24133 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY "
Building Project Identification - PERMIT NQ 413 3
Building Address:
D 3 6 /�riv
Here�j Q QAU -K, ._57 7 CITY OF CUPERTINO-BUILDING DIVISION C�
• cnno-�or.Name: T/f /� ue.Nre APPLICATION / PERMIT ��� `
'mss/ G .SO/Ir I%O3 BUILDINGELECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL♦
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: SS cJr/Z PERMITISSUANCE ULIJU I,L�l PLUMB MU-11
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affrmthat l am licensed under pmvbpoasof Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB DESCMUION
Ing with Section 7000)ofDivIsIon 3 ofthe Businessand ProfessionsCode,and my
licenmbinfull a deffect. -s PANELS l�illf4�,n
LicenseC r Lic.M G 59 /y
Date UP TO 200 ANTS
CoMmcl. Q//J
ARCHITECPS DECLARATION J 201-1000 AMP5
,up��a0 O I understand my plans shall be used u public records.
OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E Licensed Professional SIGNS ELECTRICAL
G fOWNER-BUILDER DECLARATION n - SPECIAL CIliCUIT/MIST
p, owing r affirm
on. that on 7031 apt fromass a d Profetor'sedo License Lw cl or
7.o'^a following reason.(Section 70315,Business and Profesabns Code:Any cihe
ty or
FZ' TEMP.METE2OR POLE INST.
� countywhkh requlreaa permit tocoatmct,alter,improve,demolish,orrepalr
anystructure prior to its Issuance,also requlrn the applicant for such permit to ]OWER DEVICES
Rk a signed statement that he Is licensed pursuant to the provisions of the
3 u,y Contractor's License Law(Chapler9(commencing with Section 7000)of Owl-
SWIMMING TOOL ELECTRIC,- VALUATION
f, Oa Bion 3 of lhellusinns and ProfessionsCode)orthat hats exempttherefromand
G
he basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXTURES /r�x�0 ev
appliant fora permit aubjectsthe appllnnt to a civil penaltyanal more tMn
five hundred dollars($500), NEW RESIDENTIAL ELECTR
❑1,as owner of the 5QFL. STORIES TYPE CONSTRUCTION
property,or mm employen with wages n thele sole
eompensat0KBuldothe work and the rtmcture is heC intended or offered for
O sale(Sec.apply
to Business and f property
Code:The or imp Roes Licensees hemon Law
doeswho clo.such torn owner ofp rough who builds orimprwvided that
OCC.GROUIe LAPN
whodoem ntsw notinte f or dedoraugh hbowne.If,ho hie,proer,the buildi goo uch
Improvementsarenotintended earofco (orsab.IL howeveg deer idhaw TOTAL:
Improvement pr o i g that oneyhedada m buil Portorahs a for p r pose of sale.).llLj Las ower ofthepMdpdna exclor Unp contrating win Beans. QTy, PLUMBING PERMIT FEE p[,pOD 7ANE
u 4 or mucor to the property,am exclusively Business
and
with ns Codd PERMITLSSUANCE
The Cotmrtocoatcen the project(See apply
Business and of property
Code:
The Coor impro License Law dcee not apply tct an owner a property who ALTER-DRAIN&VENT-WATER(EAI
Wilds clues)
Improves thereon,and who contracts t.such p(ojscb with a - FEE SUMMARY
cgBjfaamexmnt under Secnt.
the Contnatm'e Llnnx Law. BAIX FLOW PROTECT.DEVICE.
LII am exempt under Sec. B&P C for this reason
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. - SANITARY Y N_
Owner Date RECEIPT p
WOBKMAN COMPENSATION DECLARATION FIXTURES.PER TRAIT SCHOOL TAX Y N_
❑f hereby ar ers that I have o losurate o consent to opytherre,ora RECERrf X
certificate of Workerr'Compeaatlanlnura�nce[ora certified copythereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y_ N
polis Lab C. g a/
policy a ROCKET It
Com acv ��y[[��[_ii. a
GAS EA.SYSTE7d-0VEA4(EAJ BUILDING DIVISION FEES
[�C Iced pyIs erebyfumished. GREASE/lN iUSTRL WASTE INTERCEPTOR - PLANCHECKFEE
RC-OiBed copy b coed with the city inspection divwon.
CERTIFICATE OF D(EMPI'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
SEWER-SANITARY-STORM EA 200FT Date Remi t#
(This section need not be completed lithe permit tsforone hundred dollars
(8100)or len.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the perfornunceof lhework forwhich this permit is thinned,
I shall not employ any person In any runner so as to become abject to the (NATER SYSTEM/TREATING
Workers'CompensaHan[Am of Californts.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
ZO NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subject to the Workars'Comperuation provisions of the Labor TOT
CC LA Code,you moat forthwith complywBh such provisions orthts permit shall be BUIL NG
ydeemed revoked.
W
W G CONSTRUCTION LENDING AGENCY' SEISMIC FEE
I hereby attirmthat there Is a construction lending agency for the perform-, TOTAL: ELECTRIC FEE
M Z ance of the work for which this permit Is banned(Sm.3097,Civ.Q
O O Lender'.Nacre PLUMBING FEE
LL F Lendee.Addreas QTY. "MECHANICAL PERMIT FEE MECHANICAL FEE
O O . Icetilythat]haveread this application and slatethatthe above information -
LU
iscomact.I agree tocomp)ywith all city and county ordinances,and statepawn PERMIT ISSUANCE FEES PAID:
repatpng tobulidir g mnstruct(on,and hereby authorize representatives of this
(.. Z dtyto enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmlem the City of Cupertino Date Receipt#
V against liabilities,judgments,cosisand expenses which may in anywayacnue AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL:
agai .aid c ry jn co ernof th scaling a AI
thi. nnB' - CONSTRUCTION TAX
R HANDLING UNIT(OVER 10,000 CFM)
Signature of AP,11— ate EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUERIALSU CLOSURE
Will the applicant or future Wing occupant stare or handle hazardous, HEATING UNIT(TO 100,000 BTU) Date Recej #
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 1!0,000 BTU) TOTA
❑Yes ,+L-,i No
Will the applicant or uture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE'
which emit hamrdous air contaminants as defined by the Bay Area Air
. Iity Management District? BOILER-COMP OR 1(0,0(0 BTU) P. p 'I ,®
Yes ❑No aW
shave read the bazar�ous materials requirements under Chapter 6.95 of BOILER-OOMP(OVER 1!0,000 BTU)
the California Health&Safety Cod,Sections 25505,25533 and 75534.I S�/]
understand that if the notify
the occupant
of to currently have which4that It is my NEW RESIDENTIAL METH. SQ.Ff ff 3 '(T9
responsibility to of a theeiate of of the requirements which must he met y s7
prior m issuance o(a Certificate of Occupancy.
City
Owner or authorized agent Date i55lRiD BY:
TOTAL:
OFFICE COPY