24286 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE SALL POINT PEN ONLY
Building Pru ed Identification . PERMIT N24286
. 4 2 8 6
Wildinn^g"��Address:
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w rahone A
`^ M (� CITY OF CUPERTINO-BUILDING DIVISION A „Q
rep tractoYa Name: Lie.Na: APPLICATION /PERMIT
BUILDING-ELECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL#
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Arcot ett Engine r.
Lk.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:I(M r PERMITIS5UANCE [:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
RATION
hereby a(firmthat l am licensed under provisions of Chapter9(comdom, APPLIANCESSRESIDENTIAL JOB DESCRIPTION
IngwBE 5eaion7000)of Dlvislon3ofthe Buslnessand Profen maCWe,and my
license to in fullforce and effect. PANELS
License Cia® Lie.#
Date Contractor UP TO 2DO AMPS `r
ARCHITECT'S DECLARATION 201-1000 AMPS
ctO Z, I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
Pqqp±± SIGNS ELECTRICAL f
Licensed Professional n 7 #..�
rcnc'' 11G6�77 OWNEReBUILDER DECLARATION SPECIALCIRCUIT/MLSC - ')
0R a owing raf0rmthatlam31.5,B(ro Business
Contractor'sLicen.e Law fort he .,
�,� Q following reason.(Section 7031.5,Boniness and Professions Cade: h, tl or
1pp'� countywhich requlresa pemNtto rorewct,alien improve,demolish,orrepair TEMP METER OR POLE]NST.
q�5 anystmu mpdormirelsauance,alsorequlieatheappBrant(orsuchpert tto POWER DEVICES
Epa G�6 file a signed statement that he is licensed pursuant to the prois+ors of the
0 3 u,i Contractors License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
t.,Et aion3.fthe BuslneMand Professions Code)orthat he ti exempttherefromand
til thq basis for the alleged exemption, Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars hepr. SQ,FT. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages r their sole NEW RESIDENTIAL ELECTR
n, rom(Sec.70K wmdo the work,
rofeasusCode:
de:TheCntroctr'o License
dfor Law
� O sale(Sec.apply
to anDonmes,
owner
of property
Co builds or Improves
Uceme Law
does netoessuch torn owner ofprough hiswho
nemorlmproovidedthatsuand OCC.GROUP EAPN
UNITS
who doeniunh amrk himself a through hisownemployees,provided thatsuch
Improvementsared withi oneye tuffs pleflo ,the owevep ffider ilt gorhave TOTAL:
improvemen[beold withinoneyearofcompletion,theowner-bu0derw111have
tleburden of proving that he did net Wim or improve for purpose of sale.). (ITS PLUMBING PERMIT FEE FLOOD TONE
u 4 as owner of the property,am exclusively contracting with limnaed PERMIT ISSUANCE
ocrumcnes to ceretruct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wild,or improves thereon,and who contracts ntras for such ptojects with a
ogDS(�ctor(a)licensed pursuant tis the Contractor's License Law. FEE SUMMARY
V I am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
•� Owner Date RECEIPT N
WORK MAN COMPENBATION DECLARATION TITRES PER TRAP t^e SCi{OOL TAX- Y N_
❑I hereby affirm that 1 have o Insurance
of consent to self-insure,ora RECEIPT#
mrtpflrab C.Workeni Comperuation Wurance oracedi(kd copy (Sec, GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab CJ
Polley X
aRECEIPT
GAS F.A.EA.SYSTEM-OVER 6(EA) 8UILDING DIVISION
ISION FF.ES
edified
copy b hereby furnished.
thecity
- CREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
�Cedified copy us(Bed with the ty lropection division. '
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 200PT Date Recei t#
(Tm.seco.n need oat be completed if the permit Is forone hundred dollare
'($100)arlesa') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify thato the performance n the work so
co eemNtis Ito the
I shall not employ any person in any manner w as ro become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of CallfomW. Date � PAID
O Z Applicant NEW RESIDLNTIAL PLMB. SQFT. Date Recei t#
ZOO NOTICETO APPLICANT:If,after makJngtme Cedl(kateof Exemption,you
should become subject to the Workers'Compereation provisions of the Labor TOTAL:
Mf5 Cods;you must forthwith comply with such provid..orthis permit shall be BUILDING 'E
W > deemed revoked. .
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a cowtruction lending agency(cribs perform- ELEC'T'RIC FEE
Z anceof the work for which this permit b heated(Sec.3097,Cl,CJ
U O Lenders Name - PLUMBING FEE - as—
u. Lend.e.Address - QTY. MECHANICAL PERMIT FEE
O W n
lmdifythatl Wvemadthbapplirationandmawthattheaboveinformation MECHANICAL FEE
1 mect.I agree to complywith all city and county ordinances and state paws PERMIT ISSUANCE FEES PAID:
relating to bu(IdIng construction,and hereby authodee representathoa rd this
H Z city a capon theabove-mentioned property for inspection purposes. ALTEt.OR ADD TO MECH. Dale ReCel t#
_ e)a e lo'save, damnify an keep harmless the City of Cups Ino P
akst a Iltles,pd rate, as expenseswiichnuyinanyway AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
suer d City m ce o e ip roing of this permit.
AIR HANDLING UNIT(OVER IQ000CFM) CONSTRUCTION TAX
of Appl " / ti or Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
IlltheappBcentortown,building occupantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU). TOT /�
F1 Yes N No
ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID), ISSUANCE DA'Z'E
which emit barardous air contaminants as defined by the Bay Area Air
Quality Management District? ` BOILER-COMP OTIP OR 100,D00 BTU)
Yea No P D
A
a p4,
❑ A
have read the hazardous materials requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&SafetyCode,Secdma 25505,25533 and 25534.I SEP 28
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. a 1992
responsibility to not lfy the occupant of the requirements which at be met
prior to issuance of a Certificate of Occupancy.
rat t 1;U#
Owner or euthodzed agent ]Ate ISSUED BY.
TOTAL:
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