24021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prm'et Identification 7 PI LVIT NO.
emdamg address: P��o
'' , �GFE �fj � + — /' �3) 24021
/t/ (Dne A A
7_19WI/(ts CITY OF CUPERTINO-BUILDING DIVISION Q f r•jq
ContrannrsName: uoNo: APPLICATION / PERMIT — �"� —
Slime• BUILDING-ELFCTRICALPLUMBING-MECHAMCAL CATEGORY CONTROLN
Archited/En em Lic.No:
o�E Qtt ELECTRIC PERMIT FEE BUILDINGPERMIT
[—]PERMIT INFO
Address: PERMITISSUANCE "fir ❑
LICENSED CONTRACTOR'S DECLARATION `
I hereby affirm that l am licensed under provisions of Chapter 9(mmerchu, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Scdion 7000)of Mvislon3ofthe Businedand Pmfessiona Code,and my
license is infiWf�cue pflect PANELS
License Cis Yj C�PL�oN 77-50 ` ■^!\
Date,'.a g— CoMracmr UP TO 2DO AM
ARCHITECT'S DECLARATION 201.1000 AMPS
he Z I understand my plansshall be usM u public mconla OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
qOq
Iv/U Licensed Professional I SIGNS ELECTRICAL �r
W OWNER-BUILDER DECLARATION
G FR SPECIALCIRCUIT/MOC
fo-, a m
IherebyatOrthat l am exempt from the Contradors License Lawforthe
OPF.a following reason.(Section 70315,Business and Professions Code:Anycity or TIME.METER OR POLE INST.
muntywhichrequlrnapermittommk d,a)ter,lmprovede=o h,orrepair
gFg .moi anystmc mpdortolbissuance,alcorequireslheappBmntlorsuchper tto POWER DEVICES
f5' file a signed statement that he Is licensed pursuant to the provisions of the
Q3w� Contractor's License Law(Chapler9(commencing with Section 7000)of Divl- SWIMMING IDOL ELECTRIC VALUATION
O cion Iofthe Businessand Pmfeniom Code)crib.be is,exempt therelmmand
6 the basis for the alleged exemption. Any violation of Section 7m L5 by any OVILETSSWI.ICHESFIXNRpS / 420applicant fora permit subject not applicant to a civil penalty of nmore than (/
r, O five hundred dollars(5500). NEW RESIDENTIAL ELECTR .FT.
1 as owner of the employees with wa es as their sole SIORIFS TYPE CONSTRUCTION
�7 ❑, pwork,aormy, B
compensation,Business
usBothe wwlc and thea Code:
reh rot intended or offered for
p
sale(See.apply
to th ow owner
of properProftsolonty
Co Wilds Contractor's LicenseLaw
S
does red applytoanownerofpropertywho Wildsorimprovethermrtand OCC.GROUP RES.UNITS
whodoes suss are not
hisow ale.IL ov,eprovidedthatsuch
Improvementsarenot Intended earofodforsale.If,howevegtheerildl have
improvement ksold within he,did of Wild
semon,theeforP Purpose
of ill sahave
t rd eno neerprovingof the property,am
Wild or impmvefwpngwith!cense QTY. PLUMBING PERMIT FEE FLOOD LANE APN
�l,as ownero!the property,am.70K exclusivelycontracting licensed PERMIT ISSUANCE
conThe,Contractor's
ronswt thew doe not apply
Business and Professions Code:
The Cool odor's License law docs h apply tct an owner of Property who ALTER-DRAW k VENT.WATER[FA)
Wads or improve thereon, and who contracts ice such plojeM with a FEE SUMMARY
,,yyTTadorexmnce under Snt to the Contractor's License BACK FLOW PROTECT.
LJ I am exempt under Sec. B h P C for this reasonOUTSIDE FEES
DRAINSFIAOICROOF,ARE.&COND. SANITARY Y_ N
Owner Date 1 RECEBTp
WORKMAN COMPENSATION DECLARATION PER TRAP TOOL TAX Y_ N_
❑1 hereby affirm that I have a l rt cone of consent to salf-fissure
me,on RECD N
certificateof Workers'Compevatlonlrounncemacetifled mpy thereof(Sec. GAS -ANCA OUTLETS• �' ARK FFR Y_ N_
ra�'wb C.)/S9r/S3S0�
RUMPT N
P
and cAs eA. ovERi Fn)I ! yl l� G� BUILDING DIVISION FEES
Crtilled mpy k Hereby furnished. GREAS /INDOSRtL WASTE INTFJ39FLPV3M PLANCHECK FEE
CCrtBied mpy V filed with th<tty Inspection divlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GR TRAP Dd
NII_ PAID
COMPENSATION INSURANCE SEY✓ER-SANITARY-STORM FA.200FT. Date RCC21 t#
(This section need notbecomplted if the perMt b forom hundred dollars
(slm)nrled.> WATER HEATER W/VENT/ELGCTR ENERGY FEE Y_ N
rm _
I certify that in the performance of the work for which this permit Is Issued,
1 shall not employ any person in any manner n as to become subject to the WATER SYSI.EM/.I.RFA.DNG PAID
Workers'Compensation laws of California. Date
O Z Applleant NEWRESTDENTIALPLMB. SQ.FT. Date Remi t#
Z ONOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
PN should become subject to the Workers'Compevat ion provisions of the Labor TOTAL:
CC ox
j Code,you must forthwith nply with such provisions mrthb perrNl shall be, BUILDING FEE re
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a o Ihereby affirmthsl there b a mnstmctton lending agency for the perform ELECTRIC FEE
Z ante of the work for who is�ema�}dil is issued(Sec.3097,Civ.C.) TOTAL:
O O 1<neers Name_"ANT-7 PLUMBING FEE
LL I erd&.Addmu
QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 1 cert Ify that I have mad this ap plication and nate that the above Information
O
a iscorrect.l agreeto complywith all city andcounty,ordinances and nate lawn I PERMIT LSSIJANCE FEES PAID:
Trelating to Wilding construction,and hereby authorise,repreantatives mfthis
fD city to erupon the stave-mentlonel property for inspection pu rposes. ALTERORADDTOMECH.
? e a e to seven indemnify an d keep h cad the City of Cupertino Date Receipt#
V aWtllablltln,jud menti sand rape w Ich maylnanywayaceme AIR HANDLING UNIT CTO 10,000CFM) SUBTOTAL:
gaWtsald arty in fon ofthe tact this permit.
p7� AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
mreof AppR nt/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hafardous HEATING UNIT(TO 100,000 BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the /yC
Health and Safety Code rr�Section 25532(x)7 HEATING UNIT(OVER 10,000 BTU) TOTA IO LJ
F-1Yen1I No
Will the a ppllcant or future Wilding occupant use equi pnent or devices VENTILATION 17AN(SINGLE RESID) ISSUANCE DATE
which emit havardomair mntaminantsaa defined by the Bay Area Air IP A b V
Quality Management District'! BOILER-COMP(3HPOR 100,000 BTU)
Yes ��JJ No
have read the hxucld us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BI U) AUG 6 1992
the C�rnia Health k Safety Code,Sections 25505,25533 and 25534. I
understand that notify
the
docs not theerequir Maven which
coast It met NEW RESIDENTIAL MECH. SQ.F7
priori Issuance
of aCtheicte of oftherequircrrenlawhich rwst be met
prior rim issuance ofa Certificate of Occupancy. CII'{ Uf VUf I:.)'
Owner or authorised agent Uccle TOTAL: I%UED gy;
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OFFICE COPY