24073 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
B Ildln Project identification PFRhIr NQa 4 0 7 3
txu.ding Address: A
ame: one:
CITYOF CUPERTINO-BUILDING DIVISION
Contrador'•Name: LIc.Na. APPLICATION /PERMIT
A [ted/Enginnr. - Lic.N. BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL a. -
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE 11 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am Bttmsed under provisions of Chapter9(commenc- APPLIANCES-RESIDENTIAL
ith SJOB DESCRI'TfON
Ingwe ton7000)of Diwsion3ofthe Busimmand PmfesslonsCodq And my '
- license Is in Tali force and effect. PANELS
Licence Clan Lir"a
Date Contractor
ARCHITECTS DECLARATION - 201-1000 AMPS
po+�COC I understand my plana shall be used as public record& OVER1000AMPS SQ.FL;F100A' S/SQ,FL
k z U Licensed Professional SIGNS ELECTRICAL
R 6�i1 OWNER-BUILDER DECLARATION SPECLALCIRCUIT/MISC
,Z ao' � Ihereby affirm that l am exempt from the Contradoes License Law for the
D2FO following reason.(SectionrngtW Businesomtmc and Pimpm ns Code:Anydty it TEMP.METER OR POLE INST. �I Y�� acountywhichrequiresapermittocanstrod,alter,impmve,demolbh,orrepalr _
.a-1 anyetruclure prbrtoib lasuance,aeese
lso requireatheappBwnt(ar such psmelt to POWER DEVICES
U file a elgned Ratement that he la Bcenud pursuant to the provLslow of the
0. Commerera Licerue Law(Chapter 9(common heg with Se[Ion 7000)of Divi- SWBatMINC['DOL ELECTRIC
O elon3a(thPIPS
e Bualnmeand Profenb-Code or[haI hob exempt therefromand VALU ON
the bash for the alleged exemption. My vialatbn of Section 7Bf1S by any
QC~C applicent(ora permitaubject.the applkant ton dull penalty ctnot more than OUTLETSSW[TCI-IFSPIX7'UAES
five hundred dollars(5500), NEW RESIDEMIAL ELECTR
�n ❑I,as owner of the property,or rtry employees with wage.as their sole SQT"T. STORIES TYPE CONSTRUCTION
compeasatlon,wili do the wove,endthe rtrudure ta no[Intended or offered for
O sale(See.7044,guslneas and Professioro Code:The Comrsel. a License Law
R doesoat apply to an owner&(property who build.orimpraves thereoe,and OCC.GROUIa RES.UNITS
who doea.uch work MmeeB or th rough hl a own employees,provid ed that such
improvementa are not intended or offered forsale.If,however,the bu0dleg or TOTAL:
impmvementlssoldwlthlnoneyearofcompletion,the owner-buRderwill have
thgkurden of proving that he did not build or improve for purpose ofeale.). QTY, PLUMBING PERMIT FEE FLOODZONR, APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntracton to construct the project(Sec,7044,Business and Professimu Code:
TM Contactors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon„and who contracts for such pm”with i
gi�factar(.)Rceved Pursuant to the Contractor's License I.
c LJ I am exempt under See. B k PC for this reason BACK FLAW PROTECT.DEVICE FEE SUMMARY
DRAINS FLOOR,ROOF,AREA,COND. SANRARY Y N
Owner Date
WORKMAN COMPENSATION DECLARATION BBC=& '
FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby storm that I have o Icaureac of concent to self-insure,ora RECEIPT a
3800,codifiLab of Warken'Camperuatlanlruuranre oracertified copythereof(Sec. GAS EA,SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polis # CJ
PINI a
Policy
RECEIPT' Com anrey GAS EA.SYSTEM- &
OVER4(EA) BUILDING DIVISION FEES
CertlRed copybheby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E]Certified copy Is filed with the dty inspection divlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
QSEWERSANITARYSTORM EA 20011, 'Date Remi t#
Mssection need not be completed lithe permit bforone hundred dollars
(5100)oAessO WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify thatoy an person
an i=nnerhe work for tobacres,ch this subrmit ject
booed, —
I s1u11 not employ any person In any manner so u to becom subfed to the
Workem'Compensatlon laws of California. ATER SYSTEM/TREATING
la.Date PAID
Z Z Applicant
Z 5NOTICE TO APPLICANT.]Lafter making this CertRiute of Faemptlon,you NEW RESIDENTIAL PLMB. SQ.FT.
P: Date Reset t#
ah.Id becomenubicet to the Warke ''Compensatlon provisions ofthe Labor TOTAL:
M N aCode,you moat forthwith comply with such provisions orthis permit shall be
W > deemed revoked. B
UILDING - „.
a G CONSTRUCTION LENDING AGENCY
I hereby smitf tlat whichthere i e permit
mtruction d ding(Sec. agenry foC.) perform- TOTAL: E
3 0 once of rhe workforwhichthla permit bissued(Sec.3097,C1v.C.)
U _ lender'.Nerve EE
IL Lender'.Address QTY. MECHANICAL PERMIT FEE FEEOW Icertlythatl have readthisapplicatlonand statethatthebw.Information
Is correct.I agree to comply with all city and county ordinance.and state laws PERMITISSUANCE N relating to building construction,and hereby authorize representatives ofthls cityto enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD IO MECH.'
(We)agree to save,IndemNfy and keep harmless the City of Cupertino Receipt#
against liabilities,judgments,costsand expenses which may in anyway accrue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
against said City In consequenceof the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID: -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum Wilding occupant store or handle hazardous HEATING UNIT(TO 100,030 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,antl the
Health and Safety Code Bed ion 25532(4)7 HEATING UNIT(OVER 104000 BTU) TOTA .
_ ❑Yea ga"dyC ,No
Willthesppllcentorfuturebuilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID), ISSUANCE DATE
which emit hazardous air contaminants as deflned by the Bay Area Air
Quality Management DbMd7 BOILER-CAMP OHI'OR 100.000 BTU) -
4 Yea No
have read the
Health
a Tet Code,materiSe rcon.25505,25533
5505,255 3 and 255 4.1 of BOILER-COMP(OVER 100,000 BTU) P di to
the
understandt Health he building
Code, et currently
have.t nset that
a'9
veep. andthati(tifythldingdoes notcxmquly haves which
that b mat NEW RESIDENTIAL MECIi. SQ.FT
vapor i ty..f sty the occto cIf Iparcy ire enta which must be met AUG 319
prior Dias i aceofaCertifiate ccupancy G {
.� r r authonzed agent Date CII y
TOTAL: ISSUED
OFFICE COPY