24128 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI POINT PEN ONLY
Building Project Identification w PETkUT NO
Building Addres.: O
j03 �. Makes : LA+1 I Q
ams: -�f one: -
(Jwmeta 723";2400 CITY OF CUPERTINO-BUILDING DIVISION ^
Comm ora-a�Name: - uc.No: •APPLICATION I PERMIT
B6LDING-1].ECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL#
Architect/Englitaim Lic.No:
- - ..r. u a }. •.'. 's t -,t., .:BUILDING'PERMIT:INFO,,,••;
- I 'QjY,:• f ELECTRICPERMIT ii �'),;Jed, FEE j' 1
Addma ✓ PERNUTISSUANCE •, ,. '� . . ❑ .. . ❑ ❑ "
LICENSED CONTRACTOR'S DECLARATION s
I hereby affirm that l am licensed under provisions of Chapter 9(mmmanc APPLIANCES-RESIDENTAL JOB DFSCRR'iION
ingwith Sedlon 7000)o(Dlvlslw3ofthe BuMmmand Profesdon.Code,and my /^'
IicemPANEL
SC,
In full rcr and dfM. PANS C,
LlcenseCla,s Lie.# y _
Date
-C�� Contrad.r. -
ARCHITECPS EC ) ION 701-1WOAMPS
q�q�uu p CO I understand my plans shall be used as public mounds. OVRR IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
b:0(� Licensed Professional SIGNSELECTRICAL - '( (� ^ ` t) -
.<c. OWNER-BUILDER DECLARATION SI'fOIAl Cl2CUIT/MISC !'><•
7� & IherebyaffirmthatIs.rmmptfeamtheContractor's License Law for the r] p
following reason.(Section 7031.5,Business and Professions Code:Any city or
OTEMP.METER ORPOLEINST. j�] L' Y U -
P�g ceunlycture eortosa psuarcealsoreuilmstheapmvgtiorsuch permit pair
any awdud state tents that
he Is license pursuant to the pr mislomof e POWER DEVICES
4`yP D Elea signed istemma than he fa r 9(cern pursuant to the pon 7000) o! the / _1
sion 3 of the
Business Law Cha per commando with Section of and - E
( P ( B sv ) SWI.(MING IDOL ELECTRIC � ,
SOS the bastthe the
PrdmionaCode)iolaatheis exempt therefrom and VALUATION,
<u the basis for the alleged exemption an. Any violation of Section not m re any OUTLETSSWITCHFSFIXTURRi ���)
p aPPlirant fora permlNubjMaFeapplicant toa civil penalty dnd mare than IZZS/ V
o fiveundd .rs%5D0). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
Pf,as red ownerollof the property,or my employees with wages as their sole
compensallon,will dothe work and thestrudure Isnot Intended or offered for
$ In sale(See.70f4,Businessand Profession Code:The Contractors License Law
$ does nmpplytoanownerofpropenywhobulldsorimprovesthereon,and
^ who doessuch work himself orthrough his own employee,,provided that such "OCC.GROUP RIS.UNITS
improvements are not intended oroffered for sale.If,however,the bulldingor TOTAL:
improvement Is sold within one yearofmmpletion,the owner-builderwill have
t rden of proving that he didnot build improve for purpose ofsaF.).. QTY: '''FEE';'., FLOOD ZONE APN
jor
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
Wilds or Improve thereon, and who contracts for such pk.*oes with a. FE�SUMMARY'
J�ador(s)licensed punuant to the Contractor's Lt...Law. BACK~COW PROTFOT.DEWCE: �): ,,'I�,'., 'E1
1_j 1 am exempt under Sec. B k P C for this reason
•
Date
DRAINSLO
FOR ROOF,AREA,COND. SANITARY Y N Owner „o .
WORKMAN COMPENSATION UECDECLARATION �EIq#
FIXTURES PER TRAP SCHOOLTAX' Y N
FIT
haveaf hereby em that have a certificate of consent to self-Inwre,ora RECEIPT#
3800LbofWorken Compewationlruur ceoreoertlfied mpyrhereof(Bac. GAS.EA.SYSTEM.1 INC-4 OUTLETS PARKII Y N
38W,Lab CJ AlRECEIPT#
Pollry# 7 - GAS.EA.SYSTEM-OVER 4(EA) —
Co�any B UI LDINC DIVISI ON FE ES
Certified copy is hereby furnished. CRE
ASEANDUSTRL WASTE INTERCEPTOR PLANGHEGK FEE
rtlfled copy is filed with the city inspection divMalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPIimpleedifheie INSURANCE SEWER-SANITARY-STORMEA.2WFT. Date RcCi tis
(this section need not be compacted
COMPENSATION
permit 1.forom hundred dollars P
(Sl W)orless.> WATER HIEATFIt W/VEM'/ELECTR ENERGY FEE Y N
I mrtifythat in the performance of the work for which this permit is issued, _ _
I shall not employ any permn In any manner.o v to barons subject to the WATER SYSTEM/TREATING
Workerie Compensation Laws of California. Date PAID
ZZ Applicant TINEW RESIDENTIAL PLMB._SQFT. Date Reccf the
O NOCE TO APPLICANT: =king king this Certificate of Exemption,you
sbouldbemmesubjed mthe Workers'Comperaatlon provisloro o(the Lobor TOTAL: ,
N Code,you must forthwith comply with such provisions urthis permit shall be UI E �
W > deemed revoked. _
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby afOrmthat there is a mrutmctlon lending agency for the perform~ ELECTRIC FEE
Z once ofthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
o O Leridere Name- r PLUMBING FEE
LL ~ Leader.Aaaress QTY. MECHANICAL PERMIT',, FEE, , MECHANICAL FEE
OW I certfythat l have read this applicstionand state that theabove information
C Ismrrect.l agreem comply with all city and county ordlhances and state laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize repersentatlyesof this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recei til
against liabilities,pdgrienta,coatsand expenses which may in any wayamme AIR HANDLING UNIT(TO l0,000CFM) SUBTOTAL'
,gal bald Cllr n encs granting of 1.permit. -
.. '0 AIR HANDLING UNIT(OVER ill000CEN) CONSTRUCTION TAX
Signature ofA Imnt/Cont a Date MHAU5T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARD0 ATERIALSDISCLOSURE —
Wllltheapplicantorf,rum building occupant store orhandle hazardous HEATING UMT(TO 100,000 BTU) Date ReceivtA
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the '— -
Health and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,M BTU) TOT
❑ Yea No
Will the applk,ant or forum building occupant use equipment or devices VFNDLATION PAN(SINGLE RFSID) ISSUANCE DATE -
which emit hazerdow air centamiranta a.defined by the Bay.Area Air
Quality Management Distdd7 •• : BOILER-COMPOTIPOR100,0001117(n '
4Yea ❑❑No underC q yy
M1avereadlcidth&rvafetyC de,Sereon,255nb5533.ahapter6.95mf RORER-COMP BTU) P H 1 D
the C.II(ornla Hleche&Safety Code,Sect rtlyhave a toad255J4.I "
. 'understand that if Wilding does not a nequiy have a temamq that it is my' NEW AESIDENi]Ai.MECIi. SQ.1.1. ��� ��
responsibility ce of a Cthe ompart of the requlrementa which must be met 1992
prior missuance o(a Certificate ofOmpanry. � s717C
Owner or authorized agent Date ISSUII
' TOTAL:
OFFICE COPY