24295 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ing Add ress: Z 4 29 5
nera a hone: - APPLICA iION SUBMIT IALA In
mYS '�Q1q4- Z74CITY OF CUPERTINO-BUILDINGDIVISION
C Fra 'a Na Lie.Nd: APPLICATION / PERMIT r -�P
P 635 b BUILDING.ELECnUCAL-PLUMBING-MECHANICAL CATEGORY CONTROLN
Architect/Engine . Llc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO "
Address 3 IC 17P L°� IS IaV - PERMIT ISSUANCE . . ❑ 1 ' M
�j ❑-
LICF.NSEDCONTRAC R'$DECLARATION L1'
I hereby affirm that l son licensed under provisions of Chapter 9(commen APPMANCESRESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)ofDlvlslon 3 ofthe Bus]ressand ProfessamosCode,and my
license Is in full fa and died PANELS' -
L.Imnse Class C, b!Lic.x
Date Contexcer UP TO 2DO AMPS "
.ARCHITECT'S DECLARATION 101-1000 AMPS
qoZ I understand my plans shall be used as public records. OVFRIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.`
q��u CO
E (0 Ltoomed Professional SIGNSELECTRICAL
FLr'17 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST '
Zw•iT 7� Iherebya(firm that lam exempt fromthe Contractor's License Law for the
q following reason.(Section 7Rf1.5,Bubiness and Professions Code:M t or r
FH countywhkhmqulresaper ttommtrut,alter,impmve,demolish,orrepair - TEMP'METER OR POLE INET., +
'� .a any structure prior to its isuancs,also requires the applicant for such permit to
POWER DEVICES
file a signed statement that he ts licensed pursuant to the provisions of the
Contractor's Licence Law(Chapter 9(mmmenclog with Section 7000)of Divi- SWIMMING POOL ELECTRIC --
sion 3 ofthe Buslneuand Protessicru Code)either he is exempt therefemand VALUATION
the basis for the alleged exemption. Any violation of Section 70I,5 by any
applicant fora permit subjects the applicant to a civil penalty of not marethan OUTLETSSWITCHESFIXFURFS
dollars
fiveI,as
nerofthepr. _SQ, STORIES TYPE CONSTRUCTION
`4..' ❑hundred as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR FT.
C < mmpensatlon,wllldothework.andtheetructure aintendedor offeredfor
O sale(Sec.7094 Business and Proinamis Code:The Contractors License Law
�$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RES.UNITS
who does suchwork himself or through hisown employees,provided that such
impinvenents,are not intended oroffered for sale.If,however,the building or TOTAL: -
mprovementl widwithinomyearofcompletion,theowner-buBderwllhave
thIE*rden of proving that he did not build or improve for purpose ofule.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with llmneeitPERMpp ISSUANCE /
cont ractors to coraswctthe project(Sec..."f/14,Business and Profeuna loCode: -
7he Contvctore Licence Law don net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such plojem with a -
"Ellicensed pursuant to the Contractor's License Law. FEE SUMMARY '
'EI am exempt under Sec, B&P C for this reason BACK FLOW PROTECT.DEVICE
O
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N wner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a certificate of concent to self-Inmre,ora RECEIPT N
certltlrate mfWorken'Compensation Interstice ora certified copy thereof(Sec. ' GAS EA.SYSTEM-1 INC.40UTf.ETS FARRIER Y N•-
3800,IabCJ _
Policy N RECEIPT N
GAS FA.SYSTEM-OVER d(EA)
Com any BUILDING DIVISION FEES
Cetlfiad copy is hereby td. CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK.FEE.
❑Certified copy V filed withh the tM city Inspection division.
CERTIFICATE OF aETIPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE NITpgY-STORM F.A. 01' ��s Date - Remi
[#
a TThissectlonneednotbecompletedifthe permit isforonehundreddollare' _ P
($I00)mless3 WA fiEA.1.ER wivENT/ELECIR ENERGY FEE Y N_
I certify that to the performance of thework forwhlch this permit Is issued,
I shall not employ any person In any manner so an to become subject to the WATER SYSTEM/TREATING PAID
Works.Come n do w of Califomia.Date 9`li0`Q[
PP 1/ pp R�lrpp B.
Z 0 NOTICE TO APPLICANT: ,after making this Certificate e I nryo, �'�'' Date Recei t#
should become subject lm the Worken'Compenuatlonprovl oras fthe Labor .i TOTAL:
L4 Code,you neunforthwlth complywith such provisiomorth mdt.hsIlb.ff1 n A
y deemed revoked. I / BU NG
W — 1 CONSTRUCTION LENDING AGENCY "U I I S SEISMIC FEE
FEE
CL Ihereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
M Z ance ofthe work for which this permit is issued(Sec.3097,Cis.�ATE
j U O Lender.Name - PLUMBING FEE.
LL F Lenders Address f: - ^—••-- QTY, MECHANICA ERMITE MECHANICAL FEE '
OW Imrtlfythatl have read thlaapplicetionand statethatlbeabove intermitter,
1 iscormot.I agreeto complywlth all city and countyordinances and gate laws PERMITISSIIANCE r FEES PAID:'
�. relating to building construction,and hereby authorize representative ofthis
N .
F U) city to enter upon the abovementioned property for inspection purposes. . ALTER OR ADDTO MECH.. ' Date Receipt#
Me)agree to uve,Indemnify and keep.harmleu the City of Cupertino -
V
against Babilllln,Pdgerents,cossmand expenses which may in anywayamrue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
agairet d try Inca equenm of the granting of this permit -
AIR HANDLINGUMT(OVER1Q000CF .. CONSTRUCTION TAX
7-30-117,a - CONSTRUCTION TAX PAID:
nature of AppBunt/CW�pp�1 r Date IXFIAUST HOOD(W/DUCT)
HAZARIW US MATERIALS DISCLOSURE -
Will ialas defined
bytheant or Lure ruin ngmmpantstore ods,Ch Chapthand er
Zanha,rardous HEATING UNIT(TO]f0,f00 BTU) Date RectB [#
Heals alasdefined od Cupertino Municipal Code,Chapter 9.17,and the
He tys.d SafetyCod Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOT :
-❑Yes 1$Q,No
WIIl the applicant of futurebuliding occupant use equipment or devices VEN71LATION FAN(SINGLE RESID) ISSUANCE DATE,
which sour havardous air contaminants as defined by the Bay Area Air _
Quality Management Dis ct7 BOILER-COMP DHP OR 100,000 BTU) p
❑Yes I��+INO -
Ihavemadthe b..#us materials requirements under Chapter 6,95 of BOILER-COMP(OVER 1(0,000 BTU)
the Cal dorms l Iealth&Safety Code,Sect ions 25505,75533 and 25534.]
understand that it the building does not currently have a tenant,that it is in NEW RESIDENTIAL MECH. SQF �T i� 1992
- - rnponslbllltytomtifytheo=pantofthemqu4emenis,..I Imus(be met Guy
�prior to lssuance of a Certificate of Occupancy. car L
Owner or authorlud agent Date ISSUED BY.
TOTAL:
OFFICE COPY