24541 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IDALUINli-ELF. RI-AI. PERMITNQ
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 24541
ISO ILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRIISS: SANITARY NO. APPLICATION SUHMI ITAL DA'FH
e (/(/VL UNITx LOT t10
OWNS NAME: Pf10NE: CON' ACT 'S NAME: LIC NO: l•
N/C CONTROLA
ARCHI I ECT/ENGINEER: ES
LIC NO: ADDRESS:
JU ❑
sS dw�CGwd+� .S
CONTACT PHONE:, BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E:] � ISI, 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL pV
QWz I hereby affirm that l aniNvensed under provlsionsofChapmr9(commencing with LOB DESCRIPTION
4100 Section 7000)of Division 3 of the Business and Professions Cade.and my license is in PANELS
CFCS�+W full floor,and effya� .� p .}� )
aje, Liccnnc Cluss_1`36 Liv.,, ,/ 75' UPTO200AMPS
V,,Qp• Dae 7201-IOD)AMPS
�7� �49_ 'Comnumr
1-yi TECI'S UIiCLARATION SQ.PT-FLOOR AREA E/SQ.FT.
ZOcyO 1 undersand my plans,hall housed.public momAv OVER 1IXIO AMPS '
W SIGNS IiLECTRICAI. " ii "" ® IN
S, Licensed Professional - _
7.
IC'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ! u I ' " II
KOaO I hereby affirm that I am exempt from the Convenors License Law for the ` 4E R
413¢ following rason,(Section 9031.5,Business and Professions Cede:Any city or county TEMP.MUTER OR POLE It ST.
0g which requires a Permit to construct,alter,improve,demolish,or repair any structure
Y7 prior to its isvrmrr,also refroms the aplAicarn for such conit to file a signed statement POWER BE DATE
W <0 that he is licensed pre unm to the provisions of @c Committers License Law(Chapter - -
❑�, S W IMMING POOL F,LF.CTR
aao 9(commencing with Scelhm T000)of Division3ofthe Businessand Professions Code) VALUAFIOIN�
SMV, or that he is exempt thcrefmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES (TV
F Z QSection 9031.5 by any applicant for a permit subjects the applicator no a civil penalty of
immure than five hundml dol Ian(ol5of.
CElI,axnwnernftheproperty,ormyclnpinyceswithwnesastheirsulecnmpenxatiaa, NEWRIMEENTIALELECTR SQ.FT. STORIES TYPECONS1'RUCTION
a,3_ will Jo the work.and the Structure is not intended oroffcmd forsole(See 7044,Business
.it Professions Calc:The ConBacmes Llceme Law does not apply to an owner of
pmpemy who builds or impmvee Deman,and who does such work himself or through his
OCC.GROUP RES.UNITS
ever.the building d
that such impniv ld wit arc not intended moffered forsale.If,
howaeTwill avetngurden ofpmentiehat hethinor build of improve fir-hcaose of �" TOTAL:
builder will have the burden of proving Ihut he did not buil)or improve for purynse of
`ale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,S, he project
ov.70p.I.Business
and onmnsio withlice Ta,Commences
License t the projcet(Sec.00aro Business and Profession build Code)The Comracmfs PERMIT'ISSUANCE s�
Licensel.nwdnesnntapply bimownensfpmpcny who builds nafet o east,,,',
License
s�
whense Law,for such pnijem w)Ih uennvnnart-,)licensal putsuunuo the Contradnr'r
License Lnw, ALTIiR-DRAINffi VIiN'I'-WATER(EA) FEE SUMMARY
❑ I nm exempt under Sec. B&P C Illi IM1is reason OUTSIDE FEES
-BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dat° DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT
cove WORKMAN COMPIicamofNSA ONDF,C selfpr ON SCHOOL TAX Y N
❑ ers'Co haven onilicateof copythe ol(Seeure,or a certificatewhich FIXTURES'-PERTRAP RIiC1iIPfb
Workcrx'Compenzaion insurance oraccnified copy thcrcol(Scc.38W,Lod,C.)which PARK FEE Y N
ell cmploYa's under this omit. RDIVISIO
GAS-G.SYSTEM-1 INCA OUTLETS
Poli<yp � BUILDING DIVISION FEES
Conifer, ya/ GAS-FA.SYSTEM-OVER 4(EA) PLANCRECK FEE
❑ CcdiO py is volition,
icy
�Cerlificd<npy is tiled with the city inspection division. GRWSIJINDUSTRI.WASTE IN'IERCfiFTOR GRADING hlili
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Upas section need not be completed lithe cemet is(nolle hundred dollars($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or IcxI c x Sao
Icenify that inthe perfomtance of the work forwhich this cemtit is issued,lShall WATER HEATER W/VfiN'1'/ELECTR V
not employ any person in any nomme,
at as to become subject to the Worker' PAID
Compensation Lswaof Califomia. Dae WATER SYSTENI/TREATTNG Date Recein It
0 z Applicant
z C) NO]ICH TO APPLICANT:ILafter making this Ccrlfcom of Exemption,you should NEW RESIDENTIAL PLMLL SQ FT. TOTAL:
1-+ EI) became subject to the Worker's Compensation provisions of the Labor Code,you must
[FC 7 fonor hwilh comply with such provisions ohis permit shall he deemed revoked. BUILDING -EE
C17 Q
6.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihcmhy affirm lhnnhcrc is to consortium lending agency teethe performance of TOTAL: �Q ELECTRIC 19717
U O ice work Ibr which thio pe....n ie rwud(Seo.3097.Civ,C.)
Lendefa Nance PLUMBING FEE
0 F Lender's Address QTY. MECHANICAL PERMIT' FEE
UI certify that I have read this application and stem that the above information is MECHANICAL FEE
>'s toren.l agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F-' 00 Inatingconstructinn,and hereby authmioc representatives ofthis city to color upon the CONSTRUM ION TAX
U z above-mentioned property tiro inspection purposes. ALTER OR ADD*10 SUCH.
(Wes)agree lessee,indemnify and keep Initiation the City of Cupertino against
liabilities.judgments,costs andexpenses which may in any wayaccme against said City AIR HANDLING UNIT(TO to."CFM)
'wc�fthe grpitin¢�f this permit. /„ ,”
( " �f}IxwL/l1/ � � AIR HANDLING UNIT(OVER IQO(I(I CPM)
mature of Applicant/Cotnrector Doc EXHAUS-1'1IOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt x
Will the u,]Ivant,orfare.building cocupant some or handle haardaus material T 1:
as defined hymn,Cupertino Municipal Code.Chapter 9.12,traffic Health and Safely HEATING UNIT(OVER 100,000 BTU)
Code.Seelinn 25532007 VEN'1'11A1'[ON PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
-
Will «heapplicwcurfutumbuildingupanlusee9uipmentordeviceswhlchemit BOILER-COMP(311p
POR 1(0.000BIU) r A D
hapro n o air contaminants in defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU)
i Dislfi,t?
❑Yes ❑No NEW RIISIDENTIAI.MECH.-SQ.FU
I have read the hueduus materials requirements under Chapin 6.95 of the DEC 1 1992
n
California Health ffi Safety Code.Sections 25505,25533 and 255M. 1 undemand that
if the building does not currently have a tenant,that it i,my responsibility to notify the CII Y OF CUrrn
occupant of the rcyuircon nls which nuot be met prim to issuance 0 u Certificate of
Occupancy. -
Owner m ambonmol agent Dam TOTAL: ISSUED BY
OFFICE