24195APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NQS
BuOding Address:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
o^ && Name Lk. No
Cil I O
BUILDING-ELECTRICAL-PLUMBING-MECitAMCAL
CATEGORY CONTROL 0
Archlte Engineer: Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDINGPERMIT INFO
,
Address -
PERMITISSUANCE
1:1 El ❑
LICENSED CONTRACTOR'S DECLARATION
'
(hereby affirm that l am licensed under provisions of Chapter 9(comment,
'sense lseR1ullfor Divisionandef,et. (1he8uelneseand Pro(eWonsCode, and my
Ing with inion (orae wddfect.
APPLIANCCSRESIDENTIAL
F JOBDFSC"-TION
n
PANELS
License Class LIt.a
"
1��
Date Cormador
— UP TO 200AWS
211-1000 AMPS
AACHITECI•S DECLARATION
I understand my plans shall be used as public mmrds
OVER1000AMPS
SQ, FT. FLOOR AREA
$/SQ. FT,
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/
TEMP. METER Oft NT..
following reason.($ection 7031.5, Business and Professions Code: Any city or
rountywhlchrequircsapermitmmnstmd,alter,impmw,demolleh,ornpalr
J V
anystrocturc pdortold issuance, sive requlmtheappnrant forwch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmmencing with Sedlon 7000) of Dlvl-
Yon3oflhe BusineuandPMenlonsCode)orthrt he bexem)H therefromand
the We' for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars (¢SW). I
❑ I, as owner of the property, or my employers with wages as their sole
POWERDEVICES k0a
SWIMMING POOL ELE.17
0[TILETSSW[iEiIES-H%'IVRFS
VALUATI ON
NEW RESIDENTIAL ELECTR _SQFT.
STORIES
TYPE CONSIRIlCT10N
compensatlon,wnldothe work, and lhestrochim is not intended or offered for
sale (See. 7044, Business and Pmfeukoro Code: The Contractors License Law
TOTAL:
does not apply to an owner of property who builds or improves thereonand
who does suchwork himself orthrough his own employees, provided that such
Improvements are not Intended proffered forsake. If, however, thebullding or
improvement owW withinoneyearafcomplation, theowner-bunderwllk have
OCC. GRO(1P
RES. UNITS
tho�+rden of proving that he did not build or improve for purpose ofsale.).
LI Lae owner of the property, am exclusively contracting with licensed
contnders to construct the project(See 7614, Busessi.ed Professions Code:
QTY, ':i'. . PLUMBINGPERMIT � ,i FEET.
PERMITISSUANCE mg
FIOODZONE
APN
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pipjects with a
op"chor(s) Rcenaed pursuant to the Contractors License Law..
LJ I am exempt under Sec. B & P C for this maven
. ALTER -DRAIN & VENT- WATER (EA)
. FEE SUMMARY'
BACK FLOW PROTECT. DEVICE
OUTSIDE FE
DRAINS FLOOR ROOF, AREA, GOND.
FIXTUINS PER TRAP -
SANITARY Y_ N—
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to sxIMnxure, o a
SCILOOL N_
TA% Y_
certiflote of Worknn'Compensatlrnlnsunnce ora artRled copythado((Sec.
RECEB M
GAS EA. SYSTEM -1 INC40UTI
INCAFIS
PARKFEE Y_ N_
M
RECEIPT p
ny
Rertilled
GAS LA. sys1F-OVRaA)
BUILDING DIVIs10N FCFs
edified copy is hereby furnished.
ropy is flied with the city Inspection division.
i
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECCFEE
TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'CREASE
COMPENSATION INSURANCE t
(Thissedlon need sad W completed Bthe permit isforons hundred dollars
($100) errfyth '
Icenot thato the person
performance tmanner w as beemsh this esublec Ito theed,
I shall not employ any Uws In any manner w a to become wbject to the
W Applicant Compematlon Gwe of Gllfomla. Date
Applicant
NOTICE TO APPLICANT: If, ager making this Certificate of Exemption, you
should become subjed to the Workers' Compensation provislom of the Labor
Code, you at forthwith comply with such provisions orthls perndt shall be
deemed revoked.
PAID
Date Remi t#
SEWER-SAMTARY-STORM EA. WIFE.
WA HRATER W/VENT/ELECTR
ENERGY FEE Y N —
pplp
Date RecqjjL#
A STEM/TREATING
RESIDENTIAL PLMO. SQ
TOTAL:
B IN
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDINGACENCY
Iherebyafflrm that them is a construction lending agency for the perform
once of the work for which this permit is Issued (Sec. 3097, Civ. C.)
1`naera Nana
Lender'.Address
1 uAifythatl have read thisappllotionand statethattheaWs xinformatlon
- -
QTY. MECHANICAL PERMIT:i:., ":;:. FEE
PLUMBING FEE
.r^
MECHANICAL FEE
'
FEES PAID:
Is tomtit l agree to comply with all city and county ordinances and Yale laws
PERMITISSUANCE
relating to building coratrudlon, and hereby authorize rep.wntativcs rf this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemnify an d keep ha en the City of Cupertino
agal Jlabllltles' dgmenb sand ex Ich in an ova amus
agairu ncon moft ng oft e
ALTIRORADDTOMFCH.
pate ReCC1 t#
p
AIR HANDLING UNIT CIO 10,000 CFM)
AIRHANDLING UNIT (OVER 10iorioc•M)
SUBTOTAL:
CONSTRUCTION TAX
Sig reof Appll sat/Collin ate
EXHAUSTHOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
" HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CTO 100,000 BTU)
Will the applicant or future building occupant store or handle hazarldus
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Hes It and Safety Code Section 25537(a)7
❑ Yes No
Willi the applicant wgWm building occupant use equipment or devices
Date Revel
HEATING UNIT (OVER 100,000 BTU)
TOT '
VENTILATION FAN (SINGLE REBID)
I$SUANGE'DATE
which emit hamrdous air contaminants as defined by the Bay Area Air
Quality Management District?
1 Yes I—INo
have read the hazer�us materials requircmenh under Chapter 6.95 ^f
'
EP 9 1992
BOILER -COMP OTE' OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
the California Health & SafetyCode, Sections 25505, 75533 and 76534. I
NEW RESIDENTIAL MECH. SQ.rr
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the —P --t of the requirementswhi,h must be and
prior to Issuance of a CertiflcamofOccopancy.
CITY ur
_ 's Urrnilliv
ISSUED BY:
Owner or authorized agent Data
TOTAL:
OFFICE COPY