24108 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification 4:1-112>1DPERMRTN4�}a
Building Address: balk ^ r J 41 0 U 0
O U . C k"L-F V-0 GG I
one. A
waters a CITY OF CUPERTINO-BUILDING DIVISION �_ ���
Co dors hme: LIc.N. APPLICATION /PERMIT
QrV BUILDING-ELECTRICALnUMBING.MECHANICAL CATEGORY CONTROL O
Architect/Engineer: 'Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
BLOC IIIiLl PLUMB 1,11,L11
Address: PERMITISSUANCE
LICENSED ONTR!under rDECLAMTION
I hereby Sedioirmthatl imi,i.3.fthduMp.l.lona.(Chapter9ae,.rd c APPL7ANCESRE9DENTIAL JOB DESCRRxfION
Ii...1 Section famm.f Divik.n3.(the Bukneasand Pro(essloneC.de,and my
Litere b In RrB(orae and effect. PANELS
Llcen.Clam Lk.N `r
Date Contractor
ARCHITECPS DECLARATION 201-11000 AMPS
IXO ZZ I understand my plan shall be used v public records. OVER 1000�� SQ.IT.FLOOR AREA $/SQ.FT.
d() Licensed Professional SIGNS ELECTRICAL TA I_ D IN A� 1
fn< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC flig
Vowing yason.ei atlamexempt.in.. d mraatorsLitemsLwforthe R
f ntyngreawn.( sap? ttoBustmdand PmfpmvesCdeMydtyir
]pp cnuntywhkh requlrcaa permit tommtvctaltegimpmve,demolish,orrepair TEMP.METER ORIOLE INST. /�
q45� anystvcom prlorto its issuance,alsorequlrestheapplicant(orsuch permit to POWER DEVICES AT 7
6 r tEY file a signed statement thm he ta licensed pursuant to the provisions of the
zi
Contractor's License law RC u 9(commencingwith Section 7000)of CIA.
30�<^ slon3ofthe Busmeaaand Professions Code)orthat hebexemptiberefromand SWNIMINCIWLELECIRIC _ VA TION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
g G 5 1TILETSSWITCFIFSFlXTURFS a
appBantfor a permitsubjects theapplicanttoa civil penalty of not more(Kan �� QA
Ove hundred dollars($500). NEW RE5IDENITAL ELECT$
R �.F7'. STORIES TYPE CONSTRUCTION
7 i^n ❑L as owner of the property,or my employees with wage as there dole
compensation,Business
work and ionstC de:Th ata intended or offered for
sale(Sec.7004,Busmna and Professions Code:The Contractor's License Law
rj $ does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RES.(INKS
E: who does such work himself or through hlsownemplgers,provided that such
Improvements arc not Intended oroffered for sale.If l uweveg thebuilding or
Improvement issold within.ne year ofcompletion,the owner-bullderwill have
trys�+rden o(pmving that Mdid not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profrssbre Code:
'Ds Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT WA'I'FI4(EA)
Wilda or Improves thereon,and who contracts toe such pT"with a
ag0t{ad.r(s)licensed pursu.ct to the C.ntrador's Limn.Law. FEE SUMMARY
I_J I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEPT M
WORK MAN COMPENSATION DECLARATION FI%NRF_S PER TRAP SCHOOLTAX V_ N_
❑I hereby affirm that I have a certificate of consent to aelLinsure,ora RECEIVE N
cenOlcateufworlocs Compens.Bonlnsuranreora certified copytherand Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKME Y N
policy
Lab C] RFLEIPT M
Colley N OAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
Com y
O rtlfled copy u hereby furnished, PLA CHECK PEE I� 1 5
Certified copy b filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR i]o
CERTIFICATE OF FXE'M PTiON FROM WOR K ERS' GREASETRAP PAI r"[L dq ?
COMPENSATION INSURANCE SEWER.SANTTARY-STORM EA.XIOF I'.
Qhis section need not be completed If the permit V for one hundred dollars D2[C Receipt
(S1ODorlm.) WATER HEATER W/VENT./M crTEE ENERGYFEE Y_ N_
I certify that in the performance of the work forwhlch this perndt is hawed,
1 shall not employ any person In any manner w as to became subject to the WATER SYSIFM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NE'W RESIDENTIAL PLMB. SQF. Date Recel t#
'Z NOTICETO APPLICANT:ILaRer making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
I" f/1 Code,you most forthwith comply with such provialom.rthis permit shall be BUILDING .
CC ] deemed revoked.
CONSTRUCTION LENDING AGENCY ISEISMICFEF
CL I hembyaffirenthatthem Is a construction lendlegagency forthe perform- TOTAL: ELECTRIC FEES
7 Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
V O IsndWs Name
LL f LenderSAdd.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U (certify that l have read th9appliatam.nd state that the above Information
O W iscomed.l agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
y a misting to building construction,and hereby authorize representatives ofthle i 6gz�
(_ Z city to enter upon the abma
ove� entiod property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harrelm the City of Cu pe Lino ate Receipt#
V against llablllRea,judgments,mks and expenses which may In any way somas AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said Cin consequence of grantingof tis erns. CONSTRUCTION TAX
1 z AIR HANDLING EMT(OVER IO,WOCFM)
Slgatum of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IO0,000 BTU) Date Recei l#
material as defined by the Cupertino Municipal Code,Chapter 9.12jAir
I leahh and Safety CWE, 75532(a)7 }[EATING UNIT(OVER ,000 BTUs TOTYes No
Wllltheapplicant Oure building occupant use equipment orVENILLATE RESID) ISS'UmANCE DnATE
which emit harardous air mats Mans as defined by the Bay Area VA U OQuality Management DisMctt BOILER-00,0W BTU)Yes o4havercadtheh ousmaterialsrequirementsunderChapteBOILER-C00BID) ��� a.saesthe California Health&Safety Code,Sections 25SD5,2593 and 7553 26 Wundersta nd that if the building does not currently have a tenant,thaNEW RESI . SQ.FT.
responsibility to notify the occupant of the requirements which mutausuancard.ceriflate.f0 anryII YUA Vvrr"r1111V1�IIent DatISSUED BY-V L „�C�
TOTAL:
OFFICE COPY