24012 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruett Identification - PFRMITNO.
Building Address:
�Zjigjglso NAAZA &v6 0,uPr=A4C, cA, 24012
vara arra: one: A
M,Tml i PS CITY OF CUPERTINO�BUILDINGDIVISION
Caneneror'e Name: L UA IT
Lic.No: APPLICATION /PERMIT —)Z
BUfLDING-ELECTRICALPLUMBING-MECHANICAL CATEGORYC Lj
Architect/Engira@r. Llc No: -
QTY ELECTRICPERMIT FEE BUILDING PER MIT INFO
BLUU ��I PLUME MULTI
Add.. OD
PERMIT ISSUANCE L-V
LICENSED I a CONTRACTOR'S
pr DECLARATION �•J LCA
I herebyaffirm ion7OOD)ofDi lken3oftheerprovland ProCslons9(romma AI'1'LIANCESRESIDENITAL JOB DESCRfPfION
Ingwlth5ect1on700D)ofd flecn3o(the Buelrreaand Pro(essloneCode,and my
license le In full farm and dfect, PANELS
Llanse Clam Lk.N s
DateContactor '
ARCHITEC'PS DECLARATION 201-1000AMPg
At Z I understand my plans @hall be used u public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
oFj Licensed Profe skmal SIGNSELECTRICAL L, E R I N
«Z�u OWNER-BUILDER DECLARATION
I"n][d SPECIAL CIRCUIT/MLSC
F' Eaeng..A.(S disco exemptfroms and Prraeor'@Ll ode:Law dyorf�ths 4TER
F� followlnhich requires
perra tocosinerandr,Imprve, emlishnydtyor ; R
O f,� TEMP.METES OR POLE INST.� rountywhkh requbeapermit locoatruct,alters improve,demoLLsh,orrepalr
anystructure pdgrm ltsiwance,elaorcquircetheappBantfonuch perMtto POWER DEVICES Q
file a signed statement that he is licensed pursuant to the provisions of the
3wy Contractor's License Law(Chapter 9(comareenctng with Section 700))of Divi- SWIMMING POOL fl.ECTRIC 710N
H O:F elan 3 of the Bualnessand ProfessionsCod0 or that he I.exempt therefromand
V1 o.•33 the hasb for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
D
applicant for a permit subjects the applicant to a civil penalty of not mom thin
five hundred dollars%50O. NEWRESIDENIIALELECI'RSQIrr. TYPE CONBIRUCTION
I,as owner of the property,or my employee with wages as their sole
compenation,wlll cloths work,andthe structure b rat Intended or offered for
qale(Sec.7064,BLLslnea and Professlga Cade:The Contractors Liceae law
pj r$Q does not apply to an owner of property who builds or improve lheman.and OCC.CROIJI' RES UMTS
E who doe suchwork himself orthwgh his own employees,provided that such 'D
Improvements proveets see nnot intended oroffered for ale.I(however,thebullding a TOTAL:
improvement lasold withinoneyearo(compledogtheowner-W Bderwlll have
t)ypfTsy.A of provingthat he did nes build orlmprove forpurposeofale.). QTY. PLUMBING PERMIT FEE
�I.as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
Mntractan to coatmct the protect(Sec 7044 Business and Profealau Code: PERMIT ISSUANCE DO
The Cantaegrs License Gov,don not apply to an owner of property who
WilALTER-DRAIN kVENT-WATER(EA)
Wilda or improves therrory+rad who contracts for such ptaJem -
with+ FEE SUMMARY
cgB(actorts)lian
nsed uant totha doi'a License Law. BACK PLOWI'ItOTFLT.DEVICE
L� m exempt I B k P Cor th aaon
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Ovagertns_- Date RECEIPT M
WORKMAN COMPENSATION DECLA TIO FIXTURES.PER•TRAP 'D SCHOOL TAX Y N
QI im &(firm that I have a certificate of consent to self-Insure,ora �®ry N
artlflateo(Workera'Comparuallon Insurance as certified copy themof(Sec.
3800,LAb C.) CAS EA.SYSFQd-1INCA OUTLETS PARK FEE Y N
Policy CAS EA.SYSTPM-0VC•R 4(EA) DING DIVISION FEES
Com any
BUILRECEIPTN
ffCx fled copy b hereby fumished. GREASE/INDUSTRL WASTE INTERCEPTOR PIANCHECK FEE
CertlRed copy b fBed with the city inspection division.
CERTIFICATE OF h7(EMPTION FROM WORKERS" GRE'A'SE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIC3AM EA 200F7 Date Reeel tN
(Thlssectlon need not be completed lithe permit bforora hundred dollars
($1M)orless3 WATER HEATER W/VENT/EL[CIR ENERGYFEE Y_ N_
I rertifythat M the performance of Ihework forwhlch this permit b eased,
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z. Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Rece1 [
Z O NOTICE TO APPLICANT.If,after naHngthb Cernlfiate of Exemption,you
F
should became subject to the Workers'Camperoatbn prov6loa ofthe Labor TOTA
Code,you=at forthwith comply with such provialua arthla permit shall be
W y
j deemed revoked. _ BUILDING C O
CONSTRUCTION LENDING AGENCY SEISMICC FE e
[lam eof ebythe orkf hat far
isaroatmctlon sued(Sec. ,CIv.ncy C.) perforrm TOTAL •� Q ELECTRIC 13
0 Z anceofs Name whkhthb permit (Sec.3097,C1v.C.) aaD
02 Larder's Name PLUMBI •E 3 YD
ILL Q Londer@Addrws QTY. MECHANICAL PER FEE MECHA FEE
r O W Iant.Iain tocomave comply
is with
all and
nand
unAsia y hat ordinances
rdinancs a ld gate laws
a s PERMIT ISSUANCE 0 FEES ID:
a isrelat correct.building comply with alnd hembcothorum lnanreaand atatelahis
N city to
enteru pont construction,and d prop rty,or in rcprio ntativas purposof this
'F cityW)aree to save,indemnify
an
property,forCit purpose. AL7ER ORADD TO MECH.
Z (We)agree to ave,Indemnify and kept harmless the City o(Cupertlno to e
I„I agaliat Liabilities,prdgrnbareas,,areas, ma
@ and expenses whlch y In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) $ TOTAL:: O
again Id CRY In roe ince f aAtiagdlhispe I. AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION AX
Appllant/Con actor -te EXHAUST HOOD(W/DIX:T) - S CONSTRUCTIONT PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapp0cent&future building occupant store or handle haranutts HEATING UNIT(TO Iffl W0 BTU) Date Recei
material a dd0ned by the Cupeni.MuNdpal Code,Chapter 9.11,and/he
Ilealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No .
Will the applicant AMA,lou llding occupant use equipment or devim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE.
which anal haarict? sae defined by the Bay Area Ab
a
Quality Ma gementaac.t airircontaminants BOILER-COMP DI-0a DR 100,0(0 RTU)
r7 Yea No
'Fl have read the haza�us materials rcquirermnts under Chapter 6.95 of BOILER-COMP(OVER 1(0,0110 BTU) P A pa
the California Health k Safety Code,Seelmu ISMS,25533 and 25534. I V
understand that if the building does not currently have a tenant,that It is,my NEW RESIDFNTIAL MECH. SQ.FT.
responsibilitye of a CrAegme ofOcfthe pancy.lrcmentswhich moat be met JU
prig to Laurence of a Certlfkate ofOccupancy. /�
Owner or authorized agent Date ISSUED BY t I I 1 I flVt�
TOTAL: '
OFFICE COPY