24399 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building project Identification PERMIT NO
Building Addmaa: . lV 24399
11h/N
w er
en A
CITY OF CUPERTINO-BUILDING DIVISION
c° :•Name: Lie.No: APPLICATION /PERMIT �b y
/' 376997 BUILDING.ELECTRICAI PLUMBINCMFCHAMCAL CATEGORY CONTROL.
Archimet/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERNUTISSUANCE ❑ ❑ ElLICENSED CONTRACTOR'S DECLARATION -
IFthSecdn7Otlu[lam Been3ofth, uunder d...rel PrfChapter 9(mmmenc APPLIANCESRESIDL•NTIAL - JOB DESCRIPTION
Ingwith SeMon70p and ivlelon3o(Ihe Bumnneand ProteaeloneCmde,and m
license la In full and died. �1 —a PANELS ar
Lkcne9 C{a�LIc.M 3 I! I (�
Date_/p7/ Contndor 'L
ARCHITECTS DECLARATION 201-IODO AMPS
Oz I understand my plans shall ire used as public record& OVER I Opp AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
O
y Llrenud Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION �-,a rr
)n`,7`� SI'ECIALCIRCUIT/MISC p, ',I I N
z`., owing affirm(Sed on 7 exempt fromBusiness
a d Protrusions
Llrense Law for the r
QQ q county greasoq iced permit
ttocomned and Piropro ns Code:Anydty or _
FZ~:y county which rcqulmaa permit to mnetmd,aller,lmprove,demollsh,mrrepalr TEMP,METER ORI'OLE INST. I- 'rI
a°'] 7 anytmdure pdo it,bwance,also requlrcstheapplicant forsuch permit to �� fy,y! u L
S file a signed statement that he s licensed pursuant to the provisions of the RAWER DEVICES
3�fnContractor's License Law(Chapar9(mmneocingwlth Sedlon 7000)of DIA- SWIMMING POOL ELEC77tI DAT
the b sHho the alleged exemption. Any)violation
n of exempt therefrom and - � UgT10Y
G the basis for the alleged exemption. Any violation of Stolon 7891.5 by any OUTLETSSWITCHFSFIXTURES JJ'•I'M��1 iiVV77
applicant fora permit subjed•theappllcant to a civil pershy d not moreW n
five 1,as
dollars ofthe D9Lpro NEW RESIDENTIAL ELECTR SQkT. STORIES TYPE CONSTRUCTION
�s ❑I,a•owner of the property,or my employed with wags ae[herr sole
compensatics,700 Buldothe work and ions Code:
s not Intended or offered for
sale(Sec apply to an ess owner
df property Code:The or improves
Licenseenon law
�$
does not apply toanownerm(prough hismn ilds emplrtmprovdthereoryand OCC.GROUP RIS.UNITS
whodaements a erkhinise ded orwgh Meows employed,provided ihal such
Improvementsarenot Intendedearofcdmorsels.theo ver,lheerildsgve TOTAL:
Improvement bold within orrcycarofcompldbn,theowner-buBderwlil love
thAvolen of proving that he dM not build or Improve for purpose of ukd. QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to mrdtrud the project(See 7614,Business and Professions Code: PERMIT ISSUANCE
The Contractor'•License law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such pi jests with a ALTER-DRAIN VENT-WATER(EA)
cgftMdors)licensed pursuant to the Contradera License Law. BACK FLOW PRO=DEVICE FEE SUMMARY
L_I I am exempt under Sec. - B k P C for this reason
DRAINS.FLOOR ROOF,ARE k CONED. SANITARY Y N�
Owner Date RECEIPT N_
[Elf-hereby WOR KMAN COMPENSATION DECLARATION FIXTVRFS PER TRAP !aZHO0L TAX Y N
i orfirm that I have a cedtu,uncificate of consent to opythemo ora RECEIPT I
certificate o(Worken'Compedatlon lruuranre on certified mpythereof(Sec. GAS EA.SYSTEM-1 INC.l OUTLETS PARR FEE Y N
3800,Lab CJ
Policy q U OO DING DI p
GAS EA.SYSTEh1AVER d(EA)
Co
anv a L BUILDING DIVISION FEES
�i Certified copy 6 heed with the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Certifled copy s filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY
(This section need sea be completed if the permit s forms,hundred dollars STORM EA.200Fr. Date Recei t#
(5100)or led.) WATERR HEATER W/VENT/ELECTR ENERGY FEE Y N
l certifympsthe persomnceof tmannerlorwhkhtldspermitsitothe —
I shall not employ any pemm�In any manner n ae to become eabjM t°the WATER S,3].N/TREATING
Workers CompensallmnLwe o(Callfoms, Date PAID
O Z Applicant
NEW RESIDENTIAL PLMB. Fr. Date Recei t#
Z O NOuld bee APPLICt tothe mkx.'k.mpaing ti.provisions
of the Labor
sode,yo cmmeforth it the Workers Comperovisio orthIs permit all be TOTAL:
N Code,you must forthwith comply with such provlaioru dribs PerrnB shill be
W 9 deemed rooked. BUILDING
IL F3 1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL eofthe orkfo w ichthem sammlmdlsnlendingd(Sce. age097,cy Civ.C.)
pedmrrt. ELECTRIC FEE
D Z ante of the work for which this perMtbbsued(Sec.3097,Civ.C.) TOTAL:
U O Lender.Name PLUMBING FEE
LL I— Lenaer:Addmu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icerti(ythatl have read lhsappucatbnaM matethattheabovein=tIon
1 bmrred.l agree to complywith all cityand county ordinances and gate law• PERMITI.SSUANCE FEES PAID:
relating to building construction,and hereby author co mpresentaevd of tha
Zdtytoenterupontheabove-m,nuonsd propertyfm Inspedlon purposes. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify an d keep harmled the City of Cupertino Date Recei t#
V against llabllltks,judgm,ns,comund exp,nsea whkh may In anyway accrue AIR HANDLING UNIT(to 10900 C4M) SUBTOTAL:
agaWtaaid City lnconsoquenceof the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 151,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Salcey Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTA
Ytheea [jNo - VENTLATION FAN
Wllioll appllcant or ousair himcont building accupant use s deflodbythe Bay nt Area
devices (SINGLE REBID) ISSUANCE DATE
which eMahagement air contaminants a•deBnM bytM Bay Arca Alr
F1 Y Management Dlsirid7 BOILER-COMP(31;P OR 100,0(q OTU)
F1 Yes n No
'of}lveni. earth a Tet mode,Se rcons 25 nsunder Chapter 6.95 o! BOE.FR-COMP(OVOT 100,000 RTU) B
the
understand
t Health kSafety Code,Sedlod2550.5,ve a tenant,and 25539.]
und,rslanity 1.If the really the ocgdealspant note requiymortshichthat it soy NEW RFSIDPNIIALMECH. SQ.FT OCTy
rdp° i utytoval(ytheotttoo cof o,herequlnnenlawhicFrtwstbemet G27 goo)
prior uance ofa Cert Lem crops /Q
ror hodre agent U)K CITY p F _'IIsV
TOTAL: ISSUEDBY:
OFFICE COPY