24248 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
Building Address: PERMIT N(,l
24248,
wnera amc: - hone:
A
.z/ ,Q% /Il . 7x39-709 CITY OF CUPERTINO-BUILDINGDIVISION c�
Commerce a Name: Lle.No: APPLICATION / PERMIT _ 2_ C Z
Architect/Engineer. Lie.No; UI
BLDING-ELECTRICAL MU BING-MECHAMCAL CATEGORY CONTROL,N
DINCPERMITi1NFO
'017 ... i ELHGTRIC`PR1�1IT t :'.FEE t .
Address: - PERMRTISSUANCE � ❑ ❑ ❑..
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commen APPLIANCESRESIDENITAL JOB DESCRIPTIONIngwith Section 7000).(Division 3ofthe Business and ProfvisionsCode,and my
license is In full force and effect. PANELS —fir
License Claw . tr p �s p C�
Date ConContractor 1
ARCHITECT'S DECLARATION 701-1000AMPS'
aO ZpI understand my plans shall be used as public records OVER1000AMPS SQ,Ff.FLOOR AREA $/SQ.FC.
5 UC Licensed Professional SIGNS ELECTRICAL is .,� ,
6 - OWNER-BUILDER DECLARATION SPECIAL C]RCUIT/MISC p�Cpl
0F'�� owingtherebysson.(affirom hatlam31.5,Bexempt froessandm the Professionstradoes Law
or ��
followingreason.ices aP Permit to
and Professve, Code: h, city or
O�i^B y ty TEMP.METER OR POLE INST.
Pg anystrwhichprior to
pertNteaborquirratheapRantfr such,orrepatr
gg
anyatrocturepaler felts issuancelicensed pursuant
to
provisions
to POWER DEVICES
t` lion a signed statement that het licensed pursuant it the provisions of the E
��O Contractor's LkenseLaw(Chapter9(commenctng with Section 7000)o(Devi. SWIMMING POOL ELECTRIC
slon3ofthe Business antlProfemlors Code)orthethekexempt therefromand
y.' the basis for the alleged exemption. Any violation of Section 7001.5 by any rrai
65 applicant fora permit subjects the applicant to a civil penalty ofnet morethan OUTLETS-SWITCHES-FIXTURES q�•!
ofive hundred dollars($500).
as owner of the property, NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�e p peaty,or nary employees ixa with wages o their sok
m(Sec.prea70K Business
and rk and ionstrocturc Isnot Intended or altered for
C1 sale(Sec.7044,Buaineea and Professions Code:The Contractors License Law
j3$ does am apply to an owner of property who builds or improves thereon,and
who doeasuch work himselforthrough h15ownemploym,provided lhatsuch OCC.GROUP —RES UNITS
Improvements arenot Intended orofferel forsale.If,howevegthe Wildingor TOTALi
improvement
idsold withkomyearofcompletion,theowner-bullderwill have
th, urden o(pmving that he did net build or improve for purpose task) Qjyt,'., 'P LUM13ING'PERMIT '7',FEE:'.�' 7•TpOD ZONE APN
u I,cue owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the pealed(Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(oje with a
og0.t deals)licensed pursuant to the Contractor'.License Law. BACK Flow PROTECT.DEVICE E6E SUMMARY
IJ I am exempt under Sec B &P C for this reson
a
DRAINS FLCOR ROOF,AREA,COND. SANITARY Y N
Owner Date — RECEIPT It
4. P. ATION DECLARATION
❑1 here affirm that I have a lasu rate of consent to op theare,ora FDCIVRES PER TRAP SCI{OOL
certificate ofWorkers'Compensatlonlrourance or a mrtifled copy thereof(Sec. RECEIPT N
3800,lab CJ GAS EA.SYSTEM-1 INC.40I1TLEl5 PARK FEE Y— N_
1'ollry It - RECEIDING DI N
Com any GAS EA.SYSI'FMAVERd(EA) BUILDING DIVISION FEES
ECertified copy is hereby the city
- GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy la filed with the city Inspection division.
' CERTIFICATE 0FLXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER.SAMTARY-STORM EA.200FI'. Date Recei t#
(Chis section need net be completed lithe permit la for one hundred dollars
410 manly®.I WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Illnot that lnthe person
rrmance soninany he manner as as tobeco penuries issued,
I shall not employ any person in any manner as as to become subject to the r
Workem'Compensation laws of California.nla.Date WATER SYSTEM/TREATING PAID
Q Z Applicant
Z O NOTICE TO APPLICANT;If,after making this Cortifkate of Exemptionyou NEW RESIDENTIAL FIMS,_—SQ,Fr. Date Recei t#
should bemme subject to the Werkens'Compensation provisions of the Labor - TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be
W j deemed revoked. BUILDING FEE
tL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyafflrm that there is a construction lending agency forthe perform~ TOTAL: ELECTRIC FEE
� Z ance ofthe workfor which this permit is lasued(Sec.3097,Civ.C.)
00 fendars Name PLUMBING FEE '
LL I— Lender's Addre s R v;.` MECHANICAE,',PBRMiT i:ME''t? MECHANICAL FEE
O W Icertilythatl tuvereadtheapplicationandstatethatthe above ln(ormatlon -
4 Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this -
Z city to enter upon the alawnmentioned property for Inspection purposes. ALM OR ADD TO MECH. '
(We)agree to save,Indemnify an d keep harmless the City of Cupertino - Date Receipt#
V'. against liabilities,judgments,missend expenses which may In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL'
agar t said City In consequence of the granting of this permit.
AIR HANDLING UNIT 1Q000 CIM) CONSTRUCTION TAX
Sig o PP cut cntra m, -21-72-Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU).
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recei t#
Ilea lth and Safety Code Section 25537(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant orfuture building occupant use equipment or devicesMNEWRFAD=ALMECH.
FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the gay Area Air. R� p
Quality Management District? OR]OO,IXq BTU) r H D
4Yea ❑❑No
havnread the harardous materials requirements under Chapter 6.95 ofER 100,000 BTU)
the Glifornla Health&Safety Code,Sections 75505,25533 and 75534. I - SEP
9-I 't(]($'
understand that tithe building does not currently hive a tenant,that it 6 myMECH. SQ.FT. SEN1, I99-9responsibility to really the occupant of the requirements which must be met _priortolssuanceofaCertificateo!Occupancy. CiIY Ur uuetnl"qu
Owner or avihorized agent Date 'TOTAL: ISSUED BY. tf l V
OFFICE COPY