24087 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building F.i.d Identification I PERMIT NQ 0
Building Address: Z
87
wnero ame: �g one: SUBMITTAL
U 1Ge � d CITY OF CUPERTINO-BUILDING DIVISION /1�1 PIPy
con IN a LIa APPLICATION /PERMIT T� ��'l L
0 Aft BUILDINGELBCTWCA PLUMBING-MECHANICAL CATEGORY
ArcMted/Engin r. Lk.N .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
I hereby edion7nthatl iv Bcm3oftheunder gp sato Profesaptar9(m,andm APPLIANCESRESIDENTIAL ]OB DESCRIPTION
If...ISection to.
effeon3o(the BUNneesand Pro(caslonsC-ode,and my
license Is iI.e fell faro:and dfect. PANES as
License Class Llcp % ^' , "
Date CoMrador UP TO 2DO ANTS
ARCHITECPS DECLARATION 201-IOOOAMPS
9022 IunderstandenyplzroshaBbaused aspubliereemes. OVERIWOAMPS SQ.FT.FLOOR AREA
k 5 Licensed Professional SIGNSELECTRICAL
<6 OWNER-BOLDER DECLARATION
j'n a SPECIAL CIRCUIT/M19C
Z F+ hat l am from s ContrLkenm
F F'ppppppu(
following
mum.
(Sect7031.5,Business a ntefessio, Any
cittyor
onywhichrequbapemttowmtrectalter,mprovedemlishorrepalr
TEMP.METIR ORPOLE INST. '
5 7 anystrucmrc prlorto its Wuance,also mrylmthe appBontforaueh permit to
POWER DEVICES .
Ole a signed statement that he I.licensed pursuant to the provisions of the
3w� Contractor's License Law(Chapter 9(commencing with Section 7000)of Diel- SWIMMING POOL ELECTRIC
SOS Non 301the Businmand ProfmimeCode)orthat he b exemptthandremand VALUATION
q
O the beets for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURPS `
applicant fora permit subjects the applicant to a civil penalty of not more than =0
lag fWXIpAddmd dollars(SM. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
(a owner of the property,or my employeeswith wages as their sole
pe timwBldutheworkandthestructurelsem intendedor offered for
O sale(See.70K Business and Pmfmioro Code:The Centnder's License fats
does not apply to an owner of property who builds or lmpmves thereon,and OCC.CROUP RES.UNITS
who dousuchworkhlmself orthrough hisownemployees,provided thatsuch
Improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement Issoldwlthln omyearofcomplmt Nthemner-WBderwlllhave
t rdanmf proving that his did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZDNE APN
L as owner of the property,am exclusively contracting with d Ilcenxd PERMIT ISSUANCE
contractors to mrutruthe preject(Sec 7044,Business Profmloro Code:
The Cemtnct.e.License Law does not apply to an owner of property who
Wilda or Improves thereon,and who contracts for such p7pee",Wph ALTER-DRAIN&VENT-WATER(EM,
cgR((actor(s)licensed pursuant to the Contractor's License Law. I`� FEE SUMMARY
LJ I am exempt under Sec. B&P C fee this ieason 'BA FLO T'DOUTSIDE FFFS
Owner -Date :a I �I DIr)A7NS�F7DOR,�- ND SANITARY Y N_ -
WORKMAN 0
MAN COMPENSATION DECLARATION "� '
[31 hereby afflrm that I have a certificate of cement to aetf-maure,oramspirk-yoSCHOOL TAX Y_ N
RECEIPT M'
3800,UbC.Worken'Compewtlonlrourance ora certilled mpythereof TE PARKFEE Y_ N
3800,Tab Cd (�__ RECEIPT M
Polhy 0 CAS EA.SYSTTM-OVER 4(EA) BUILDING DIVISION FEES
Com any
�CertNed copy tshereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE IL
Candied copy b filed with the city Inspection d1elNon. qq
�G
GREASE TRAP p�1
CERTIFICATEOFCOMPENSATION
[ON FROM WORKERS' PAID Z b sus
COMPENSATION INSURANCE
- (TNsaectlonneed net bemmplded ltd permit tsfororo hundred dollen SEWER-SANITARY-STORM EA.20017. Date Race pt#
($100)or lm.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that hi the performance of thework forwhIch this permit is Issued,
I shall not employ any person In any manner m as to become subjed to the WAS SYSTEM/TREATING
Workem'Compenaation Lawsof Callforela.Date PAID
Z Nplicant
OTICE TO APPLICANT.It,after making this Certificate of Exemption,you
NEW RESIDENTIAL PLMB.-SQ FT Date Recei t#
should become subject to the Werken'Compareat Ion provisions of the Labor TOT
CCN Code,you=at(art hwith comply with such provisions or this permit shall W
CC
j deemed revoked. BUILDING FEE
'CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyafermtfohat there bamrobuctlon lending agenry forthe perform TOTAL: ELECTRIC PEE
M Z ance of the workr which this permit is issued Ike.3097,Civ.C.)
V O Lmder's his PLUMBING FEE
U. t- Lmdcr's Addeves QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icenl(ythatl have read thisapplkatIonand Natethattheaboveinformrtion
O W
1 Iscerned.lagreetocomplywith all cityand countyordleanmand Natelaws PERMIT ISSUANCE FEES PAID:
>. N catering to building construction,and hereby authesUc reprcsentativesofthis
(. city to enter upon the above-mentioned property for Wpeciion purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d keep harmless the City of Cu portion Date Receipt#
(,
against liabilities,judgments,was and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
age buts i Me once (the granting h permit.
1lAsaAIR HANDLING UNIT(OVER IO,000 CFM) CONSTRUCTION TAX
gnat r t ntador Date FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
L3RDOUSM ER SCLOSURE
Will the applicant ce future building m iamemhandleheeardoua HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cede,Chapter 9.1$and the
Health and Safety Code Section 75531(.)7 HEATING UNIT(OVER 100,000 BTU TOTAL:
❑Yes No
Wlllthe applicant or mrc Wilding occupant useequlpreent ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emlt haeardous air mntamlwntsaa de(Ired by the Bay Area AU
lily Management District? BOILER-COMP OHP OR IOO,OOD BTU
ye, nn No yy�s
_. shavereadthehazar9iousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU E" A e D
the California Health&Safety Code,Sections 75505,25533 and 75534.I
u nderstand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which moat be met DEC 9 q
prior to Issuance of a Certificate of Ocwpa nry. 14.
G . Y
Owner or authorizeTOTAL
d agent Date _ ISSUE p By
OFFICE COPY