24146 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project Identification PETLMT" 414 6
Building Address:
losSl tw. ,)L r- �
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From:
A
fi'�QJ(',Sij ( CITY OF CUPERTINO-BUILDING DIVISION � 'a.� I �
Cont ac or,Name: u�oNo: APPLICATION / PERMIT !tel
9§ /c BUILDING-ELFCTRICAL-ML RING-MECHANICAL CATEGORY C OWN
Architect/ gheer Lic.N. CJ
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE •�
LICENSED CONTRACTOR'S DECLARATION _
]hereby affirm that l am llcensM under provisions ofChapter9(comment. APPLIANCES RESIDENTIAL ]OB DESCRIPTION
ingwithS dton MW)ofMbl.ion3ofthe Busimssand ProfesslonsCode,and my s
Ilcenselsin. forceanddfl's w u PANELS
LLnscC MT
Me. iS7ID
DUP TO 200 AMPS
ate$ / _CHITEmr MI-1000 AMPS
ARCHITECTS DECLARATION
O 7 I understand my plans shag d be us as public reeordc OVER 1000 AM15 SQ.Ff.FLOOR AREAS/SQ-FT.
oO TA/54) may.
f Licensed Professional SIGNS ELECTRICAL 4p V ,,,...'F`J1
<Q�
OWNER-BUILDER DECLARATION SPECIALCItCU1T/ SC 1 �-§I!
t.., ]hereby affirm that l am exempt from the Contractor's License Law for the
O H a following reason.(Section 7031.5,Business and Professions Code:Any city or
county which requiresa pemUttocowtruct,alter,improve,demollaM1,or repair TEMP.MECFR OR I ST., ,{..{[
py4V� anystmmmprlartoltslswanc,aWrequlrestheappli.nif.wchpermitto POWER DEVICES
y. 1 file a signed statement that he V Bcensed pursuant to the pmvlelom of the ___
3 w G Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- WE MgNG POOL ELECTRIC VALUAT ON
debasisforthealleged exemption. AnyCodeviolation
behemmpttherefromany _aj6>9
Q 5 thebashfortheallegedjectsthea. Anyt to
o!naction not rereany UTLETSSWITCFTFSFIXTURFS
appll.nt fora permit subjects the applicant to a civil penalty a not rtnrc than
c. five hundred dollars($500). NEW RESIDENTIAL ELECTR FT.
.. n 1,as owner of the property,or my employees with wages as their sole SQ STORIES TYPE CONSTRUCTION
7Q, compensation,will do the work and the structure b not intended or offered for
' ❑ set le(Sce.7044,Business and Professions Code:The Contractors License Law
5$ does not apply to an owner of property who Wilds or improves thereor,and OCC.CROUP RES.UNITS
whodoessuchworkhinself orthrwgh bieown employees,provided thatwch
Improverrentsare not intended omffered for sale.If,however the W ilding or T _
Improvement proving
rovi gthin he did ,ofWildo Improve
for
purpose
ur pose adult.).
tr�,¢uraenwner of the pope idna Wild orimpmveracting oBeotsense QTY, PLUMBING PERMIT FEE
Ll L as owner of the property,am exclusively contracting with Licensed FLOOD)ANE APN
PERMIT ISSUANCE
mntracton to construct the project(Sec.7054,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN VENT-WATER(FA)
Wilds or improves thereon, and who contracts for such piplects with a assee FEE SUMMARY
coA,1BIactor(s)licensed pursuant to the Correctcc's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B k P C for this reFIES
awn DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Uvner Date
RECEIPT N
WORKMAN COMPENSATION DECLARATION FIX'NFtFS PER TRAP �� SQ50DL TAX Y_ N_
QI hereby affirm that I have•rertifiote of enteredto uB-inwre,ora RECEIPT N
rertNmteofWorkers C.rn,.tm.I..rce or a certified copy thereof(Sec. GAS F.A.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,lab C)
RECERT N
Pa Talicy Y GAS.EA.SYSTCM-OVER4(EA) BUILDINGDIVISI NFEES
e Ified ropy is hereby famished. CR[ASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE 74 a4�
rlified copy b fl4d with led city W penton division. 1 J
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID y
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT Date eCCI .�yo
Of a..
(This section need net be completed lithe permit Is foram hundred dollars
($10()orles.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N_
I.difythat Ntheperformanceofthework!.,whichthispermitiswu ,
1 shall net employ any petsen In any manner so as to become subject to the WATER SYSTEM/TREATINGWorkers'Compensation s of California.Califola.Date PAID
Z Z NOicant TICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. atRemi tN
,h.1d become.ubjeO t.the W.rkers'C.mpe..It..provisiom of the Labor TOTAL:
N Cod,you most forthwith comply with sort,provisions or this permit shall be MI
NG FEE
W > d.rted revoked.
CONSTRUCTION LENDING AGENCY MIC FEE
a Ihereby affirm that them b a construction lending agency for the perform TRIC FE� �s
7 2 an acefineworkmrwhichthbperretbiBwed(Sec.3097,Clv.C.) MBING
(� U :arder'BName
IL F l.endcr'aAddece QTY MECHANICAL PERMIT MEC FEE �►
U 1certilythat l have read this application and statethatthe above information O W Is corretl,Iagree to comply with all my and county ordinances and state law, PERMIT ISSUANCE PAID:
r d relating tobulidtng construction,and hereby authorize mprexntatives of this
fn city to enter upon the above-mentioned property for Wpection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,Indemnify as d keep barmier the City of Cupertino Dateagainst habiltties,judgments,mita and expenses which may In any way accrue AIR HANDLING UNIT(DO 10,00)CFM) UBTOTA[a
againstvidCi in ons . the' antingofthls permit. AIRITaNDWNGIINTT(OVFR10,0D0CPM) STRUCI70 TAX
Z STRUCTIO TAX PAID:
Sigmlureed Applies Contractor 2 EXHAUST HOOD(W/DUCT)
_ HA RDOUS MATERIALS DISCLOSURE
Will the applies at or future building occupant store or handle hazardous HEATINGUMT(TO100,000BTU) Date CCC] Ig
material as defined by the Cup.rdoo Municipal Cod,Chapter 9.1 Z and the -
1leallhandSafelyCodeSection25532(a)I HEATINGUNIT(OVERID0,000BTU) O ,
Yes MNo
Will the appliam W
nt or foruilding oc vpant use equipment rn devi<n VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemit laurdoua sir.ntamimnbmdefined bythe Bay Area Air pp y
Quality hlamgernum District? BOILER-COMP OIB'OR 100,000 BTU) W
YesNo
1 havcrcadthe haza esu,materials requlrementsurider Cha pter6.95of BOILER-COMP(OVER 100,000 BTU) ���,191992
the California Flealth k SafetyCode,Sections 25505,8533 and 25534.i
understand that if the building does net currently have a tenant,that it is my NEW REM DENnA1,MECH. SQ.FT.
rmponslbility to notify the occupant of the requlrrmenls which most be met
prior to issuer.of a Certificate of Occupancy. UT vurar"
Owner or authorized agent Date ISSUED BY:
OFFICE COPY