24025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project ldmificaion PFRMIT NO.
BnBd�Addre,,: 24025
neveSa/. ane:
A A
/ CITY OF CUPERTINO-BUILDINGDIVISION as
Contr or'aNa No: APPLICATION / PERMIT
0 �Roq BUILDING-ELECnUCALPLUMBiNG-MECHANICAL CATEGORY CONTROL a
Archit h/Englaee Lie.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aaare.:/077,3,
PERMIT ISSUANCE ❑ ❑
by a LICENSED CONTRACTOR'S DECLARATION Ihereection70that l iv Bcensedunder prwtaonaof Cssions9de,and c APPWANCFSRESIDENFIAL O�f(I�DESCR ON
IngwitIt...h I.full fmcc.fdaffeon3ofthe Buanessand ProfessionsCode,and my J.Z.--
license Is In full fora and effect. PANELS
LicenseClat LLic.cour
Date Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION MI-1000AMP$
ct0 2 I understand my plans shall be used as public records. OVER I ODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL D
OWNERBUILDER DECLARATION I, - A
F, 7 IherebyalRm
rthatlamexempt from the Contractors License nse wfor the SPECIALCEtCUIT/MISC �V
following reason(Section 70315,Business and Professions Code:Any city or
Eg tr
p coon whichre OnaPe n tto-wtaci,alter,bnprove,devnllsh,orre pa IFMP.METER ORPOLE INSI.
g
a�' '3 any,tructurc prlormits lawance,alaorequlreatheappBcant(or such permit to
y'e file signed statement that he is Bansed pursuant to the provisions of the POWER DEVICES
bIE R
1 /7 C�
O w Contractors License Lew(Chapter 9(commencing with Shinn 7000)of Divi- rT _/
F,�OS i.n3.fth-Businnsand Prof.a .Cde).rth.the6emmptthemfmmand SWIMMING POOL ELECTRIC UATI Q
S the basis for the alleged exemption. Any violation of Section 7031.5 by any �A
OUTLE7
� appBant fora permitaubjnts theapplkant too civil pealtydnot rtnrellun SSW[TCHESFIKIURFS. � (1 Oma\
five hundred delta.($SM. NEW RESIDENTIAL ELEC7R �` C)
�n ❑I,as owner of the property,or my employees with wage as their sok SQ FT. STORIES TYPE CON'SpkUCTIO\
compensation,willdothe work and the structure fanner Intended or offered for
O sale(Sec.7614 Business and Profassiorn Code:The Contractors License Law
does not apply to an owmr of property who Wilds or improves themes,and .
who does such work himself orthrough lib own employes,provided that such OCGGROIIP RFSUNITS
improvements arc rat intended orofferd forsale.IL however thebuildinger TOTAL:
improvement 6sold withinonerarofcomplOiontheowner-W Ilderwill have
th Iden of proving that he did net Wild or improve for purpose of sac.). QTY. PLUMBING PERMIT FEE FDZDNE AIIN
L as owner of the property,am exclusively contracting with licensed pFRMITISSUANCE
contractors to construct the project(Sec.7614 Business and Professions Code:
The Contender's License law does nu apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contract,for such pt.ojetle with a FEE SUMMARY
cq�t caom Bcensed pursuant to the Contractors Licenx Law. BACK FLOW PROTECT.DEVICE
.,LJ I am exempt under Sec. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
Date RECEIPT=
WORKMEC
AN COMPENSATION DECLARATION ION
PER TRAP �� SCHOOL 7A% Y N
❑I hereby affirm that 1 have a ce uranc of mnxnt to seBdneare,ora RECEI T Y
eertiflc.b C.) orken'Compenatlonlnsurance ora ceklfied ropythereof(Bec. GAS FA SYSTEM-1 INCA OUTLETS
DJ,Tab CJ PARK FEE Y— N—
oma ey GAS EA.SYSTEM-OVER4(EA) BUILDING IVISIONFF.ES
sniped copy 6 heed with to cityurd GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CedBied copy ls filed with the city inspection divblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAI, PAID
ls
COMPENSATION INSURANCE
(fhlasection need not W completed the permit .orone hundred dollars SEWER-SANITARYSTORM EA"Yr Date Recei t#
{5100)or
Icenify,y that In the performance of the work forwhkAthla permit bbound, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I,hall not employ any person in any manner so as to become subject to the WATE{SYSTEM/7REATTNG
Works Compensation laws of California.Date PAID
0 Z Applicant
Z oNDITCETO APPLICANT.If,after making thin Certificate of Exemption,you NEW RESIDENTIAL P(MB. SQFT. Date ReCel t#
Haheuld brume subject to the Workers'Compensation provision=Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be �s
LU >_ deemedmookd. BUI DING FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby eflemthat there 6 a construction lending agency for the perform
0 ance of the work for which this permit 6 Issued(Sec.3097,Civ.C.) T ELECTRIC FEE
V Landers Name :MECHANICAL
ING FEE
LL ~ Lender's Address QTY. MECHANICAL PERMIT FEE FEE0 W Icertlfythatl have read th6appliratlenad aatethat theabove in(omutlona lsrom'ct.lagnetocomplywith all dtyand countyodinancea and state laws PERMITISSUANCE ID:} W resting to buildsg conswction,and hereby authorize representatives althlsWcity to enter upon the abovcmentioad propertyforimpectien purposes. ALTER OR ADD TO MECH.(We)agree to eindemnify an Mem the ty of Cupertino e RKci t#a Wtlkbwt d mens, ndex P8a 8 pen ,which ,,anyw AIR HANDLING UNIT RO t0,OJ0 CFM)agahss i ty in conseque onhe gr ngM ` SUBTOTAL:AIRHANOWNG UNIT(OVER IO,000CFl1) RUCTION TAX
-Signature of Applicant/Contractor
HA]AROOUS MATERIALS DISCLOSURE Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
Will the appiicantorfuture building occupant store or handle hazardous I MATING UNIT(TO 100,00 BTUI
material as defined by the Cupertino Municipal Cde,Chapter 9.12,and the Date RCfel t#
I lealth and Safety Code Section 25532(.)7 FIEATING UMT(OVER 1 W,(Rp BTU)
❑ Yes C3 No TOTAL:
Will theappllant or future Wilding occvpantuse equipment ordcej.a VENN'DLATION FAN(BINGLE RESID) ISSUANCE DATE
which emanagementa air irontamianb as defined by the Bay Area Air
Quality management D'uWctt BOR.Eft-COMP OHPOR 100,IX0 BTLI) PAID 9
LC7
❑❑No Wadthehazardous materials reqummente under Chapter 6.95 of MOILER-COMP(OVQ(100,000BTU)
Is s Health&Safety Code,Secilons 255QS,E533and 25534. 1 ��� ��that ifthebuildingders net currently have a tenant.theltismy NEW RESIDENTIAL MECH. SQ.FT 1992
ty to notify the occupant of the requirements which must be met ^ance o!a Certi(lateo(Occvpanry. blIYb Ur CUrcn,,,,thodud agent Date
TOTAL: ISSUEDBY: -
OFFICE COPY