24092 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IeeNifica0onPIRMIrN2 4 0 9 2
BwlamgAaams: k PR-
one: APPLICA11UN bUbMil IM, A
s a 2 CITY OF CUPERTINO-BUILDING DIVISION
c ciao aName: u4.No. APPLICATION /PERMIT 6_4371 z
BUILDING-ELFCTRICAL-PLUMBING-MFOHANICAL CATEGORY CONTROL M
xamArehitat/Engineer. c,
QTY , ELECTRiCPERMIT FEE BUILDING PERMIT INFO
Addms: PERMIT ISSUANCE BLDU EL❑ ❑ Ty El
LICENSED CONTR under S vie TION - L�
Ihereby Sectio 70 that Diviam sien3o under proviui ofCssions odeanenc APPLIANCESRESIDENfIAL - JOB DESCRIPTION
It...h ].fon 7000)ofd dielon3o( s net ProtesslonaCode,and my
Lion s lsm(u8floor and .a. PANELS
af
Date Contractor
ARCHITECTS DECLARATION 2014000 AMPS
CO Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
q O
Z u Licensed Professional SIGNSELECTRICAL
< w •
OWNER-BUILDER DECLARATION
fn Fn
(., Thereby affirm that lam exempt lmmthe Commune'sCommune'sLicense Law for the SPECIAL CIRCUIT/MISC
ZO 'n
O 7- following reason.(Seaton 7MIS,Business and Professions Code:Any city or "
H TEMP.MEfFR Oft I OCL
rountywhlch requires a pemdtron
constct,alter,improve,demolish,orrepalr � 9 B r �^ t�
�44 :j anystm=mpriortolts wanealaorequlmtheappbantforsuchper tto POWER DEVICES ` 1 r')
<J
fila a signed statement that he is licensed pursuant to the powbiom or the 1�><
�aa�S5,Ow Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELE RIC
VALUATION
sion3ofthe BusNessand Profe.W.Code)orthatheuewm therefromand \
a }n 5 the basis for the alleged exemption. Any violation of Sedtont 90315 by any OUTLETSSWITCHESFIXTURES ��-
,o`�i <a
applicant for a permit subjects the applicant to a civil penalty of not more than
c.�:o five hundred dollars(SW. NRW RFSIDEN)A ELECTR
j Z I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,wlll dothe work and the structure is not intended or offered for
D sale(Sec.70K Business and Pmfesalo.Code:The Contradoes License Law
does notapplyto an ownerof propertywho buildsor improves the vn,and OCC.GROUP RFS UNITS
who doessuch work hirmself orthrough his own employees,provided that such
Improvements are not Intended oraffered forsale.If,however,thebuilding or ,TOTAL:
improvement issold within oneycarofcompletiagtheowner-builderwaI have
thc_�a rden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMITFEE FLOOD ZONE APN —
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISUANCE
contractors to construct the project(Sec 7014,Business and Proreagons Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(liV
Wor Improves thereon, and who contracts such P'Pjacts with a FEE SUMMARY
contractor(s)licensed pursuant to the Condor's Mask,Law. SACK FLOW PROT[CT.DEVICE
LJI am exempt under Sec. 8&P C for this reason
OUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
01 heretiy affirm that I have a certificate of consent to self-Insure,or a FIXTURES PER TRAP /� SCHOOL TAX Y N
1� medfrcate of Workers Comperuation Insurance or a certified mpy thereof(Sec. RECEIPT
380,Tab CJ• GAS EA.SYSTEM-]INCA OUTLETS PARKFEE Y_ N_
Polley Y RECEI'C N
CffCany
BUILDING DIVISIONFEES
enifed
copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OFEXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE STORM EA.200FT. )RIC RCCeI lb
(This section need not be completed 8the permit h for one hundred dollars SEWER-SANITARY- F
($100)orlev.) WATER}]EATER W/VENT/ELUCTR ENERGY FEE Y_ N
certify _
1 rtify that m the performance Lus
ormance of the work for which this permit is ted,
I shag not employ any pe"wjjn any manner sou be pme wy�a�,�p the WA.I.Q2SYS.fEhf/.RtEA.DNC
orke-.,C �&fN f n Lwsdf Callforrda. Date I-S"Y/ - PAID
C) pBas �u /. . Date Recei t#
Z oO NEW RESIDENTIAL PLMB. SQFT.
Z U NOulGET AI' je he akerrrnking Certifipro o(Exempt eLyou
should become subject to the Workers Campenaalon provlslona of the Labor TOTAL:
fA Code,you most forthwith comply with suchpowlslons orthis permltsha8be BUILDING FEE
de,ro d revoked.
W Fn CONSTR is acro LENDING AGENCY SEISMIC FEE
CL ]hereby hat lending Sec. W7,Civ. the perform- TO ELECTRIC FEE
7 O ance of work(or which this permit VLssued(Sees.3097,CIv.C)
Tender's Name PLUMBING FEE
V L) Lenders Address • QTY. MECHANICAL PERMIT FEE
LL U ImnitythaH have read thisappliatmnand Aatethattheaboveinformation MECHANICAL FEE '
O m is comet.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} S relating to building mnslruaion,and hereby authorize ottertativesofthis
(_ N city to enter upon the above-mentioned property for impeafonpurposes. ALTER OR ADD TO MUCH.
? (We)agree to save,indemnify an d keep baroness the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said Ciyf s m of the granting a this pemat.
Cr�;��G4_ AIR HwNDUNG UNIT(OVER 10,000CIFM) CONSTRUCTION TAX
Signature q Applicant/Contractor Data IXHAUSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle havardous IlEATLNG UNIT(TO IW,WO BTU) Date Recei tit
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
n Yes Lj No
Will the applicant or future building ocmpant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which cook
anagements air ries? unb as defined by be Bay Area Air
Quality Management air
NOILEIR-COMP(3FI'OR100,000 BTU) A .0
Yes 11�II No
have read the hazarRas materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California I lealth&Safety Code,Sections 25505,25533 and 25534. I AUG
—� and erstand that if the building does not comenlly have a tenant,that it is my NEW REST DFNTIAL MECH. SQ 17 AU 13 1^4asYaGi
nspomibllity to notify the ocmpa rat of the requirements which most be fret
prior to Issuance of a Certs flute of Ocm pa ney. c Iq
Y
ur wrtnnlr%.
em
Owner or authodred agent Date ISSUED BY.
TOTAL:
OFFICE COPY