24340 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ. 4 3 4 0
Building Addersic
O 1 Wo 1 c
rs are: one: ALIJAIL
7 j O'qsyCITY OF CUPERTIN&BUILDING DIVISION �m
Cent ctorsNa : Lic.No: APPLICATION I PERMIT 6'�1 ,
Q O I I I Cl S T, N T 392;06r<S- BUILDING-ELECTRICAI.PLUMBINGMECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lite.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE � ❑ ❑ ❑
by a LICENSED CONTRACTOR'S DECLARATION
Iheh Sedco 7O that lamlicensed fthunder Bupessand mChapter9de,and c APPLIANCES JOB DFSCRD'ITON
It...11.full to.
ttheBualneaeand ProfesslonsCode,and^T
limnw le In full Toros and effect. . PANELS
LicenseClaeacl9 LIC# 3����5' (T
Date /D2� -91 Contactor C rsau Soae UP TO 2DOAMPS2
ARCHITECPS DECLARATION 201-1000 AMTS
�p+OZOC I understand my plans stall be used a public records. OVER1000AMP5 W 5Q.Fr.
E U Licensed Professional SIGNS ELECTRICAL MPUT E R
H G OWNER-BUILDER DECLARATION SPMIALCMCMTIM1SC
Z a•�7i Ihercbyaffirtnthalamexemplfrom the Contractor's License Law fee the
qqq�y following recon.(Section 70313,Business and Professions Code:An cityor
F 3 county which requlrcsa preset Mcomtruct,alter,Improve,demollsh,ormalr TEMP.ML•p02OR POLE INST. ATE
7 anystruchom pdortolb Issuance,also requlreatheappBont for-such permit to
0 file a signed statement that he Is Ilceved pursuant to the provisions of the OWER DEVICES
G: Contractor-License LawtChaptre9(rommencingwlthSmile.700%ofDIW-
1.,30 elon3ofthe Business and Professions Code)orlhat hebexempttherclromand SYs71`('WNC A70L ELECTRIC VALUAT](lly.
the basis for the alleged exemption. Any violation of Section 70315 by any OI771.ETSSWITCHFSFIKTVRES 1 \ e(,` C.i���•
applicant for a permit subjects the applicant to a civil penalty of not more than l
o five 1,as
nerofthepr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
GGGGGG111111 ❑has owner of fico property,or my employes with wage as there sole
C
compensation,will dothe werk,and ad Prefessi. etrucum ode:Tle Cormanded oreff I.. -
$ p dale(Sec. pply Loan owamifpropeons Code:The Contactor-Wave Law
$ does not apply loan ower ofproperty who nbuilds
mporimprweathereon,and OCC.GROUP RES.UNITS
who due ssuchwork t Int eRerthrough hisown employee,provided that such
Impruverrenbarcnot Intendedearofcd(orale.If,h ser-gtilderwdingve TOTAL:
improvemen[hsold withinovycarolesmpldlorytheowner-bullderwillhave
tFg.�urden of proving that he did nm build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
Lf FLOOD TONE APN
1,as owner of the properly,am exclusively contracting with ns Codd PERMIT ISSUANCE
DieconCotors nteale covtmct the w do (Sec.appy to nes and of prop rt Code:
The Contractor's License Law does sat apply grace f owner d property who
W llde t r Improve-thereon, and who mune. for such p(ojecte with a ALTER-DRAIN&VEM-WATER(EA)
mpG'actor(s)Bceneed pursuant to the Contractors License Gw, FEE SUMMARY
4I,-J 1 am exempt under Sec B k P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDEFITS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Dae RpCJ=N
WORKMAN COMPENSATION DECLARATION p�RpS,PER TRAP SCHOOL TAX Y N
E3, m 1 hereby affirthat I have a cerHOcate of consent to self-Insure,or a RECEIPT N
certlfiate o(Workere'Compensatlonlvurance oracartifled copy thereof(Sec. GAS EA.SYSTEM-1 INC.YOUTLETS PARK IEE Y N
3800,Tab C.)
Pollry Y RECEBR N
GAS P.A.SYSTEM-OVER Y(EA) BUILDING DI VISION FEES
Com any
❑Certified copy Is hercbytd. GREASE/INDUSIRI.WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified copy Is filed withh tthhe e city
dry inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' CREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIC)RM EA. Date Reeel t#
(phissection need not be completed If the permit b forov hundred dollars
etlMmlea.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of thework for which this precut is blued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTFIH/TREATING
Workers Compevatlon Lawn of California.Date PAID
—
Z Z Applicant NEW RESIDENTIAL PINE._SQFf. Date Rece1 [#
O
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
rshould beromesubject to the Workers'Compensat ion proviel ofthe Labor TOTAL:
N Code,you must forthwith comply with such provkslons orthis permit shall les
Wj deemed revoked �e
a C CONSTRUCTION LENDING ACG`CY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
7 Z -race ofthe workforwhich this permit b Based I"..3097,Clv.C.) TOTAL:
U 4 lenders Name - PLUMBING FEE
Tyr Leederenddrees OTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythat l havereacithisappEratbnand gate thatthe above Information
R iscomd.l agreem comply with all cityand county ordleances and gate lawn PERMIT ISSUANCE FEES PAID:
>- IL tobullding construction,and herebyauthorea,representativesofthb -
F 2 mInspection toenterupon the above-mentioned property for pection purpose. ALTERORADDTOMECH. Date ReCei t#
_ (We)agree to ave,Indemnify an d keep harmiew the City of Cupertino P
ez� a Inst llablllllns,jodg tat, sand expenses which may manywayaccrue AIR HANDLING UNIT(TO 10,M CFM) SUBTOTAL:
ago aid City in Yon a of the gram Ing of this permit.
_ AIR FIANDWNC UNIT(OVER l0,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contactor Data IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CFO 100,ODOBTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
I leaith and Safety Code Sedton 25532(a)2 HEATING UNIT(OVER 100,000 RTU) TO
❑ Yea No
Wllllheappllcant or lure building occupant use equipment or devices VENTILATION PAN(SINGLE RF.SID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? MOILER-COMP OHPOR 100,000 BTU)
Yn MNo
tivercadthehaza'3ouematerlabrequimn nbunderChapter G95of BOILER-COMP(OVER100,000 BTU) PAID
tM Caldomia l lealth&fafely Codq Sealov 25505,25533 and 25534. I
sends.tondthatifthebulldingdoenotmrmntlyhaveatenant,thatltismy NEW RESIDENTIAL MECH. SQ.FT OCT ��
reponsibllfty to notify the om
upapt of the requirements which must be met 1992
prior to Laduance of a Certificate ofDcmpanry.
f) �U ra
TOTAL: y{
Owncrorauthorized6
agem Date ISSUED;B BY: iPP
OFFICE COPY