23244 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 03 8r 23244
Phone: A .
CITY OF CUPERTINO-BUILDING DIVISION ,—J��,Z
Centrechres me f k Npi� APPLICATION I PERMIT ��71
BUILDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL#
Archimet/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE •{� ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffrm that l am licensed under provisions o(Chapwr9(comment, APPUANCFSRESIDENfIAL JOB DESCRIPTION
ingwilh5ectlon 7000)o(Dlvlsion3ofthe Busimmand PmfesslonsCode,and my
lirena is m fu d effect PANELS
LlceneeC LICM �64I
Date Contractor
ARCHITECTS DECLARATION 12014000 AMPS
q�q�uu�rz I understand my plans shag be used u public records. OVER I OOO AMPS SQ.FT.FLOQ&AREA S/SQ.FT.
6i I. Licensed Professional SIGNSELECTRICAL 1s i A/1 D N
<� �d
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC T E R
zl, a Ihercbyaffirm that I -BUIL ER the LARATtOrBLlrena Law for the V,
op followingreawn.ices a permit S,Bustruct and PImprove, Code: h, ci ar
OZI. muntywhich requbnepermitromminesBald Prefproons Codlbh,oeity or TEMP'METER
ORPOLE INSf.
anystm=m prlorm its Issuance,alsorequlrestheappllcant forsuch permit nto POWER DEVICES -�
file a signed statement that he Is limed'pursuant to the provisions of the
38 Contractor's License Lew(Chapter9(comnsencing with Section 7000)of Dwi- SWIMMING POOL ELECTRIC VALUATION
SOS eam3ofthe B.Aressand ProfessloreCode),rthai he b exempltherefremand � O
6 the Weis for the alleged exemption. Any violation of Section 7MIZ by any OUTLETSSWITCHES.FIXTURES
applicant fora perMbubjecb the applicant to a civil penalty of not more than �4.
five hundred dollars(epm NEW RESIDENTIAL ELFGTR_SQ.FT. STORI)S
�n ❑I,ae owner of tha property,or my employees with wags r thele dole TYPE CONSTRUCTION
C
compensation,700 will do Bugruthewor,.f umthe Code:ure is
ContraIntenctors
offered.La sr
5 0 dale(Sec.apply
to an owner
f property
hob ilhe Contnnora Lt.herein law
$
does net apply toanowner ofpropertywhobuildsorimprovesthermmand OCC.CROUP RFS.UNITS
whodoeseuts;am not
edoraughed(mue.If,ho eprovidedthatsuch
Improvementsarenotintended earoeredfmak.If,however, deer ill have TOTAL:
Improvement issulci within one yearofcompletlon,the owner-bulWcrw111 have
t"rden of proving that he did nat build or Improve for purpose of dale.). QTY. PLUMBINGPERMIT FEE FLOOD TONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMITI55UANCE
contractors to resulted the project(Sec.7614,Business and Prdesaions Code:
The Contnctor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves themed and who contracts (m such ptcocb with a
c7V.cer(s)licensed pursuant to the Contracto'sLlrense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C(or this reasonOUTS[DE FEES
Owner DRAINS FLDOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of concent to ae0-Imre, FIXTURES.PER TRAP SCHOOL FAX Y N or RECEIPT N
3eo(Workers'Campensatlonlnsuranceararertl(kd ropythereof(Sec. CAS EA.SYSTEM-1 INCA OUTLETS Po8li 00,LaLb C.) PARK FEE Y_ N_
Poli # GAS LA.SYSTEMOVER 4(EA) DINO Of VI
Com any BUILDING DI VISION FEES
❑pCeni py b hereby
with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Bed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Ff. Date RCCCI I#
(fhb settlors need not W completed I(the permit b(orom hundred dollars
Islw)oify that
WATER HFATFRW/VENT/ELECTR ENERGY FEE Y N
I certify that o the performance of the work an as to b this permit d to the —
I shall not employ any person In any manner w u m become subject to the WATER SYSTG{/TREATING
Workere'Campenutlon Laws of California.Date PAID
O Z NOAppTICE
NEW RESIDENTIAL PLMB. SQ,FT. Date Remi t#
Z O NOTICE TO APPLICANfal akar nuking this Certificate of Exemption,you
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orlhb permit shall be _ IN 1—
deemed revoked.
d
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there 6 a construction lending agency for the perforrry ELECTRIC FEE
Z anceoftheworkforwhkhthbper tie Wued(Sec.3097,CIv.C.) TOTAL:
0 O 1,enders Name PLUMBING FEE
LL F Lender's Addmsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I.nifythatl Wvereadthisappllatbnandgatethattheaboveln(ormation
(1 Iscormat l agree to comply with all city and county ordinances and kale laws PERMIT ISSUANCE FEES PAID:
>_ relating building construction,and harebyauthodze representatives of this
W city to enterupon above�menIoned property for inspection purposes. ALTERORADDTOMECH. Date Reeel [#
lWe)agree t ave,indemnity an d keep harmless the City of Cupertino
against habill -1judgconmente,costsand expenses which may leanywayaecres AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
zgainstul ty In o the ant of this permit.
AIR HANDUNGUNTT(OVERIO,ODOCFM) CONSTRUCTION TAX
91goaftleRof Appllca /Contractor GA. EREIAUS'f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DiSCLOS RE _
Will theapplicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material m defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 2.SS31(a)? FIEATING UNIT(OVER 100,000 BTIB TOTAL:
My
No
Will
the applicant or utum building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) fi}Rra[,I (DDATE
which emit hazardous air contaminants as defined by the Bay Area Air U"'4� IWY-
Quality Management District? BOILER-C0MP(3HPOR100,DMBTU)
Y's ❑❑No ^
• 4Wve read the M1azarclDue materlab requirements under Chapter 6.95x( BQILER-CONp(OVUt100,000 BTUI N 31 %2
the California Health h Safety Code,Sectiam 75505,25533 and 75534. 1 •6 a
u adorns nd that if the building does not currently have a tewnt,that It is my NEW RESIDENTIAL MEG{. SUIT CITY
resporulblllty to notify the occupant of the requirements which must he met OFCUNtHIuvU
prior to Issuance of a Certificate of Occo pa racy. Qi
Owner or aulhodred agent Data TOTAL: ISSUED BY.'yl +?E!!^Ltai'+�'G.aF
OFFICE COPY