24082 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identfflcallon PERMIT NQ, 4 O 8 2
Building Address: NG7
2 � S
/r' ,ama: one: A
W N k t, CITY OF CUPERTINO-BUILDING DIVISION
Ctr rte' Name: Lir. APPLICATION / PERMIT
nnO-gNL
amLrLIL C 22 BUfLDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL Is
Architect/Engineer. Lie.No:
/y QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: NSE RATION CJ PERMIT ISSUANCE �{/ ❑ Ia�I ❑
��l PLUMB
Lmthat EDCONTRARO 'S DECLARATION L.Rf `�Y
I hereby Sedton7OOhatlamsim3 d under provisions ftheBuinmandPmfeskpter9(corronanc.
my APPLIANCESAF_SIDENTIAL ]OB DESCRII'1lON
Ing with SI fon7000)of Dlvidon3a(theBminessand Profedone Code,and my 1
li em lsln lull( and d(en. PANES
Llcen- Co tractor J!I?DL4���` �1 C'
Date
ContractorUP 10 2DO AMPS
ARCHITECTS DECLARATION 201-IOOOAMPS
rx0OL I understand my plans shall be used az public romrds. OVER1000AMP5 a, �� SQ.FT.FLObJ FA S/SQ.FT.
G U E Licensed Professional SIGNSELECTRICAL 1 I _
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC - / R
1„ 7 I hereby affirm that l am exempt from the Contractor's License Law for the (y ��
__O Y" following recon.(Section 7MI S,Business and Prolenbv Code:Any city or `
O 2 F^ 7T1NP.MEIPR OR POLE INST. J
anycoustywhich rrinetoi its
e,constroct,alter,Improve,applicant forsuch,or repair
any atructurc tatee oite�hat he Is lice sed pu thanthe ttheprovisions
ofpermit e POWER DEVICES
x'c 1 file a signed statement that he V licensed pursuant it the pro 7000) of the
ContractorsLicense lad( 9Ccoe)arns with Sectio.7emfm Divi. VALUATION
F,�05 don3oflhe Business and ProfenlonsCode)arthaBheuexempttherelromand SWIMMING POOL ELECTRIC - Q
65 the basis for the alleged exemption. Anyviolationol Srction7MI.Sbyany OUMETSSWITCHESFIXM2FS ^ O
applicant subjects
ntfor a permit the applicant to a civil penalty of not more thin Z` �
five hundred dollars($S00). NEW RESIDENTIAL ELECTR SQ.FT. STORIES ••7 TITECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
C7a compensation,will it o the work and the structure is not intended or offered for
5 O
axle(Sec.7014,Business and Profeadom Code:The Contractors License Law
�SsB don not a pply to an owner of property who builds or imn eeprove thereon.and OCC.GROUP
RFS.UNTfS
whodosuch work himself or through his own employ ,provided that such
improvements proveents are not intended oroflered for sale.If however the Wilding or TOTAL:
improvement issoldwithinoneyearo!completion,theowner-builderwill have
thEyelen of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to c'onsbuat the project(Sec,70K Business and Professions Code: a�
The Contractors Lirense law does net apply to an owner of property who ALTER-DRAIN k VENT WATER ff-NN
Wilds or Improves thereon,and who contracts for such ptojects with a FEE SUMMARY
.A.gaotm(s)licensed pursuant to the Cantrector'e License Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under See. B h P C for this reason
OUTSIDE IT ES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y - N ---N_
RFCF31'1'N
WORKMAN COMPENSATION DECLARATION FIX.Cl1RESPER , • SCHOOL TAX Y_ N_
f-11 hereby affirm that 1 have a sxrtifiate of consent to self-Insure,or aI RECEIT T N
certi(late o(Worken'Compensatlonlnsurance oramrtl(kd copythereof(Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N
3800, isCJ
RECEIPT
S EA. IM p
Pollryp Q - GASYSf -0VERdFA
( )
Gom ary BUILDING
DIVISION FEES
�Cemn re (urn GREASE/INDUSTRLWASIEINTERCEPTOR PLANCHECKFEE
❑Certlfled copy b filed with the dry inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This on sectineed not be completed if the permit inlor one hundred dollars
($10()orlev.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
ledifythatinthepedomanreoftheworkforwMl hthispermitist ed,
I shall not employ any person In any manner n as to become subject to the WATER SYSTLM/TRG7ING
Workrn'Comperaatbn Lawsof Glifomb.Data PAID
O Z NOTCApplicant NEW RESIDENTIAL PLMB. SQFr. Date Recti t#
Z O WTICETO esubje APPLICANT: Wter rs'Commaking er Certificate Exemption,you
shoui,you must fort moths Work en'Comperovisi n provisions per it s Labor TOTAL: _
2 N Code,you must forthwith comply with such provisions or this permit shall be BUILDING
W > deme.)revoked.
CONSTRUCTION LENDING AGENCY SEISMIC PEE
(LZ Ihereby affirm that there b a construction lending agency for the perform- OT - /— ELECTRIC FEE
ance of the work for which this permit is admit(Sm.3097,Civ.C.) _r
00 Lender.Nanr PLUMBING FEE
F- Lenders Address QTY. MECHANICAL PERMIT FEE
LL U 1mAifythat l have read this appllotlonand date thattheabove information MECHANICAL FEE
O W lecomect.I agree to comply with all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
} 1 relating to building construction,and herebyauthoriwrepreentativeso!this
F N city to enter upon the above-mentioned property for bapection purpose. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d rmiesi the Cityof Cupertino Date Receipt#
V against llabll ,jrdgments, andexpen swhich may in anyway accrue AIR HANDLING UNIT(TO 10,000 GEM) SUBTOTAL:
agalnsta a meon7a "' gr ego cola pemtle. CONSTRUCTION TAX
L / /'. AIR HANDLING UNIT(OVER IO,000CFM)
igwture (App!ant/ etre o W'� to EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HA l= SMATERIALSOISCLOSURE
Will the applicant or tutu building occupant store or handle hazanlous HEATING UNIT(T0100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Coder�Section 25532(a)7 HEATING UT(OVER 100,000 BTU) TOTAL:
F1 Yea u No
Willtheappllant orfuturebuiidingoavpantoseaquipment oedevim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haardous air contamimnts as defined by the Bay Area Nr
Quality Mawgcmrnt Disiri97 BOILER-COMPOHPOR 100,IXp BTUIry p
4Yrs ❑No LL^^ aq
have nia Health
&rdfe mode,Le tions 25505,25S33
Chapter 6.95 of BOILER-COMP(OVRI4100,000 BTU)
the understand
t Health building Code,Sen lora 7550.5,ve a t and 75534.I Alin
understand that rallytheoccupoe not mriently encs which
that it met NEW RESIDENTIAL MECH. SQ.ET (� � O 7(I
responsibilityortce notifytheoate of ofthenqulremenb which nwst be met O1
prior m Lasuanre of a Cedlllatr ofOccupancy.
V n,/r
— VIIYV
Owner or authorbed agent DateISSUED BY:
TOTAL:
OFFICE COPY