24424 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building I'm ad Identification 7 PERMIT N
Building Address: (,I 4 4 2
Ae 3 6
mere {Y ` one: APPLjcATIZA
CITY OF CUPERTINO-BUILDING DIVISION ' ^
cpntradora Name: Lie.No: APPLICATION / PERMIT (�
N J� BLJILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL If
Architect/Engineer. Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMIT ISSUANCE !^ a❑ `ff ❑ ❑
LICENSED CONTRACTOR'S DECLARATION jam
I hererd1onmehatl wId.3.fthc erpessandsof Chapter9(mmndm APPLIANCESRESIDEMIAL JdB DFSCRB'fION
inense I.ed ion 7000)of effeon3oftheBusin/nsand Profesalom Code,and my
license Is In fail fonts a e,c //O �+ PANELS
License LIc.M
Dale Contractor - UPTO ODD AMPS
ARCHITECT as public
TE N 201-1 OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
qw a0 7I understand my piens slug be used u public recortls J
Fi Licensed Professloml SIGNS ELECTRICAL
a ur OWNER-BUILDER DECLARATION
In SPECIAL CIRCUIT/MISC
owing reason.
thnton 7MI,mpt(romthe Contractors License Law fort he
0OF� .o tywhichoquimsape7 1$Business
tmdand
te Professions ]e hnydryor TQ,(g MEITR OR POLE]NSI.
anystm hkhregrtolts a ttocomance,alsomq imsthlmpmvntforsish, er ttr
q any atmcturetatemeite Issuance,ahorequ pursuant to the provisions of lte POWER DEVICES
file a signed statement that M b licensed pursuant to the provisions of the
3 Contractor's License Law(Chapter 9(commencing with Section 700D)of Divi. SWIMMING POOL ELECTRIC VALUATION
O sion3oflhelhermassand Profeadom Code)orthat helsemm therefroand
the basis for the alleged exemption. Any violation of Section m
70315 by any
OUTLETSSWITCHESFTXTVRES
fE5 O appllwntfor a perMtsabjectsthe applicant too dull penalty of net moretlun
five hundred dollars(S500). NEW RESIDENTIAL� ELECTRSQ.FF.j?Q ❑1,as owner of the property,or my employees with wages as their sok SIOWLS TYPE CONSTRUCTION
mmpenatiomwilldotheworkandthestmc mbnot Intended or offered for
5 ❑ vie(Sec.7046,Bus Wass and Profassiora Code:The Contractors Llceme Law
N$$ docs not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RES.UNITS
who doessuchwork himself orthrough hisownempicyees,providecithat such
improvements am not Intended proffered for sale.If,hervevm the building or
Improvement Issold within one yearofcomplellon,the owner-W Ilderwill have
an of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODTONE APN
L_j L as owner of the property,am exclusively contracting with Ikenxd PERMIT ISSUANCE
contractors to construct the pmject(Sec.7044,Business and Professions Code:
The Contender's License Law does not apply to an owner of property who ALTTR DRAIN k VENT WATER(FA)
Wilds or Improve thereon, and who dentrids for sock p(ojects with a FEE SUMMARY
,,AAttfLactor(s)homsed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
L j T am exempt under Sec B k P C for this reasonOUTSIDE I`Ev�
Owner Date DRAINS FLOOR,1160 BAR D,, �'", SA u
RECEIPT
WOA KMAN COMPENSATIONDECLARATION FIXTURES PER TRAP +aX Y_ N_
[—]I hereby affirm that I have•certificate of consent mself-insure,ora ._
T-4 '� I'_ RECEPT N
certificate of Workers Compensation Ingenuous or a certified copy thereof 6ec.
3800,LABQ GAS EA.SYSFEM.t IN .46UI1,M �� PARK
Y_
N_
oliryp I
If
Coanyhed. GAS EA.SYSTEMOVER4(EA) BUILDING RECEIPT
N FEESmn
fified copy ts hereby FanlBed mpybfiled with the city inspection division. GREASE/INDUS41,W INTEC R PLANCHECKFEE
CERTIFICATE OF D(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM G.200FT. Date RCtt•1 t#
(fhb action need net W completed if the permit b for one hundred dollars
0I0(fiorless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of thework forwhlch this permit Is issued,
I shall not employ any person in any manner se as to became subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recel t#
Z p NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you
should become,subject to the workers Compensation provisions of the Labor TOTAL:
C y Code,you rtwat fanhwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
tL Iherebyaffirenthat there ba construction leadingagency forthe perform- TOTAL ELECTRIC FEE
7 Z ance of the work for which this permit Is kssued(Sec.3097,Civ.C.) PLUMBING FEE
V O Landers Name
LL Lenders Address QiY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I rcnifythatl have read thbappilcationand state thattheabove information
0 W iscomed.l agracto complywith all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. IL rel#Ingto Wilding construction,and herebyauthorixereprexntativaeofthb
Z city to enter upon the above-meatioruA property for Inspection purposes. ALTER OR ADD TO MICH. Date Receipt#
(We)agree to uses,Indemnity andxpenharmless the In any ayace Cu a MR HANDLING UNIT 10,000 CFM)
V
against lkbilitin,' d menti,costs and expenses whish mayIn an ova accrue SUBTOTAL:
against said City in consequence of the granting of this permit. CONSTRUCTION TAX
AIR IiANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appliesest or future building occupant store or ha end ie hazardous HEATING UNIT 00 100,000 BM Date Reeel t
material as deft ned by the Cupertino Municipal Cole,Chapter 9.1 Z,and the - —
Health and Safety Code Sectlon2S532(a)t HEATING UNIT(OVER 100,010 BTU) TOTAL'-!7y
❑Yes Im No
Will the applicant o future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hammlous air contaminants as defined by the Bay Area Air
Qjj�lay Management Diss�MNNct7 BOILER-COMP(311V OR 100,000 BTU) 11
yes
ID
have read the haeardousomaterials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) U
the California Health k Safety Code,Sections 25505,25533 and 25534.1 NOV
� 'I
understand that if tM1 Ilding don not currently have a tenant that it b my NEW RESIDENTIAL MECH. SQXT. 1tlO V
rnporaib sty ton a occupant of he requirements which must be met
prl ance f 1 t5�f panty. • vsIaNS'
2' L•I I �Ll tr u..Ier u..a
mer or otlicubedragera y Date ISgIIED BY:
TOTAL:
OFFICE COPY