpal Code,Chapter 9.12 and the
Ilealth and Safety Code Section 25532(a)i HEATING UNIT(OVER 100,000 BTU) . O
e
'
Rill
No
ill the zpplicantor .tum building occupant use equipment or devices VENDLAHON FAN(SINGLE RESID) ISSUANC DATE
which emit hazard..,air roma aureate a defined by the Bay Area Air '
Go a Iky Management D6irict7 BOILER-COMP DHP OR 100,000 BTU)
4 Ye-res No. pp
have read the haze ue lerlala requlremenl,urderChspter 6.95 of BOILER-COMP IM000 BTU) - PAID
D
the California Health&Safety Code,Sections 2S505,25533 and 25534. I
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT n
priori Issuancebility to Of a r-th.icamoftoliherequlremenb which must he act OVT a 1 j11
psponsissuance notify
the occupant
cupa Ocmpa ncy. ( - '.Iq
Ownerar authorized agent Dale _ �~ aVI1X1
• , TOTAL: ISSUED BY:`. �!
OFFICE COPY