24322 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identlfl.tlon I PERMIT NQ, 4 3 Z 2
Building Address:
103.9 -7 Irl �ucg.
wnen one:
JAL LJA1h
CITY OF CUPERTINO-BUILDING DIVISION
Conlran�jols Name: Lk:.No: APPLICATION /PERMIT C
JaLle �f' BUILDINGELECTRICAL-PLUMBINGMECtI NICAL CATEGORY CONTROL M
Architect/Engineer. Lk. o
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE ❑ ❑ �l ❑
LICENSED CONTRACTOR'S DECLARATION
IhehSocti firm,7000that iv Rc 3.fthunder pmvhldPO Chapter9(mmmrnc APTT.IANCESRESfDENTfALOffevitJOB DESCRIPTION
house .1.fon7000)of d affem3ofthe Budneeeand Profeselane Coda and my
lianas le ie(uB fora and d(ea. S �— PANTOS
License Chea _ LICM - p ea
Date Contna9r �[„ z
ARCHITECrS DECLARATION 201-1000 AMP"'
µppµ!!a0 OC I understand my plans shall be used as public re OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E IZU Licensed Professional SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/NEST
7s, a 1heaffl
byarenthat l am exempt from the Contractor's License Law for the
following reason.(Section 7MIS,Business and Professions Code:My city or
O gatTEMP.METER OR POLE INST.
F 4 rountywhlchrequimaperanttommtmdalteplmpmvemo
,delhh,ormpalr
qqq anystruaum price to its isseance,also requires the applicant forsuch Ferrell to POWER DEVICES
ilk a signed statement that he L licensed pursuant to the provisions Of the
3µ�+ Contsome,License Law(Chapter 9(co.scing with Section 7000)of Diel- SWN1h9NC IDOL ELECTRIC
SOS slon3 ofthe Business and Pro(CssloseCods)orthat he is,exempttherefromand VALUATION
the bash for the alleged exemption. Any violation of Section 70315 by any OU ELITI&SWITCFIPSHXTURES
appllant fora permit subjectsthe applicant to a civil penalty of na mom than
five hundred dome($SM.
NEW RESIDENTIAL ELECTR
�O ❑I,asOwner ll of property,orhe employees with wages r their sole �'�' STORIES TYPE CONSTRUCTION
compensation,0K Business workand theetmde: is not Intended oroffered for
93 vie(Secpply to Business
nOwand PMessions Code:The Contractor'sheram law
$$ daenotapplyt ,kht erorthmg hisoWildsor laymspv idedthtand OCC.GROUP RFS UNITS
whodmunts am ktInten edorough hlaownemp,lemeeprwheleihatmch or
Improvemenhartnot Intended l.l.fredforeale.If,however,theerlid Ngve TOTAL:
Improvement h mid within oneycaro(complcilon,the owner-bullderwlll have
tlLIfurden of penving that he did not Wild or Improve for purpose of aide.). QTY. PLUMBING PERMIT FEE fDBy ONE APN
LJ L as owner of the property,am exclusively contracting with licensed ppgMfl ISSUANCE �A
conm
tractors to rutrua the project(Sec.7044,Business.nd Professions Code:
The Contractor's License law does Asst apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilds or Improv.thenen,and who ruminants for such p( tld
ojewith
m,a1TaaorW licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L-i I am.erupt undar Sec B&P C for this masers
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Date RECEIPT M
WORKMAN COMPENSATION DECLARATION
[—]IaFD('NRES PER TRM D SCHOOLTAX Y N
I hereby affirm that I have a rtiB. rete,of consent to self-InsuRECEre, N
certificate ofWOrkers'Compeneatlm Insurance me certified copy thereof(See. GAS�EA.SYSTEM-1 INC.4 OUTLL`TS PARK FEE Y_ N
3800,lab C.)
Policy a RECEPrN
Com GAS.EA.SYSTEM-OVER 4(EA)
Y BUILDING DIVISION FEES
Certified copy h herebytcity
d. GRFASR/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
C]Certified copy h(fled withh the the tlty inspection division.
CERTIFICATE OF E(EMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE $EWER.SANITARY-STORM EA 2057 Date Recti t#
(I)oreealon need na W completed If the penmt h forone Hundred dollars
(5100)oify that
WATER HEATER W/VENT/ELECTR ENERGYPEE Y N
]certify that Nthe Person
any manork so as to which
permitisthe —
I Worhalkers
not employ any penes In any manner m u to 6emme subject to the WATER SYSIEM/TREATING
Wcelicant Compensation Ewe o(GBfomla.Data PAID
* Z AppNOTICE
ZO NOTICEco MPLICttothe after making thhCertificate ss Exemption,you
NEW RESIDENTIAL PLMB.__SQFf. Date Recei t#
shoulCode, become forth to the Workers'Comp rovisinprovlatons of rethe Labor TOTAL:
� U) Code,you meat forthwith comply with such provisions or this parent shall be BUILDING FEE
deeed revoked.
LU
mCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there h a construction lending agency for the pedorrry ELECTRIC FEE
Z ante of the work for which this permit h Issued(Sce.3097,Cle.C.) TOTAL: 4.00
U O [,.due.Name PLUMBING FEE e0
LLI— I.endcreAdd.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertify thatl have read thhapplimbonasd sudethat theabme information
CL hcorrect.I agree to complywlth all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. relating to building mnstruaio,and hereby authorae repaeentatives ofthis
H Z city to enter upon the above-mestlomd property for Inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,Indecently an d kap harmless the City of Cupertino Date Recei t#
against llabllitiea,judgments,costa andexpes.which may lnanywaysecrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag Id Sns Of the gra sling a(tha pertnit AIA HANDLING IINTC(OYER ID,000CIM) CONSTRUCTION TAX
s� a
signat�7ta of Appl onDate IXHAlJS'T}[OOD(W/DLX;T) CONSTRUCTION TAX PAID:
HAZARDOUS
MATERIALS DISCLOSURE
Will ia the applicdefined t or bythe future building omipal Code, hhandle 9.IZ ahaeardous the HEATING UNIT OT,10D,000 BTU)
material as dented by the Cupertino Municipal Code Chapter 9.II,and the Date Receipt#
Health and Safety Code Section 25531(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: -Q�—
❑ Yee No
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) I$$UANE3D�1TE
which cant haaurdous air mmaMnanta as defload by the Bay Area Alr a'
Qu Illy Managcmcnt Dutrict7 BOILER-COMPOHPOR 100,00(i
EYea No
. ave read the haz Hous
tetlalerequlamentsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) OCT $ 1
the Glllomie, ealth&Safe Code,Sections 15505,25533 and 75534.1 99992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. '
respoeulbllity,to notify the occupant of the requirements which moat be met CITY Ur 1aUranI IIYU
prior to issuance of a Certificate of occupancy.
Owner or aulhorlaed agent Data - ISSUED BY: a'�'�� �✓
TOTAL:
OFFICE COPY