24211 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES"- USE BALL POINT PEN,ONLY
Building Pre'eRldentification ,' ' P PERhBTNQ 4211
Building Address:
/o Le ►2 .
were came. one: - APPLICA RON SUBMI17ALA
9,11— CITY OF CUPERTINCrBU1LDING DIVISION ' N� "
contreRnr,Name: APPLICATION I PERMIT — '
V BUILDING-ELECTRICALPLUMBINGMECt{AMCAL CATEGORY CONTROL M
j CIA
rcMteR/Engineer. L o.
E �Q'[Y .•'.` l 6LECTRTC,P�`AIvTT to'F,EE ' BUILPLUMB
T)7,rG;P,EftMIT1NF0
Address - �• PERMIT ISSUANCE ❑ 1:1
❑
LICENSED CONTRACTOR'S DBC RATION
I berebyeffirm that am licensed under provisions of Chapter9(commenc- APPLIANCES RESIDENTIAL JOB DESC ON
Ingwith SeR/on7000)O[Dlvlaton3aide,Bus]reassert Professions Code,and my - r ,
license is In Full and effect. p , PANELS
Liren la - e Lick 7 r I
Date Contractor up 1
ARCHITE DBCLA ON 2([]-1!00 AMPS T• t 'i I
pre0 O I underetand my p6re s1uI16 used n pu recnraa. . OVER 1000 AMPS n .. 0 I II mJ e•Q. OD AREA $/SQ.FT.
p��u ❑❑❑❑❑❑
Fi�(0 Licensed Professional SIGNSELECTRICA \' Is, B��
OWNER-BUILDER DECLARATION - SPECIALCIRCUIT/ 3RC_,- 7
F, Ihereby affirm that am exempt from the Contractor's License law for the
O
0- following recon.(Section 70315,Business and Profession,Code:Any ctty or Tptfp,METI940RPOLE[NST.
F4 cauntywhichrequlmsaper twcomu ct,alter,impmve,demlWh,orrepalr
anyatmeturcim rtoitslssuance,also re"Brestheapplicamforsuch permit to POWER DEVICESfile a signed statement that he is licensed pursuant to the provisions of the
3 u. ContnRoI's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
�O sion3 ofthe Businessand PrefessionsCode)or that he is exempttherefromand VALUATfON
6 the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty ofnet morethan OUTLETS-SWITCHES-FIXTURES
five hundred dollars($500). - STOglp�n
(((ililil �n ❑ as owner the property,or my employees with wage,cue thele sole NEW RESIDENTIAL ELECTR �� TYPE CONSTRUCTION
compensation,Business do work,dcashmstmcture Is h.0 intended oroffered for
O sale(See 7014,to Businessand
property Cade:The Contractors License
ereon Law
whodot apply assuchtoanownerofpessighwhonemplrimproves es,Proidedtatand suchOCC,GROUP RES.UNITS
whodoem nts are not mself intended or
hlsowne.If,
however,the
building
or
improvement issuld within
one caro redfor platio.tf,hmverebuhecrwfll have TOTAL:
improvementlssoldwithinoneyearofcomplNioMtheownervbullderwBlhave � - 't '
tFIgJ%ten of proving that he did nmbulld or Improve for purpose ofsale) �!LUM,BIIryGP 811311' 'a` •]'rEQn;� }T-OOD ZINE APN
u I,as owner of the property,am exclusively contracting with licensed ppgMlT ISSUANCE,
contractors to ceretroct the project(Sec.7044,Business and Profeaslotu Code:
The Commelor's License Law does not apply to an owner of property who ALTER-DRAIN&VENTW
Wilds or Improves thereos,and who contracts for such p(ojeR - - ATER
a with a (EN
cq➢f{actor(a)licensed pursuant to the Contractor's License Law. +':i',', x'IY F:EE+$UMMARY+•' �'t;;t
t�l I am exempt under Sec. H&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner - Date
WORKM COMPENSATION DECLARATION RECEPT#
FXT(mESPER TRAP - SCI{OOLTAX Y_ N
E3,hereby affirm that I have a certificate of consent to self-Insure,w e
artlflcate o(Worken'Compnuatlon]wurance oracemiedcopythereof(& RECEI'c. C pGAS EA.38M Lab CJ 4- )I1 It � PARK FEE Y_ N—
Pollq RECEIPT#
Com an GAS EA.SYSTEM-OVER4(EA) .- BUILDING DIVISION FEES
❑Cerrttlfled copy is herebyth the city
�l G GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE'
{�Certlfied copy is filed with the city ivpectlon division.
Yom' CERTIFICATE OF EXEMPTION FROM WORKERS' P GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA 200Ff Date Recei t# I ,CO
(Thineed net be completed lithe permit b(oroe hundred dollars -
($100)orl.rlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE . Y - N
[certify that in the person
in
theworkso se to beta pevmtle lso the
I s)uall not employ any person In any manner so v to become subject to the - WATER SYSTEM/TREATING
Workere'Compensation Lp�pf California.Date PAID
O Z Applicant /V
Z O NOTICE TO AIPIPLIC .If,aftermaking this Certiflosteof Exemption,you NEW RESIDENTIAL PLMB, SQ,Fr. Date Remi t#
should become subject to the Workms'Compereatlon provisions ofthe Labor / TOTAL: .
N Cede,you mu at forthwith comply with such provisions orthls permit shall be BUILDING
W ) deemedrevoked. - .
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
IberebyafRrm that there is a construction lending agency for the perforrry TOTAL > ELECTRIC FEE
M O once of the work for which this mit is Issued(Sec.3097,Civ,C.) ^Da
V ]enders Name �` : PLUMBING FEE .QQ
ly F endersAddrea, - -/ QTY,t.''. ,MEC HANIGAL 1'ERlv1I `tt ;IEEE
O W Icertify that]have readthbapplicatkmand AaFthatth,above lne,man. MECHANICAL FEE
Il iscorreR.l agree to comply withal)etyand county ordinances and state law, PERMIT ISSUANCE FEES PAID:
y relating to building coelmction,and hereby authorize representatives of this
f" Z city to enter upon the above-mentloned property for inspection purposes. ALTERORADDTOMECH. `
— (We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Receipt#
against liabilities,judgmetds,creased expenses which may In anywayaceme AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL: .d
against said City in consequence of the granting of this permit.
AIR HA LADLING UNIT(OVER I QOOO CFM) CONSTRUCTION TAX -
SignstureofAppliont/Contractor Date . EXHAUST HOOD(W/DLJCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfuture building occupantstore or handle hazardous HEATING UNIT(TO 160,000 BTU) Dale Reeej t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
)leap and Safety Code Rion 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ yea
the applicant J Men building occupant use equipment oreYes
devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air ..
QualitYee y Management Die riR7 BORP ER-COMP(3H OR 100,000 BTU) ,
4haver ousoreadtheh m terlal,regWrementsunderChapter6.95of, BOILER-COMP(OVER 100,0f0 BTU)
the California Health&Safety Code,Sections 25505,75533 and 25534. I '
understand that ifthe building does not currently have a tenant,that It is my NEWRESIDEMIALMECH. SQ.FI
r Cr--•• ,s,„ (}
responsibility to notify the occupant of the requirements which must be met ' !.Issuance ofa Cardio to (Ocevpanry. - ra (�J
airr lazy
Uf
nerora on a Data rtf'IT I1Yk/
• TOTAL:- � ' ISSUED OY: '
OFFICE COPY