24276 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.i en Identification PERMTNQ 4 2 7 6
Building Address: Z
CIFIM sma-c- lorz_
one: A A A
caner 4 Lr CITY OF CUPERTINO-BUILDING DIVISION Q�� fnslel
• Gmur 'an1c1 U/� 1 Lic'No: APPLICATION /PERMIT l ��Gri
YaP14r 40 BLTLDING-E].ECTMCAL-PLUMBING-MECHAMCAL CATEGORY CONTROLN
Anhui /Fsglneer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
I'FRh9TIS5UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ectionaffirm that l+m0cenedunder provisions of CudonsC(commmc- MPLIANCSRESTDENTIAL jouD d.o„„,,,�I
ingweh infullforeanDivfect. ofthegusinessandProfesdemCude,and my -`Fa "'aN"r\R�'('�L"�`
limns,isin /one and c.N PANELS
LimDate Chss LION
Date Conhador
ARCHITECTS DECLARATION 781-1000 AMPS
I understand my plan shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
O
q J E Limned Pmfe alm al I SIGNS ELECTRICAL l
< w OWNER-BUILDER DECLARATION r
Iherebyaf . hat l am exempt fromthe Contractors N
License Law for the SPECIALCIRCT/MISC I
7.O—iOO° following reason.S4cti.70315,Bualness and Professions Code:Any dty ora 0
conn whkhr i rt twcomtmMalter,lm W TQ.fP.METER ORIOLE INSI'. _
ty equ rvape prove,demolbh,ora Ir _ 1
+nysuw
uctu¢prlorto its bance,also¢qulrestheappIlant forsuch permit to POWER DEVICES III L ��
C a V file a signed statement that be is licensed Pursuant to the provblon of the
p� Contractors License law(Chap er 9(commencing with Section 70W)of Dlvl-
W r; SWIMMING POOL ELECTRIC;
thei.n3ba the the Alsand PrnfessbnC Any
violation
n of Szem therefrom and LU O
the breis for the alleged ezemthe.p Any vlolatbn of natty Section m by any
F OGS ape huntfed cloi mRSubjMathe appilcant teat dull penitydna mon than OUTLETSSWITCIiESFIXIIIR s••7 o
five
I,as owner of the em lo ees with wa es as their sole NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
�f_ �n ❑ Property,or mY employees 8
kP< com(Sec.744,Businethrworl4andthe o.Cdure Is notIntended or License
d for
Lw
die(not apply to alnoss and P.ffprope property
who
b:The Contractors hemor,Law
pf$ woanotapply work owner ofdprough who nemplds orlmprwvided toryand
c. who doasuchworkhlmseVorthrwgh his ownemplgees,provided th.tvch OCC GROIII' RFS.UNITS
Improvements an not intended aroffered for sale.If,Wwevep the Wiidln8 or TOTAL: -
Improvement bsold within mayearafcompletlon,the owner-W nderwlll have
t rdcn of proving that he did not bund or Improve for purpose of ule.). QTY, PLUMBING PERMIT FEE HADDMNE APN
L a.owner of the Property,am exclusively contracting with ll®nud
contractors to construct the project(Sec.7044,Business and Profession Code: PERMIT NUANCE
The Contractors License Law dm not apply to an owner of property who ALTER-DRAIN k VFM-WATER(EA)
Wilds or Improves thereon,and who contracts f¢such p4opc is with a
cop[(ador0011¢nsed punuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Ser. B k P C f.,,hi, reason
Owner OUTS]OF FEE S
Date DRAINSFl P,ROOF,AREA,GOND. SANITARY Y— N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES—PER TRAP SCHOOL TAX Y— N_
❑1 hereby affirm that I have a¢ni0ate of consent to selfdnure,or RECEIPT N
380i,abofWorkers'Compenabonlnuran¢oracenlflM copy themof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab CJ
Polity M — BUILRDCEDING
I N
floGAS EA.SYSTEM-OVER 6(FA)
en BUILDING DI VISION Fr.ES
m aertifed copy b heed With t ecity GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF IXEMPIION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE gCWER-SANITARY-STORM EA700FT. Date Remi t#
(Thos acdlen need red W completed if the permit Is forone hundred dollars . P
a10crtify that
WATER HEATER W/VENT/ETRCTR ENERGY FEE Y N
1 certify that In anyhe perarm I. ny he manner an as tohthisper it bjcct to ed,the —
I shall not employ any person in any manner ro v to become subject to the WATER SYSTEM/MFATING
Worlicry Compenutlon Lawsmf California. Data PAID
O Z Applicant NEW RESIDENTIAL PIMB. SQRI'. Date Recei t#
Z O N017CETOMI'LiCAM:IL akar rm'Compere2tionaid.g this laovisi.te of of the
,you
PCod,shoulYou aaImthwIect othe Workers'Comp rovisin Provblsnrmit s Lab or TOTAL' _
LUW Coda you nwst(orthwith comply With such provblonorthh permit shall be BUILDING FEE
] dmn N revoked.
LU
O CONSTRUCTION LENDING AGENCY SEISMIC FEE t.
I herby affirmthat which
t i a i lei Issued
lending agency for the perform- ELECTRIC FEE
7 Z arm dthe workfarwhkhthb permitb Wued(Bee.3097,Cie.C.) TOTAL:
U O Tended None PLUMBING FEE
LL F 1<nder.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W correct.
mnifythat I have read thbappllation and stateth+t the.WveinfmcaJon
T agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE PEES PAID:
Q. relating to building construction,and hereby authomm reprenenmtives of this
I— U) city to enter upon theabove-mentimedi property for Inspection purposes. ALTFRORADDTOMECH.
— (We)agree to save,Me999999eeeemmIuuuurr'fy an d keep harmless the City of Cupertino Date Receipt#
against Bablliiln,p� sand apensn 1 may In anywayamroe AIR HANDLING UNIT RO 10,000 CFM) SUBTOTAL:
against saidCity in of tie gr+nti dt sperm(.
AIR HANDL)NG IIMT(OVER 10,000CEM) CONSTRUCTION TAX
5 more of Appll,,m/Contractor Date IXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAM R DOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant atom or handle hazardous HEATING UNIT(10100,000 BM Date RCCeI t#
material as defined by the Cupertino Munldpal Code,Chapter 9.17,and the -
Health and Safety Code Section 75537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes M No
Willtheappllant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESiD) ISSUANCE DATE
which eMt hazardous air contaminants as dented by the Bay Area Air
. Qua lily Ma rugement Dbhlct7 BOILER-COMP OM'OR l000B0 BTU)
Yes ❑uo
G l
havrradtbehazarda s nutertaismquimm nbunder Chapter6.95of BOILER COMP(OVER 1W,"BN)
the ifernla Health k Safety Code,Section 75505,75533 and 75534.1 is qA '
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr. I� D
responsibility to notify the occupant of the requirements which most be met
Inner to issuanm of a Certificate of D.P.my. Y7G'•/
CYC ss ��
Owner or authoriud agent Date n•'• ��'
TOTAL: ISSUED BY:L7;
- •u1Yl,/
OFFICE COPY