24408APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
I'FSiMITN
0utldii Address: (
4408
wnero / - ons:
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CITY OFCUPERTINO-BUILDINGDIVISION
APPLICATION / PERM Lett)
BUILDINGELECTRICAL-PLU� BING
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Contractor's Name: Lk. No:
4'
CATEGORY
CONTROL #
Ar /En neer. L N
QTY ELECTRIC PERFEE
BUILDING PERMIT INFO
Address: Z
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f` V .YJr
❑ ❑
PERMITISSUANCE ��
LICENSED CONTRALTO 'S DECLARATION
thereby Ollc aof Chapter
ingwlthSecon7M)ofD!viso3oftheRugnessandPro(eselonaCode,ndmy
lienee is In (u rm and died "S1AANEUS
License la Lk.p. tae
APPLIANCESRE
E L
JOB DESCRREON
`Via`l`
Date Contractor SYCia;:a " _..o
D/\ YarV
ARCHITECPS DECLARATION
20 'I
'
SQ. PT. FLOOR AREA E/�.FI'.
I understand my plans a hall be used a a publicrecords.
O AMPS,
SELECTRIC
SPEC LCIliCU[T ISG
' L-'.
Licensed Professional T
OWNER -BUILDER DECLARATION
Law forthe
[wing r a(Brmihat Lm exempt from the Contractor's s Code:
following reason. (Section 7031.5, Business and Professions Code: Any city or
cmntywhkh requires a pertnitto mmtmcL alMr, Improve, demollsh,orrepalr
N
` �`
PU EE a..�
K
P LE [NST. n N1
any structure prior to its issuance, also requiresthe applicant for such permit toBV
file a signed statement that he It licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and Prolamines Code) orthat he La exempt Nerefromand
the basis for the alleged exemption. Any violation of Section 7MLS by anyk)UTLE.�SWIT0FDMJRES
applicant for a permit subjects the applicant to a civil penalty of not cre, n
CEg
_ VALUATI
O 0 D
S NG POOL EL C DA
4
NEW RESID AL ELECTR SQ.FT.
five hundred dollars ($500).
FlLas owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compeesation,willdothe work andthestrudure Laron Intended or offered for
sale (Sec. 7044, Business and Profeseloes Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon,and
who does such .,it himself.through his own employee., provided that such
OCC.GROUP
RES. UNIT'S
improvements are not Intended muttered formle. If, howeeer,thebullding or
bnprove miss old with oneyearofcompletloktheowner-bu0derwill have
to an of proving that he did nm build or Improve for purpose of sale.).
4 as owner of the property, am exclusively contracting with licensed
"actors to construct the project (Sec. 7044, Business and Profeanimoi Code:,
QTY. I PLUMBING PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
The Contream. License Law does not apply to an owner of property who
Wild. or Improves thereon, and who mntram for such ptojem with a
en
ecreate) licensed pursuant to the Contractor's License Law.
ec am exempt under SB k P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
FLOW PROTECT. DEVICE
DRAINS A, FLOOR, ROOF, ARECOND.
SANITARY Y_ N_ '
RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -Insure, or a
ate ofWorkers'Compermtlonlesuran_ce ora emitted copy thereof an.
3800, UbC.)
policy f oC) \Ci�
FATURES. PER TRAP
SCHOOLTAK Y_ N_
RECEIPT M
GAS F.A. SYSTEM -1 INC.40UILEI5
-
PARK FEE Y N
RECERxf M
Com anyggy��'.aQ
GAS G.SYSTEM-0VER 4(EA)
BUILDING DIVISION FEES
�C ified copy is hereby shed.
eCetlifled copy b filed with the city inspection division.
Ci.
GREASEANDUSTRL WA EI'TOR
PLANCHECK FEE "
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-gpNTTARY- RM EA 200FP
COMPENSATION INSURANCE
(Chi..ection need nM be completed lithe permit La forone hundred dollars
($1 I artily that
Icertlfythat lathe performance WLaa
ovnce of the work for which this lsed,
Date Recei t#
WATER HEA /VENT/ELECTR
ENERGY FEE Y_ N_ �s
WATERSYS /TREATING
I shall not employ any person In any vunner se, as to become subject to the
Workem'Compensation Lawsof Ghfomia. Date
PAID,/4, 1e�
Applicant -
NOTICE co APPLICANT: e Work making this Certificate is Exemption, you
me Lab
Workers' Compeesasonprovhloesrmit
NEWR DENTIALPLMB. SQFT.
Date Recei t#
TOTAL: Z
FEE
Code,shoulyou s
Code, you coked. comply with such provisions or lhLa permit shall be
forthwith comply be
-BUILDING
deemed revoked.
SEISMIC FEE '
CONSTRUCTION LENDING AGENCY
Iherebyat(irm that them lsamestructlon lending agency for the perform-
ane o(lhe work for which this permit Is Issued (Sec. 3097, Civ. Q
Lender'. Name
Lender'sAddress -
I certi(ythatl havereadthkapplicatlonand statethatthe above informatiorl
incorrect.I agree to complywlth all cityand county ordinances and state lawt
TOTAL:
ELECTRIC FEE
PLUMBING FEE
TY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT Issum,;cii
FEES PAID:
relating to building construction, and hereby authorize representatives of thia
-
citytoemerupontheabove-marooned property for Inspection purposes.
(We) agree to save, iedemnify an d keep harmless the City of Cupertino
. against liabilities, judgments, costs and expenses which may In any way amore
ALTERORADDTOMEGH.
Date Recei t#
P
-
AIR HANDLING UNIT (TO 10,000 CFM)
-
SUBTOTAL:
against said C In consequence of the granting of this pens
��
a ct HA UNIT 1B,000cFn4i
CONSTRUCTION TAX
A phcant ontrador - Dkel
EXHAUST HOOD(w/DUCT)
CONSTRUCTION TAX PAID:,
DISCLOSURE
Ill the applicant orfulure building occupant store or handle hazardous
cerin as defined by the Cupertino Municipal Code, Chapter 9.12. and the
Health and Safety Code Section 25532(a)7
❑ Yes MN.
Wllitheappilcantorfuture bulidmiloccupant use equipment ordevims
Date Recei t#
HEATING UNIT OD 110,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
- -
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q�Lalfty Management District?
,
BOILER -COMP OHP U) OR 100,000 BTO
Yes No
I have read the hazardous materials requirements under Chapter 6.95 of
BOILER -COMP, (OVER IOO,DOO BTU)
the California Health h Safety Code, Sections 25505, 25533 and 25534. I
understand that lithe building does not currently have a tenant, -that it is my
responsibility to notify the occupant of the requirements which at be met
l7
NEW RESIDENTIAL MECH.- SQ.hT.`-
prior to Issuance of a Certificate of Occupancy.
bxo� r
ISSUEDBY..
-
Owner or authomated agent Date
TOTAL:
OFFICE COPY rVIjj Ur V.