24403 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.-AL POINT PEN ONLY
H.U411.1,Pooled Identlflcarlan PERMIT NO 24403
Building Add..: f ^
caly
suhone: A
ra O/1/QCITY OF CUPERTINO-BUILDING DIVISION D _
ConaactoraN�me: LIc.No APPLICATION I PERMIT
/✓ Q W LQ O� BUILDING-ELECTRICALPLUMBINGMFLHANICAL CATECARY CONTROL N
Architect/Er gmeer. Lb.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE 0 ❑ 11
LICENSED CONTRACTOR'SDEur..fCLON
IhereectJonmthatl ivacg3oft eBusi wand Pro Cssions ode,ann AI'PLIANCESRESIDENTIAL ]pB DFSCRIPIION
time.ISection to.
ofthe BuelnessandProlnalonsCode,and my � r _�
license is in full farce and effect PANELS ICL(_/'!� `•.
UP TO 200 AMPS
License Chea LIett G �y�/ Z yy
Date /�1T—�.CContractor�`•-J /'✓- Q(�/
ARCHITECTS DECLARATION 211-IODDAMP$
�'Z I understand my plana shag be used n public records 'OVER IODD AMPS ARF A' 1 f/SQ.FF.
0 CCQ iF (5
r: N
Licensed Professional SIGNS ELECTRICAL ^.(
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC , l
Z"a-4 1herebyaffirmthatlame.emptfromtheContractorsLicenseLawforthe
02 following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
coneywhich requires a permit to mrutruct,alter,improve,d euroluh,or repair
�ggg� anystrunure prlorto its Issuance,also requirestheappbrant(orsuch permitto IX)WFR DENTES
r� file a signed statement that he Is Ilomaed pursuant to the provisions of the
mG Contractor'.License Law(Chapter 9(commencing with Section 7000)of Divi- SW1?v[MING POOL ELECTRIC VALUATION
l-. O slnn 301the Bushessand Professions Code)orthal he h exempt Nerefromantl D Q
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FD[TURES
applicant for a permit subjects the applicant to a civil penalty of not nnrethan
five hundred dollars($500). NEW RESIDENTIALELECTR SQXT. STORIES f TYPE CONSTRUCTION
E]I,ac owner of the property,or my employees with wages as their sok
compensatton,will do the work,and the structure is not intended or offered for
psale(Sec.7064,Business and Prolessimu Code:The Contractors Lt..Law
$ does not apply to an owner of property who builds or improves,thereon,and OCC.GROUP RFS UNITS
EEE who doessuch work himself or through his own employees,provided that such
Improvements are not intended oroffered for sale.IL however,the Wilding or TOTAL:
Improvement Is sold within one yearofcomplction,the owner-builder will have
trlcquNen of proving that he did not bund or improve for pu rpose of sale.). QTY. PLUMBING PERMIT FEE FLCODZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE -
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law don no apply to an owner of property who ALTER-DRAIN A VENT WATER(EA)
Wilds or Improves;
thereon,and who contracts for such plojecm with a FEE SUMMARY
oactor(s)II¢nxd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
nI am exempt under Sec. B A P C for this reason
OUTSIDEFEFS
DRAINS FLOOR RODP,AREA,CONED. SANITARY Y N
. Owner Date MRECEIPT-
r WORK AN COMPENSATION DECLARATION FIXIUIRES PER TRAPSCITOOL TA% Y N
Lly hereby affirm that n
I have a rtlRute of convent to.el(dnwre,ora RECEIPT N
certificate ofWorkers'Compsmadoelruurance or a certified copythereof(Sac. GAS EA.SYSTEM-1 INCAOUTLEIS PARKFEE Y N
3800,Lab C.) IRECIRxfp
Policy 0 GAS EA.SYSTEM-OVER 6(EA)
Com BUILDING DIVISION FEESfCenifllany copy h hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XIORT. Date Recef t#
frhl.sction need not be completed If the permit Is forone hundred dollars
(flm)nrless.) TR _ N_
I certifythat h the performance of thework forwhich this permit is Issued, WATER HEATER W/VENT/FLECENERGY FEE Y
I shall not employ any person In any runner an n to bTC.. to the WATER SYS[EM/TREATING PAID
Worlucre Compensatlonlawsof GRf.M.Date O� C
O Applicant NEW RESIDENTIAL PENIS. SQ.FT. Date Recel t#
Z 0 NOTICE TO APPLICANT-.If,after makleg this Certificate of Eaemptbn,you
should become subjen to the Worken'Comperentlon provisions of the Labor TOTAL]
N Code,you most forthwith comply with such provielors or this permit shall be BUILDING FEEQ�
seemed revoked.
' W � mCONSTRUCTION LENDING AGENCY SEISMIC FEE
d e IherebyafRrm that there Is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z arm of the work for which this permit Is hsued(Sec.3097,Civ.C.) PLUMBING FF$
O O Lender's Name
LL F Lenders Addrev QTY. MECHANICAL PERMIT FEE MECHAN
O W Iscoree Inn lfy that l have mad this application a nd gate that the above information FEES PAI
nvoL Iagto comply.111h.11M wn a11 cityacountyordire.ces and gale laPFRMITISSUANCE
} a relating to building comtructlon,and hereby authorlae representatives o(thb
F Z city to enter upon the above-reenliorud property for inspection purposes. ALTER OR ADDTO MUCH. D V C01P[#
(We)agree to save,indemnity an d keep harmless the City of Cupertino
V against llabllltles,pdgmenb,coenend expeneeawhlch may In anyway accrue AIR HANDLING UNIT(170 10,000 CFM) SU OTAL: 49
against aid City incons encs ofthe granting of this permit. CONSTRUCTIONAX
6 ��^ AIR HANDLING UNIT(OVER IO,000CFMD
pLosnt/Canto Date EXHAUST HOOD(W/DUC'D CONSTRUCTION TA PAID:
HA ATERIALSDISCLOSURE
Will the apph building occupant store or handle harardous HEATING UNIT(70 IOO,ODO BTU) Date Rec t#
mated.)cue deft the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cada Section 25537(•)7 HEATING UNIT(OVER 100,000 HTU) TO 1
❑Yee No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminant s..deft dl by lM Bay Area Air
• ality Management District? BOILER-COMP DEB'OR 1003100 BTU)
(��f Yes No
(have readthebaaaooamalerhIsrequimm nlsunder Chapter6.95of BOILER-COMP 100,000 BM
the California Health k Safety Code,Sections 25505,25533 and 25536.I 2 9 1992
understand that if the building don ns,currently have a tenant.that it is my NEW RESIDENTIAL MECH. SQ.FT OCT
responsibility to notify the occupant of the requbcmenlswhich most
be rret V
prior/ care of.CertifkAte,of Occupancy.
o - 2 r11. vr IjUYcnlur
or authorised agent Data TOTAL: ISSUEDBY:
OFFICE COPY