24125 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification ^��)/'' PERMITNZ 412 5
Building Address: JVa
Zn, /
Owner aces: A Q nee:
n �fd. '7 �� CITY OF CUPERTINO-BUILDING DIVISION
Cacto aces: Lle.No: APPLICATION / PERMIT
41 1 BUILDING-ELECTRICAI PLUMBING-MECIIANICAL CA FCARY CONTROL N
Architect/Gglner. Lk.Na
�n QTY ELECTRICPERMIT FEE BUILDINGPERMIT INFO
Address: 1U14Z 1 ��y''/ PERIATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S L LARATION
(hereby affirm that l am licensed under p nso Chapler9(comment, APPLIANCESRESIDENfIAL JOB DESCRU'I'�!)C�/��
Ingwlth ScdIoa7000)of Dlvisioa3 ofthe Businsasand PrefesslonaCcelaand my �CJ� rTl
license Is In full force and effect. PANELS
License Chm LIeN _ �Y
Date Contractor V
ARCHITECT'S DECLARATION 2014000AMPS
0Z l understand my plan stall be used as public rcCords. OVER1000AMP5 A.SQ.Fr.FLOOR AREA A' �$/SQ.Fr.
O I C \
Licensed Professional SIGNS ELECTRICAL
OgWNER•BNLDE0.DECLARATION "
6l l:✓ —
E'ECIALCDtCU1T/MISC
OR. owngraf@mthat lam31.5,B fromthed Contractor's PrefinnionsLicense
Code:law for the )
o q (allowingichmq(Section
saperQttomslnesand Pimp a em]Whnyr pair ` , J„
FZ ty cnystm mph ritai p mitea6oreui atheap U=tforwch,er ttr TEMP
OWERDDCES POLE(NST. -
`'� 7 any atsigne eprbment that
he In also sed pursuant t the provisions
of t e
0k a signed katemen[That he b Ilrenee pursuant to the provlelov of the POWER DEVICES
3µ Contractors License Law(Cha)ker9(wmci
menngwith Section 7000)of Divi. DATE J
SWIMMING POOL ELECTRIC
YY11�0S eio.3ofth.B.s usand ProfewiomCode)orthat helaexempttheretromand 4 VALUA790-
<� the basis for the alleged exemption. Any violation of Section 70115 by Any OUTLETSSWITCHMFIXIURES w_,CAP,
appBnnt fora pemdt subjects the applicant to a civil penalty elect mom than ZO�
a
06 1u, dollars(5500).
Las ownro(the pro", NEW RESIDENDAL ELECTR_SQFT, STORIES TYPO CONSTRUCTION
p ",or my employees with wages as their sole
compensation,will do the work,and the structure is not Intended or offered for
D .]A(Sec.7044,Bue"+•and Profession Code:The Contractors Lirene law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UMTS
.he does such work himself or through his own employees,provided that such
Improvements am not intended oroffered foraale.If,howeveq the building" TOTAL
Improvement lsaold within one yea rof completion,the owner-build erwill have
t44,ordeo of proving that he did not build or Improve for purpose ofade.). QTy, PLUMBING PERMIT FEE FT.00D TONE APN
LJ I,as owner of the property,sm exclusively Contracting with license PERMIT ISSUANCEContmctms to Construct the project(Sec.7044,Business and Professlon Code:
The Contractor's License law don not apply to as uwner of property who ALTER-DRAIN h VENT•WATER(CA)
Wild*or Improves thereon, and who wramets for such projects with a
dos)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDE FEES
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑l hereby affirm that I have•Certificate Insurance
of cwxnt to rpythemcf or a BBC=N
reklflI.bC.Workem'Campenwllanlvuranre oacertlfled ropythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.)
Poliry M GAS EA.SYSTEM-OVER 4(EA) RECED'T M
Com y BUILDING DI VISION FEES
difted Copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
Cor beco
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,200FT. Date Recei t#
Rhtssectlon need not be completed((the permit ls foron hundred dollars
(5100)mfy that
WATER HEATER W/VFNTIUXCTR ENERGYFEE Y N
I ll n certify that emin ploy
an pars re in an ofthe manner
so As to became
pesubjecrmit is blued,
1 shall rs employ any person in any manner w u to beCotlle abject to the WATER SYSTEM/TREATING
Workers Compensation Lawe of California.Date PAID
O Z NO NOTTCnt Date Recei tit
v
Z 0 /CE TO APPLICANT:If,aaer making this CerlDiate o(Exemptlon,you NEW RESIDENTIAL Pf.MB. SQ.FT.
should become subject to the Workers''Compealion provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provlslon or this permit shall be
tY j deemed revoked. BUILDING
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebyafRrmthat there isa Coeermadion lendingagency forthe perform ELECTRIC FEE
7 Z anca ofthe workforwhlchthls permit is Issued(See.3097,Civ.CJ TOTAL:
V 2 (Andef•Nam PLUMBING FEE
Jy l— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythat lbav adthlsappllmti an kale thattheabovelefomatlon
Q. A T_r .lagreet mply withal)ctt and ontyoedleanceeandkatelaws PERMIT FEEDS PAID:
} W relkingtobulldl nstnctlory And rets aulhorlu rcp ntativn o(thls
F Z city to enter apo t eabove-mentlo p rWpe on purposes. ALTER OR ADD IO MECH. Date Recei tq
— (We)a At ve,indemnify a d ep e 1 City of Cupertino P
agalnsth Illti judgmmts,wksa d pen swhlch ylnenywayacrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against in onsequen asting of thl nn
le A 1,14a p AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
to p at not o Date ID(HAUSTHOOD(W/DUCT) CONSTRUCT PAID:
RDOU ATERIALS DISCLOSURE
[heap rant fuwu bulldingoccupanbmrecrhandleharardoua HEATING UNIT(TO 100,000 BTU) at RCCCj tit
material wade( ed the Cupertino Municipal Code,Chapter 9.12,and the
Etcalth and Sof a Section 2S532(A)7 HEATING UNIT(OVER 100,000 BTU) TOT
�I Yn No
HIT he aphas Torardou,a Tom building acwpant use The layquipmentArea devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
whlcheManagement alrrwla Mnants as defined by the Bay Area Air .
Quality Management District? BORER-COMP DHL'OR 100,IXD BTU)
r-1 Yes 9 No
have read the hares ous materials requirements underChapler 6.95 of BOILER-COMP(OVER100,000 BN)
the California Health k Safety Code,Sections 25505,25533 and 75534. I
understand that if the building does not currently have tenanpthalltismy NEWRESIDENTTALMECH. SQ.FT
cent to
iitym notifytheampantofthe requirements which must be met
prior to lssuanre of a CcrtlOcatc of Ompanry. \��/�Ni.
Owner or authorised agent DTOTAL:
ate ISSIIED BY_WY
V.. .
If I
OFFICE COPY