24164 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tlulldinR Project Identlfiatbn PF3iMI7NQ, 41 E 4
Budding Addren: w Z
rs ams: hone:
CITY OF CUPERTINO-BUILDING DIVISION
•
b• •.- u No APPLICATION /PERMIT l
NTROLX
Ardated/- S`� ��� BUR.DINGELECTRICALPLUMBINGMECHAMCAL CA'CFL'ARY COglre r. Lie a:
Ql,Y"t431 ,g,, ELECTRIC1.PERMrr� r.,;>�,FEEO* '' ^ �i/BU[LDING,PERMIT INFOr
Address: PERFRTISSUANCE 'r lye
LICENSED CONTRACTOR'S DECLARATION ofCh ON
Ihereby
eeic, mthat l iviMonud under Busine Wonso(Csions9(mmmmc APPLIANCESRES[DENML JOB DESC ON
innoxo is to
fd diedn3o(the BuslnessandProleaslonsCede,and my ��y, �
Fnanon b In mu re ana erred. SU/d/Z9 PANELS l 1
te LicN
to I/ 4 Contractor '— Kt !e*+ UP TO 2DO AMPS
ARCHITECT`S DECLARATION 201.1"AMPS ,
❑QZ� I understand my plans shall be used as public recada OVERIOOOAMPS L tjbRA"MS/SQ.FT.
f$2(�J Li..d Professional SIGNS ELECTRICAL p U T E R
Z w OWNER-BUILDER DECLARATION
2 fn Fn SPECULCIRCUIT/MLSC C)hI
p., y owing off .(Seel on 7 31.5,B fromass a Contractor's Lkenx law for the
Qp following reason.(Section 7.15, o Business and Pimprov, Code:My city it
02s. perm whkh requires permit altar, P TEMP.METER OR POLE INST.
Cu5 tY requ P< 4 Proantfor sueh,orre repair _
any stwcwrttatemeprior to ithat he is also requires pumas tothet(mwions of permit POWER DEVICES
fBe a signed statement that he b licensed punumt to the provisions of the
Contractor•Lkerue 30LA.(Ch0 er9(memendn with Section 7000)of Divi- VALUATION 5 slon3 ofth llusInm and Pmfxmlmx Code)mthrt he in exempt lherefremand SWIMMING POOL ELECTRO
' the basis for the alleged exemption. Any violation of Section 70315 by anyasoo (9c
e
eppU.tfor.permit subjects the appllcam too civil penalty of set mum mere than O 20%2 � �
-. ..
FSE five hundred dollars W00). NEW RESDFMIALELFf_TR SQFT. STORIES TYPE CONSTRICTION
❑Las owner of the property,or m7'employ.with wages u their sok
CZC compensation,willdothe work and thestwcture isnot intended or offered for
O sale Cies 7014,Business and Pmfmbm Code:The Contractor's License Law
�$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS.- .who d.such work himself orthrough hisown employees,provided that such
improvements art not Intended proffered forme.If,however,thebuiWing or TOS
Improvement lawld within one yearo(complelonthe owner-bu0derwill have x.t,,,.. _
t4iLlfarder,of proving that he dm not build or Improve for purpose o(we.). pr-y. TrV PLUMBING BERIoif4,' FLOOD ZONE APN
L_j L as owner of the Property,am exclusively centrading with licensed PFRMI.I.ISSUANCE
mntntton to constrod the project(Sec 704X,BuaInm and Pmfmbns Code: _
The Contdori License Law doe•nd apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)Wilds or Improve thereon,and who comm.for So& Ploject With a ,FEE,SUMMARY,;
U licensed n
puuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under Sec B k P C for this neaten
?^� DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
--y, Owner Date RECEIPT X
WORKMAN COMPENSATION DECLARATION
❑I h.by affirm the I have a certificate of content to self-insure,or a FAI
VRES PER TRAP �� SCFIOOL TAX RECEIPT X
mrtihweofWorkvm'Compenseim Ins mmaacertlfled copy hereof Gee. GAS EA.SYSTEM-1 INC4 OUTLETS PARKFEE Y_ N_
3800,LabQ okoc lzll O(/G RECEIPTN
pniky X GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Coma!%sw �a rw
rtVed mpy b hereby fumthed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified mpy is filed with the city irepectbn divtion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER.SANITARY-STORM EA 21XB7 Date Recei t#
(rhlstectlon nee dndbecompletedlftMperrdtbfor ane hundreddollan ENERGY FEE Y N
(5100)or lmJ WATER HEATER W/VENT/ELECTR
I certify that In the performance e(thework(orwpermiteh this permit is issued,
I shag not employ any person In any manner w As to become usbjeet to the WATER SYSTEM/TREATING PAID
Workers'C.penution Lawsof CAlifmoia.Data
0Z Applicant Remi t#
Z Z NODCETO APPLICANT:H,after muWng this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFT. IOTA '
Fshould become subject to the Workers''Compewtlon provisions of the Labor
N Code,you moat forthwith comply with such provisions orthb permit shall be G FEE
s�
Wj deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
C G I hereleyefrmthat there be mnstmctim lendingegency for the perform, ELECTRIC FEE a
Z Ana of the workforwhieh this permit is bound(Sm.3097,Civ.Q
O O Landare NAme ,�.,., -, 'tie».-... _ •.u,„ r. PLUMBING FEE Li /—
h- Lender's Addren
LL U Imrti(ythatlhavemdthaapphutionandealethattheaboveinfomud MECHANICAL FEE
0 W is coned.I agreeto complywlth all cityand county ordinances and date laws PERMIT ISSUANCE "� FEES PAID:
} 1 relating to building mrutrudion,and herebyauthmizereporemative•ofths
r Z city to enter upon the above-menBoned property for impaction purposes. ALTER OR ADD TO MECH. Date Recel t#
(We)agree to save,Indemnify an d keep harmless,the City of Cu pertlno P
V agaWtlad tins judgment, sondes;xmeswhichmayinanywayacave AIR HANDLING UNIT 8010,000 CFM SUBTOTAL:
Aga Wt tel con nce (the IF
-Y J, y AIR 14ANDUNG UNIT(OVER IO, CFM) CONSTRUCTION TAX
of Apphant/Cortador Data EXHAUST HOOD(W/D[K CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willlhe Hunt orfuture building occupant store or handle hazardous HEATING UNIT ,000 BTU) - Date Recei
materal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
tlealthand Safety Cade Sedbn 2553z1a)7 HEATING UNIT VER 100,000 BTU) TOT
❑Yea No VTILA N PAN(SINGLE RESD) ISSUANCE DATE
WHl the Applies.,or Nre building ocwpantuu equipment or devims EN
«.1 whkh emit hazardous air mntandeant as defined by the Bay Area Air
ality Management Dlstrld2 BO -COMP(3HIa OR 100,0(0 BTU)
Yes No
have read the hazardous materials requirement under Cha Ater 6.95 of R.ER-COMP(OVER 100,000 BTU)
lei e the California Health k Safety Code,Sections 25505,25533and2SS34. 1
n re
understand that if the building donot currently haw a tenant,that it Is my NEW RESIDENTIAL MEIN. SQ.Ff.
respmeb0ky to really the occupant of the requirements whkh at be mel
prior to Issuance of a Certificate of Occupancy.
n,
Owner or authorized agent Data TOTAL: ISSUED BY'
OFFICE COPY ///yv