24268 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFILWTNQ
Building Address: Z
A
one:
APPLICA I 1UN hUbMi I I AL UA1h
CITY OF CUPERTINO-BUILDING DIVISION -� �j q
c�y/n"/''tl° •"'n° yy�") 1 Lic N. APPLICATION /PERMIT —�3 ( Z'
•' J -7J BUILDINGELECTRICALPLUMBING-MECFIAMCAL CATEGORY CONTROL
Architect/Engin... Lk,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adams: PERNUTISSUANCE ❑ ❑ I ❑
UCF.NS ED CONTRACTOR'S DECLARATION
Ihth Sb i..70thatlam licensedunder
nemaonsofCsionsC(mmmm PANEL APPLIANCES-RESIDENTIAL JOB DISCRITION
IngwlnhSmion7000)o(DTWdon3ofthe Busincsaand ProfnaionsCode,and my
license Is In(ul force and d(ect. ^`an 7� PANELS ^ �r o(J—I CL 1, 1 IN�, `„r LL-rD
Llcenx
Date Contr ct r9t/ .M ry,T2 Toy.
ARCHITECTS DECLARATION O 201-1000 AMPS
00 I understand my plans•hall be used as public records OVER 1000 AMPS SQ.FT.FLUOR AREA S/SQ.ITE
U E Licensed Professional SIGNS ELECTRICAL / IA
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST 0 0 ' N 1
t--'L Iherebya(Rmnthatlam exemptfrom the Contractors License Law for the E 'V
'�O.."' untyreason.irediog Permit
re Business and Professions Code:h, dryer
[� U T E R
OGt.� following y TEMP.MEITRORI'OLE INST. n
���� cguntywhich rcqulmapemdt tomnsimd,alter,improve,demolish,grrepair /1
ami Q any structum prior to its issuance,also requires the applicant for such permit to POWER DEVICES A
O c.V file a signed statement that he is Licensed pursuant to the provisions of the
Contractors License Low(Chipter9(mmnumciogwithSection7000)ofDivi. SWIdMINGPOOL ELECTRIC
DAT
O sion3ofthe Buslnevand Profenbru[gde)mthat he is exempt therefromand DA'I1DN
the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCHESFIXNRFS
p?o0 appecnd for a permit subjects the applicant toa civil penalty of not more than
five hundred dollars($500), NEW RESIDENTIAL ELI:CTR s
�n ❑1,as owner of the property,or my employees with wages as their sole SQ.Fr. STOW ES TYPE CONSTRUCTION
� < compensation,wBldo the work and thestructure 1,;not intended or offered for
D
sale&c.7044 Business and Proleaslom Code:The Contractors License Law
j$$ does not apply Loan owner of property who builds or improves thereon,and OCC.GROUI' RES UNnS
who does such work himself orthro igh his own employees,provided that such
improvements arc not Intended or offered for sale.If,however,the building or TOTAL:
improvement lssuld within one yearofcompletion,the owner-builderwill have
th Men of proving that he did realbuild or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
UI,as owner of the property,am exclusively contracting with licensed FLOOD ZINE APN
mntracton to mratmet the penject(See70K Business and Profesbrm Code: PERMIT ISSUANCE
The Contractors License Law does out apply to an owner a property who
bu �,�DRAIN . WATER
(EN J U V
Wilds or Improves thereon,and who contracts for such ptojeca&with a FEE SUMMARY
mJd[ador(s)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec B Lc P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Date RFLEIxT p
WORKMAN I have a VSAT10N DECLARATION FIXNgES PER TRAP SCHOOL TAX Y N—
hereby affirm that 1 have o cerlRcate of cots to opythsure,or RECEIPT R
certificate gfWorkdra Cgmpensaugn Insurance gracenilled copy thereof(Sec. GAS EA.SYSTEM-1 INC4 OUTLETS
3gm,pis cT�933�1n- 92 .ARK FEE Y— N—
Com ray 'I GAS EA.SYSTEM-OVER 4(EA) BUILDING RIN�TVISIONFEBS
Certified copy 6 heed with the shed.
GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�PLrrti(ied ropy ls(fled with the tlty impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissecilonneedna becomplcted lfthe permit bforooehundred dollars SEWER-SANITARY-STORM EA."Fr. Date Retei til
(91m micse.) WATER HEATER W/VFNT/ELECTR 1750 ENERGY FEE Y N
Illnot that Ntheperson
performanceof IhewgrksorwNch Wnpermitla issued, —
I shall not employ any person in any.runner x u to become subject to the WATER SYSTEM/,TREATING
workers'Compenwtlon Laws of California.Date PAID
0 Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RERDENTIAL PLMB. SQFT. Date Recei t#
N should bemmesub)ect to the Workeri Compensation previsions ofthe Labor TOTAL:
Code,you roust forthwith comply with such provisions orthls permit shall be BUILDING FEE
W > deemed revoked.
d C - CONSTRUCTION LENDING AGENCY SEISMIC FEE= Z I hereby affirm that there is a construction lending agency for the perform SEISMIC
ELECTRIC FEE
ance of the work for whkh this permit la issued(Sec.3097,Cie.C.) TOTAL:
U O Lender's Name PLUMBING FEE
0 = L nae. Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Treed.I hatl agreat comple read withallcitbndcountathatthe y,mlinano,s e Information —ndgate laws
W recorn�ct.building complywin,alld hereby
muneyoMinanmsand gate laws PERMIT ISSUANCE PEE$PAID:
} N relatcityt enter
rg to uildingp--t construe-bovctre-ti dhereby friaein reprcxnpurpon ofthls
F Z tltymenteree to save,
indcmcn0aned Propertyhrm) inspection purposes. ALTER ORADD IOMETH.
(6Ve)agree t°j u gm rats,cannily an d keep harmless the City y way accrue
Date Receipt#
against in", 4fly eonsequenotof expenses winch may Inanywayacerue NR HANDLING IIIVIT(TO 10,000 CFM) SUBTOTAL:
against Pity in consequence o(t at¢Is permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
g reofAppl t/ ."ta Dam EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AMDOUS MATERIALS DISCLOSURE
Will the applift5ant orfutum building occupant store or handle hazardous HEATING UNIT(T0100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Re el t#
1 Tealth and Safety Cede, No
Seaton 75532(a)7
Fj Yes ❑ HEATING UNIT(OVER 1W,000 BTU) TOTAL:
Will the applicant or future building occupant use equipment or devices VENILATION FAN(SINGLE RESID)
which emit hav Mous air contamloa nts as defimd by the Ray Area Air ISSUANCE.DATE
{S r, ,d
•
Quality Management lJistrimn7 BOILER-COMP OHP OR 108000 BTU)
have read the baza smaterialsmqulmmcnbunder Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the Calilomia Health&Safety Code,Smloru 25Se"25533 and 25534.1 OCT 28 1992
understand that if the building does not currently have a Lena rat,that it is my NEW RESIDENTIAL MECH. SQ-ET,
responsibility to notify the oavpnnt of the requirements which must be met
prior to issuance a a CenUlcate ofOceipancy. OII Y Vr l.UrenluvV
Owner or author--iagent Dte
TOTAL: ISSUED BY: Y�
OFFICE COPY