24333 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES— USE BALL POINT PEN ONLY
Building Proect Identification PERMIT'424333
42 4 3.33
Building Address: (J V
03 GOLFS G
eons arses. IAL WALL
L/G L• HOC1196 —9CITY OF CUPERTINO-BUILDING DIVISION
Contractor' Name: Lk.Na APPLICATION /PERMIT O
BL7LDINGELFCTMCA4PLUMBING-MFLHAMCAL CATEGORY CONTROL N
Architect/Englnser Lk No: BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE �aq
Address: PFRMITISSUANCE ❑ In
Lm that ED CONTRACTOR'S DECLARATION f�
Ihereby
roio. 000).f h,xmr3 ofunder punmand re Chains odeand nc APPWANCESRESIDENRTAL JOB DESCRIPTION
line.1SMlon to.a(DlvWon3 mfthe Buslnesaandl'rofeseloneCode,and m
limwe le In full lore and dteci. PANELSX44CN� /
Llmnre Class LI.N Y • L Q� �N /
Date Contoodor UPTO200AMPSV
ARCHITECTS DECLARATION 201-1000 AMPS
7O. I understand my plans shat be used as public records. OVER I ODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION
a 3 SPFLIALCB2CUIT/MISC
r"'YI I hereby affirm m nat
that I aexempt from the Contors Llae Law for the
po qqqq following reamn.(Section 70315,Business and Pro(eagam Code:My city or TEMP.METFROR POLE INST.
rZI"' countywhkh require a permit bmrsm
truct,alter,irep,mm,demolish,oreepair
q� anysMmmpdortolhissuameahorequlmtheapphmntfor such permit to
F file a signed statement that he as Ikened pursuant to the provisions of the InWFR DEVICES
Contractor's License Taw(Chapter 9(cammencing with Section 70M)of DWI- SWIMMING POOL ELECTRIC
30J gon3 ofthe Busheeand Professions Code)orthat he b exempAtherefromand VALUATION
�' a.•••57777 the bash for the alleged exemption. Any violation of Section 70115 by any OU LE7SSW17CHESFIXrURFS0 D O
eppIf tforaperMtsubjeUtheopplkanttoadvilpemltyofnm=mtMn
five une dead dollars($50W. NEW RESIDENTIAL ELECTR SQ.F7. SIO TYPE CONSTRUCTION
I,as owner of the property,or my employwith wage as 1Mb sole
compensation,will do the work and the structure is not Intended or offered for
OsaIs(Sec 70K Business and ProfessWns Code:The Contmdola License Law
$$ doe not apply to an owner of property who Wilde or Improves thereon and OCC.GROUPRFS.UNTfS
whodoessuchworkhlmselforthrough hisownemployees,provided thatwch
Improvements are not Intended or offered for We.If,however,the building or TOTAL:
Improvementhaddwithinoneyearofmmplet %theowner-brugderwlllhave
t rdeno(piovingthathedid rwve
tbuildorlmpro (orpurpoeeofsale.)• QTY. PLUMBING PERMIT FEE
EI;m owner of the property,am excluaively contracting with limned FLOOD TONE APN
PERMIT ISSUANCE
contractors to mounted d the project(Sm 7064,Business and Profession Code:
The Contractor's Llcame Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER tFA)
builds or Improve thereon,and who contracts for such p(ojetts wlth,a _
9allacto(o)hemsed pursuant to the Contractor.License Law,
FEE SUMMARY
c ns
u l am exempt under See B k P C for this reason BACKFLOW PROTECT.DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner EC RECEIPT N
WOR AN COMPENSATION DECLARATION FI(TURES PER TRAP SCI{OOLTAX Y N
❑I hereby affirm that I have•artifiote of consent to self-insure,or
a RECEIPT N
mrtifimteo(Workeri Compersatimin mmorameifiedmpythereof(gec. GAS EA.SYSTEM-1 INC40UTLEM PARKFEE Y_ N
3800,Lab C.)
RECEIPT N
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIV]SION FEES
Com any _
❑p Certified copy is herebytumis city GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CenNed ropy is filed with the city W pe<lon division.
CERTIFICATE OF EXEMPTION FROM WOR K ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(K)Fl. Date Recei t#
(Thissectimn need rad be completed 9 the permit is force hundred dollars
(g100)orlm.) WATER HEATER W/VEM/ELECTR ENERGYFEE Y_ N_
ce
I rtifythat In the performance of the work forwhich this permit b issued,
I shall not employ any person In any manner so as to become subjectto the WATER SYSTEM/TREATING
Worksta CmmpeneUsn laws mf Ca Ofomla.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z p NOTICE TO APPLICANT.If,after makingthh CertBiesm.f Exemption,you
should becomes subject to the Workers'Compensation provisions of the Labor TOTAL:
fA
Code,you=at forthwith comply with such provision orthis permit shall be G FEE 72.eD
W j deemed revoked.
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE 6
Ihembya(firm that there isa mnstructlon lending agency for the perform TOTAL: �0 ELECTRIC FEE
D Z 'arm of the work which this perank is issued(Sec.3097,Civ.C.)
00— Lender's Name PLUMBING FEE 3 •0
LL F lenders Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Imnifythatl have readthhapplietionand statethattheabovelnfomntlose
O W
1 ismreact.l agmto comply with all cityand county ordinances and state laws PERMIT ISSUANCE .DD FEES PAID:
} N relating to building comfluction,and hereby authoUm representative of this
F city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino - - Date Receipt#
V agaWt liabilities,Judgement,.9...d expenses which may In anyway..a AIR HANDLING UNIT(TO 10,OW CFM) SUBTOTAL:
against mid City Inof tl�e gra Ung d this penult.
e��� AIR HnNDUNc 11Nrr(OVER Io,BBBcnf) CONSTRUCTION TAX
Signature of Applirant/C Inctor Dat EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZrfdDOUS MATERIALS DISCLOSU
or ha
E
Will the defied lot future building occupant hapten 9.hazardous HEATING UNIT(TO 100,000 BTU) Date Recti t#
Healthmateriala as defined by the Cupertino Municipal Code Chapter 9.1 2,and the
Health and SafMy Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ,Q
❑Yea No
Will theapplkant or tum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) s i s� %V46 DATE
which rout hazardous air contaminants as deflect]deflect]by the Bay Area AIr �
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
Yes ' No
Ilewread the hax.9usmaterials requirements underChapterb95of BOMER-COn.
MP(OVER100,000 BN) OCT �fH12
the Callfomla Health k Safety Code,Sections 25505,25533 and 25534. 1
understand than if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECO. - SQ.Fr
responsibility to notify the occupant of the requirements which most be met �•. (;Ur•p(61114v
prior to issuance of a Certificate ofOccupanry. CIT Y
Owner or authorized agent Data TOTAL, p ISSUEDBY: A)
l
OFFICE COPY