24240 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildings Pro'ect Id t Hon - � PERMIT NQ, 4240
Building Address: Z
area: _ one:
A
CITY OF CUPERTINO-BUILDING DIVISION'
Contr dors me: Lic.No: - APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL
Arch ea gineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter 9(mmmenc- APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
Ingweh Section force ofd died. o(the Business and[srofnmonsCode,and my
license is In full force and died. PANELS
Lire ss LIC.N '
Date Contractor - _ UP TO 2DO AMPS
GHITECTS DECLARATION 201-1000AMP5
nit 2 I understand my phru shallbeused as public records OVER I000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
z z Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Ihereb a(Rrmthatlamexempt/romthe Contractors Licenwlawfwthe
Z O
KO_@ following mason.(Section 7031:5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
s-'� cinlywhich requires a permit mintruct,alter,improve,d..Iixh,mmpalr
Anystiucture priorto its issuance,ahorequirnthe appllanttor such permitto POWER DEVICES
file a signed atamment that he is licensed pursuant to the provisions of the
3 u, Contractor.License law(Chapter 9,(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3 ofthe Business and Professiwis Code)orthat he is exempt therefmm and VALUATION
the basis for the alleged edemption. Any violation of Section 70]1.5 by any Q
.the. OUTLETSSW(TCHESHXTURFS appllant(ora pe mit subjects theappllcant toactvll pevltydnot mo
five hundred dollar($500). NEW RESIDENTIAL ELDCTR
�n �I,a owner o(the property,or my employees with wages as their sole SQ'FL STORIES - TYPE CONSTRUCTION
cpmpensation,wWdothe work and thestmvcwrebnot Intended pr offered for
❑ sale(Sec 709E Buelnesa and Professloru Code:The Cdntractore WremA Law
$ does na apply to en ownerdproperty who WIlde or improves
a,and OCC.GROUP RIS.UNITS
who does each work himself w through hie own empi oyeea,provided that such
Improverrenb are not intended proffered(w Bale.If,hawevep thebulkhrifor TOTAL:
Improvement beoldwithin oneyearo(compldion,tMowner-buBderwIII have
tl urden ofpmving thatMdld na build or bnpmve(w purpose ofsalp.), QTy, PLUMBING PERMIT FEE pLOOD70NE APN
L.J 4 as owner of the property,am exduelvely mntrading with licensed I'FRMIT ISSUANCE
mntraotme to mruWct the projM(Sec.7094 Business aral Professioru Code: I.
The Contractors Llanss Law don not apply to an owner o(property who ALTER-DRAIN&VENT-WATER ffA)
bulli.or imp rsm.thereon, and who contracts for such paujab with a
i}BTador(a)lknaedpunuantWthe Contrado Licenss Law. BACK FLOW PROTECT.DEVICE - FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
Owner —Am DRAINS FLooR ROOF,AREA,CONE). SANITARY Y_ N— '
• RECEIVE p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N—
❑I hereby orke that I have a jrtren of consenauhlf to pytnmre,(S . RECD,s
certifiateofWorken Cpmpewtlpnlruurance wacertlfled copytherepf(Sec. GAS FA.SYSTEM-1 INCA OUTLETS
polis 38M,Isis CJ - PARK FEE Y N
policy Is RECEIVER
m any GAS EA.SYSTEMOVER4(EA) BUILDING DIVISION FEES
ft Bad copy is he. furnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy bfiled with the city lrupectlpn division. ,
CERTIFICATE OPIAMPTION FROM WORKERS'. , GRFASEMAP PAID
COMPENSATION INSURANCE
(This aection need nut becompleted lithe permit isfor one hundred dollen SEWER-SANITARY-STORM EA.20aFE Date Recei t#
($100)orless.) ELECTRENERGY FEE Y
WATER HEATER W/VENT/ .
IreH
rti(ythanthe performance ofthe work(orwhich this permit is issued, N_
I shall net employ any person In any manner An n to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Califomia.Date PAID
0 Z OTICEt NEW RESIDENTIAL PLMB. Date Recei t#
Z 0 NOTICE TO APPLICANT:If,akar making thio Certlflate o(Exemptlon,you ��'
1'•' should become subject to the Workers''Comperuatlon provisions of the Labor TOTAL:
WN Code,you must forthwith comply with such provisions or this permit shall be
> deemed revoked. 13VILDINC FEE
Q. c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I herebyafBrm
that there is a construction lending agency for the perform- T ELECTRIC FEE
ance ofthe work for which this permit b baued(Sec.3097,Civ.C.)
V O LenderBName PLUMBING FEE
IL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lmAffythatIWvemadthbappliationandmatethatthe above lnformatlon
C bmrrect.I agree to comply with all city ami county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
} W relating to building instruction,and hereby authorize representatives of this
I— Z city to enter upon the abovementioned property for Inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recelk#- - Is
Against liabilities, imsand expenses which may,in anywayaccrus AIR HANDLING UNIT(TO Bloat CFM) —SUBTOTAL:
Against said City in consequence of the granting of this permit.
AIR t1ANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
nature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappBcant re orfutubutdingoccupantstore or handle haeardous HEATING UNIT(TO 100,000 BTU)- Date R0Ce1 t#
material as defined by no od
the CupertiMunicipal Ce,Chapter 9.1$and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) - .I.O
Yea No
Will the applicant or(uture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) II$$I9AN6EDATE-
which emit haaa rdous air MAUntinanb as defined by the Bay Area Ab y
• Quality Management District? BOILER-COMP OI-Is OR 100,000 BTU) '
Vee UNo (1�s�
have read the Aaza'7ous materials requirements under Chapter 6,95 of BOILER-COMP(OVER 100,o00BN) S I•a 17 199,2
the California Health&Safety Code,Sections 25505,25533 and 25534.1 /Jy
understand that if the building don not irrentiy have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
rn _CITYUI-
poruibility to notify the occupant of the requirements which must be met VUP'LI-I I IIY�J
prior to issuance of a Certificate of Occupancy. - ----
Owner or authotlaed agent Date TOTAL: ISSUEDBY: �''`►�/�
OFFICE COPY