24271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO
Building Address: 24271
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stn aLeC/ouuTa '�Q ;1 -783g CITY OF CUPERTINO-BUILDING DIVISION
V Contractor's Name: Lk.No:
APPLICATION / PERMIT
1
BUILDINGD.ECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROLp
Arc tet giruer.
Lim No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrnsv: PERhtIT755DANGE ❑ El ❑
LICF.NS ED CONTRACTOR'S DECLARATION
hereby Section 7000)tl of ivsionsedunderprovklonso(Chapser9(commenc APPLIANCESRFSIDEMUL JOB DESCRIPTION
Irg with I.Section andaffect. the Buslsssand ProfesstonaCade,andm
Thanes Is In(u0 foroe and died. PANELS
Ckss Lk.N
Date—Contractor Y-
ARCHITECTS DECLARATION 201-7000 AMP"' V�
OZ I understand my plans shall be used s public records. OVFR1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
ILicensed Professional SIGNSELECTRICAL
�"u{7s OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC I
Z2.
7di Ihereby affirm that I am exempt from the Comoub 's Llmme Law for the
❑❑ following rcsan.(SMlon 7011 S,Businm and Pro(emlov Code:Mydty or /
F F'� county which requires a permit to construct alter,improve,demolish,or repair TIME.METIROR POLE INST.
anystrueure prlortolts lssuaneq ales requlrestheappllant/anuch permit to III
q POWER DEVICES `JL U
[5��� !Ile a signed etatenw•nt that M Is licensed pursuant to the provisions of the
3w�p Contractor's Lie...Law(ChapterI(mmmendng with Sces""000)0"" SWIMMING POOL EI.ECTRIC ,DA'IIGN
SOS slon3ulthe Budnemand ProfewtomCode)orthathekexemptthemfromand
she bask for the alleged exemptlon. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIX'IVRFS
O�
applicant fare permit subjects the applicant to a civil penalty of on,room than
a ndreddollars(SSW).
S,Ii NEW RESIDENTIAL ELECTR SQ.FT. 51OItlIS TYPE CONSTRUCTION
�n s owner o!tho property,or my employes with wage as thele sok
pensadory w111dotM work endtheetmtlure k noHntended or offered for
(Sec.7 44,
ply to owner
end f pr esslov Code:The C impro fs ms themar,Gw
p $ d nossuchtoanimer1orprunigheperty who Wllds mpoyces,povidedeoryand OCC.GROUP RES.UNITS
0.0.
who doementsa not Intended
Nsawne.If,ho however,
builaingor
Improvements iarcnot Intended earofco facaale.If,however,theerwill have
TOTAL:
Improvement kwld within oneycar o(completlon,the owner-bu0derw111 have
ttej,uoden of proving that he did not build or Improve for purpose of sale.), QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am elusively contracting with licensed pp(h(IT IS6UANCE
contractors to construct the projed(Sec.."019,Business and Protessloru Code:
The Contractor's License law does net apply to an owner of property who
builds or Impress thereon,and who contracts for such profeds with a ALTER-DRAIN&VFM•WATER(EA)
camr.doRs)Ilmme.d pursuant to the Contractor's License Law. FEE SUMMARY
Lf I am exempt under Sec. B&P C for thin reason BACKFLOW PROTECT.DEVICE
FEES
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N�
Owner Date REC77Pf M
W
O
R
KM
ANI have
aAT1ON DECLARATION FIXTURES PER TMP SCHOOL TAX Y N
01 hereby affirm that I have a l rtcone of consent d sell-Imam,ora BBC=M
MWILsteof Worken'Compewtlonlsurance oracedlfled copy thereof(Sec. GAS M.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3500, It Cd
Poliry Y GAS EA.SYSTEM-OVER 4(EA) DECEIT?N—
Policy
any BUILDING DIVISION FE05
Certified copy k herebyfurnishedthe city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy k filed with the tlly Inspection division.
CERTIFICATE.OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCeI tet
0hIsseetion need not be completed it the permit kfor one hundred dollars
($lMorless.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I artilythat In the performance of the work forwhich this permit k issued,
I shall not employ any person In any manner an as to become subject to the ATTR SY /TREATING
Workers'Compensation Laws of California, Date PAID
O Z Applicant NEW RFSIDENTTAL PLMB._SQFT. Date Recei tR
Z O NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you
should become abject tothe Worken'Compesallon provklos olthe La bar TOTAL:
f' N
Code,you=at forthwith comply with such provisions orthls pembtshall bet
Wdeemed revoked. BUILDING
CONSTRUCTION LENDING ACCNCYSEISMIC FEG
CL IhercbyafRrmthat there k a construction lending agenry for the perform ELECTRIC FEE
7 Z ance of the work!or which thi permit k Issued T*m 309],CIv.C.) TO
t
O O Lender's Names PLUMBING FEE �a
LL Lander'.Add cos QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
OW Irertifylhat l have read this applistionand slamthattheaboveleformatlou
0, incurred.I agree to comply with all tltyani countyordlnamenand state laws PERMITISSUANCE FEES PAID:
>. N relating tobuildingcom uction,and hereby authorise representatives ofthis
(— Z city to enter upon the abovementioned property for lspectlon purposes. ALTERORADDTOMFCH. Date Recei IH
O — Me)agree to save,Indemnify an d keep harmless the City of Cu ped loo
against liabilities,Judgment.,cook and aspens.which may In anyway amue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
agabutsald 't yinconsequenceofthe ntln this perm AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
SI ture of Applicant/Contractor Date EXHALE How(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wilitheappllaest or future building occupantiame or handle haaardous HFATING UNIT 00101,000 BTU) Date Recel t8
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
I Ieallh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 10),000 BTU) TOTAL(
❑YeaNo
Willtheapplicant or core building occupant use equipment or devices VEMIILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardous air contaMrunb as defined by the Bay Area Air
Quality Management DbericT BOILER-COMP OHP OR 100,000 BTU)
4Ya �No p�
have ria Health
car ouyCode,akllons 2menk5533 and 255346,95 of OOR.ER-COMP(QVER 100,000 BTU) P' p
the
understan t Health&Safety Coesnetcaru755Q5,ve a tenant,andthat 1 aY ♦9
nespntandtlut i(the sify the ing occupcea ant of t e requiyhands whicthat It mot NEW RESIDENTIAL MRCFI. SQ.FT a�
rspr to issuance
OfaCeheiate ofocupancyuimments which must be semi
prior to issuance daCertlRcate ofOccvpanry. 44 PP mil til 19Q'
Owner or authorized agent DISSUED BY:
BY: Vr;
TOTAL:
OFFICE COPY