24058 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuIlding Project Identification
Buildi 4 Address: PERMIT NQ, 4 0 5 8
7 �7; -6 7!5_�-
ners came: - one: - A A
PP_ICAIJOR SUR
CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: ,ue_,No APPLICATION /PERMIT
Archlteg( neer. 5"� BULDING-E,EC7RICAL PLUMBING-MFICHAMCAL CATEGORY CONTROL#
Llc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addms:
PERMITISSUANCE
LICENSED CONTRACTOR'S WECLARATl N
I hereby affirm that lam Bcenud under provWoneo(Chapter9(commeno, APPUANCFSRESIDEMIAL JOB DFSGRII'lIDN.
Ing�ithemari �OninfuD 700p)of daffect. fthe Buslnessand Pro(esslonsCode,and my /
l icars, in full fo end e((eR. /`r4, " PANELS
Data rCmm 76 R(
Date Contractor
ARCHITECTS DECLARATION 201-1000AMPS
rr00 I understand my plana shall be used as public records. OVER1000AMPS SQ. RARER S/SQ.FI.
��w77 LirePs —Pmfexlonal SIGNS ELECTRICAL {�1 1
�d OWNER-BUILDER DECLARATION SPECLALCBICUT/M 'V
There affirmthatlam exemptlromthe Contractor's License law for the S�
0 following reason.(Section 7031.5,Business and Professions Code:My city or OL��'
p countywhkhrequ4evapemuttomretruct,alter,improve,denalbh,orrepalr 7EMP.METFA ORPOLE ST. i, ' E
.n anystructom poortoits issuance,also requlresthe eppucant forsuch permitto '
rYl file a signed statement that he ls licensed pursuant to the provisions of the POWER DEVICES
3w Contotdoes License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL E LUIIQ
�O sion 3 ofthe Business and Profeashms Code)or that he is mmpt therefromand VALUATIOFL�
yyyy¢ the basis for the alleged subjects
th exemption. Any violation of nadkn 7031.5 re any UTLETSSWITCHES-SWITCHESO� Gere
app6candred fora permit aubjeda the applicant toativll penalty of not more than
five 1,as owner of the pro NEW RESIDENTIAL ELECTR
X, 0I,as owner of the property,or my employees with wages as their sole SQET STORIES TYPE CONSTRUCTION
pensatlon,w111dotMwak andthealrodure V rwHneended or offered for
O sale(Sec.7094,Business and Professions Code:The Contractor's License Law
does not apply to an owner of property who builds or Impm o,s thereon,and -
who does such work himself orthroughhis own employees,provided that such OCC.GROUP RES.UNITS
lmprovements are not intended proffered for sale.If,however,thebullding or T Mw""!'
improvement issold within oneyeatofcompldiorytheowner-builderwlll have
tl)p„Zurden of proving that he did not build or Improve for purpose ofsale.). Q7y, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed p)ppp ppmAPN
contractors to constmd the project(Set 7644,Business and Professimu Code: PERMIT ISSUANCE'
The Contractors License law does not apply to an owner of property who ALTER-DRAM&VEM-
bu6ds or Improves thereon,and who contracts for sue, pWieda with a WATER(EA)
ct.[actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&F C for this reason
• Owner Date DRAINS. Lo
FoR ROOF,AREA COND, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RFCE1Irp#
[:]I hereby affirm that I have a entlfiate of consent to self-Insure,or a FIXIURFS PER TRAIT Aae_� SCHOOL TAX Y N
certificate ofWorkers'Compensation lnsurana nra codified copy them((Sec. RECEB'fX
3800,Lab C.) GAS EA.SYSf1M-1 INCA OUTLETS PARK FEE Y N
Policy# - RECI]PI X
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDING OI VISI FEES
Com
copy is hereby fumishM
' Certified copy is filed with the city inspection division, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
...
CERTIFICATEMPE SATIOEXEMPFIONS FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.20017 Date I tit
BCC
Rh.a l..)n need nor becompleted If the permit ls forone hundred dollars' (S1W)or less)
Irertl(ythat Inthe p-ofmcoanceo(the work forwMch this permit I.vaned, WATER HEATER W/VENT/ELECTR ENERGYFEE N_
I shag not employ any person In any nunner m as to become subjed to the WATER SYSTEM/TREATNG
Workers'CompenseHon Lwe of Catl(omla.Date
O Z Applicant PAID
Z O NOTICE TO APPLICANT:]Le(Ver nuking this CertBkate of laemptian,you NEW RESIDENTIAL PLMB. SQFI, ' Recei tit
should become subject Workars'Compmuatlon provisions of the Labor TOTAL-
LUN Code,you moat forthwith comply with such provisions or this permit shall be
LU > deemed revoked. J G �a
a C CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirmthat there in construction lending agency for the perform- ELECTRIC
D O anre ofthe work(orwhlch this permit is Issued(Sec.3097,Civ.C.) T
02 Lender's Name PLUMBING EE sem!
U. i- Leader's Address QTY. MECHANICAL PE RM IT FEE MEC LFEE
O W Iartilythat I have read this applicstlonand antethattheabove Information `
CL Is mond.I agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorise representatives of this
FZ dtyto enter upon the above-mentioned property for inspection pu rposes. ALTEORADDTOMECH.
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,ju dgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag Ity In con ena of the granting of this pe
AIR HANDLING UNIT(OVER 10,OW CIM) CONSTRUC NTAX.
g tureof Applicant/Contractor to EXHAUST HOOD M/DUCT - .CONSTRUCT[ TAX PAID:
HAZARDOUS ATERIALSDISCLOSUR
Will the applicant or future building occupant store or handle hazardous HEATINGUMT(TO100,0003= Date ReCel
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health❑ nd Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU OTA
Yes
Will the applicant or❑future building occupant use equipment or devices VFNILATION FAN(SINGLE MID) ISSUAN DATE
which emit havardous air contamirunts as defined by the Bay Area A4
�Lu�lity Management Mind? BOILEIACOMP OHPOR 100,000 BTU �.
I haves n No qg
B read Health
a ors materials reons 255 nh 5533 and 255 4.1 of BOILER-COMP(OVER 100,1100 6#) YI'
he CalifornW Health&Safey Code,Sections 75505,75533 and 25539.1
and erstand that if building does not currently have s tenant,that it 6 my NEW RESIDENTIAL MECH. SQ.FT AUG
TO
Ipsibllity to notify the occupant of the requirements which most be met
pr' oto issuance of a Certificate of Occupancy.
T
r11 Ur k,urcnur
ncr or authorized a gent Date
ISSUED
OFFICE COPY