24157 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin 1'ro ort Idendfleallun PERMIT NO.
Building Addaaa° 24157
10120 c,gz�c ,,va V S� .
sera sore: hone: AITUCA IIUN SUHM11 JAL
Age-m9-,,-EA-j, S CITY OF CUPERTINO-BUILDING DIVISION p
cmo-.ttnraName, LIe.No: APPLICATION I PERMIT
1) X '�^� alb ( BMLDINC-ELEC7WCALPLUMBINC-MECHAMCAL CATEGORY CONTROL.
chited giseer. Lk.No:
U ELECTRIC PERMITr;yYa �t`FEE, BUILDING PERMIT INFO
=1 PLUMS wf�
Address: -C JLI:7 a.I A'Lr� Re'I C POMITI55UANCE T.r•QQ ❑
LICENSED CONTRACTOR'S DECLARATION
VS-
I hereby af(irmthat l am licensed under provisions of Chapter 9(c'ommmc- APPLIANCFSRF_SIDENIAL JOB OFSCRI'I'ION
Ingwith Sn on7O60)ofDivieon3aftheBmiu sand ProfessionsCode,andmy
license is Ins (once and died. PANELS \ l UP TO 200ANDS n � /
License Class Crxr T {r`e •V�/�
Date Contractor 20110W AMPS
ARCHITECTS DECLARATION
0 y I understand my Flew shill be used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/`�'FT'
CO
ZCt, Licensed Professional SIGNS ELECTRICAL — � -I PH
a OWNER-BUILDER DECLARATION SPECIAL C]RCt1IT/M1SC
3 Iherebyafflrmthat l sonexempt from the Commences License Law ice the 1. \�� I-,�
following reason.(Section 70315,Business and Prnfessluru Code:My city or �{p ME[7EORPOLEINSf. V- 1:
muntywhichrequlmapermltwmutructalter,lmpmv de=n h,arrepalr Ab_{
any+tm=mprbrto Ra Wuance,alsorequireatheapphunt(cesuchpemdtto POWER DEVICES
Bk a signed statement that has is Bussed pursuant to the provisions of the DA
E G(�
Contnaoes License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMINGPOOLELECTTUC V UAT10.
05 don 3 of the Business and Professiou Code)cribs,he is exempt therefremand
the basis for the alleged exemption. Any violation of Section 70115 by any OUTLEMSWITCHES-FTXIURE5
7< applicant fora perms subjem the applicamto a civil penalty of not rrore than
five hundred dollars(5"x00).
.$.: NEW RESmEN1TALELI:CTR SQ.FI. STORIES TYPE CONSTRUCTION
❑insinuation,
u owner of the property, l nes employes of in wage r there dole
col.5, a7 KwBldothe wcek+ndthe structure CheC Intended oroffered for
;� sale t5ee 7044,Bw0tw and Professiou Code:The Contactor.License Law
$ dos not apply to an owner of property who builds or improves thereoo,ud OCC.GROUP RFS.UNITS
whodossuchworkhm gorthwghhisownemployes,providedthatwch -!
improvements are not intended oraffersd for sale.If,however,thebuilding or TOTAL:'��(-
Improvementbsoldwithinoneyearofcompletion,the owner-bullderwBi have ..
t"rden of proving that he did am build or lm rove for purpose r-ryu^'r";'� s�+i"!
Lj P B P ti rnm QTY:z.„RMIT PLUMBING'PEBMIT, it a� .fit�FEEw�» pLDDp7pNE [1PN
L u owner of the property,am exclusively..zxI P with ns C rid ppRhHp ISSUANCE
The C.ors m couicense e w cloy(Sec 7ppl; to an owner
of pro ou Coda: Q
The Contractors License Law dm nal apply b,f owner p property whokatilds ALTER-DRAIN&VENT-WATER(EA)
c9BIE.l r Improves tpurmM and who mntrsct+Lice seeh p(ojem with a
L_j I am
licensedpursuant to the Contractors License Law.
LJ I+m nempt under See. B Is P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIBE FEES
O.aner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY y—
WOR KMANCOMPENSATION DECLARATION FIXNRFS PER TRAP DD SCHOOL TAX Y N
E,31 hereby affirm that I have a certificate of consent to self-Inwre,ce a b^ RECE PT O
certificate ofWorkera Compereaticaboarance ceecertdfed ropy themof(Sec. GAS EA.SYSTEM-1 IN .4 OUTLETS PARK FEE Y_ N_
MWI Lab CJ RECEIPTM
Policy a GAS EA.SYSTEM-DYER 4(EA) BUILDING DIVISION FEES
Co any
�Certlfled cop"hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Cetill ed copy is filed with the city inspection divislon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 200Ff Dale Recei fN
(TNesetlion readnet be completed lithe permit b farone hundred dollars
($100)ce1enJ WATER HEATER W/VENT./ELECTR ENERGYFEE Y_ N_
I certify that he the performance of the work for which this permit is issued,
I shall nm employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers CompensaBoo Lawsof Califomh.Date
Z Applicant NEWRESIDENTIAL PLMB. SQFI. Date Recei tad
O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Workers'Compensation provislom of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthh permit atoll be BUILDING
jdeemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
C
S lherebyaffimn that there is a construction lending agency for the perform- ELECTRIC FEE
anis of the work forwhich this pemdt is issued(See 30W,Civ.C.) TOTAL: .6
O lender'.Narrc - , --.- ,w PLUMBING FEE ♦ C
E- Lendar's Address Q7Y. L;:'.%,MECHANICAL-PERMIT;`:};n.�;;-�,�FEE�,,:
611 .
U Iconti"atl have read thooppliution and statethaltheabove information r MECHANICAL FEE
C lscarred.Iagree to complywithall city and county ordinanm and dale laws PERMIT ISSUANCE ,g•OO
FEE$PAID.
N relating to building mmtrudion,and hereby authorize representatives ofthls
Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Receip[H
(We)agree to save,bWemni/y an d keep harmless the City of Cu Fortino
agaimt liabluties,Judgments,cods and expenses which may In any way accrue AIR HANDLING UNIT(7010,000 CFM) SUBTOTAL: 1A.7C
ago Inst said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Cantradar Data E(HAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO]00,WOflTU)
Will the applicant orfttom building occupant store or handle hazallous Date Recei tq
materui as defined by the Cupertino Municipal Code,Chapter 91Z and the
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ys r]No
Will the applicant or future building p..t useequipment or devices VENOLATION FAN(SINGLE RESID) I$SUANCE.DATE
which emit haurdous ab contaminants as defined by the Bay Area Air f-; ! BUJ
Quality Management District? BOILER-COMP OHPOR 100,00)BTU)
4Ys ❑No
ha.ere.dthehaaadmt torudarequlrementsunderChapter6.95of BOILER-COMP ER BTU) ti� 26 1992
the CaIBamla Health&Safety Code,Sedlons 25505,25533 and 25534. 1
understand that lithe building does not currently have a tenant,that It Is;my NEW RESIDENTIAL MECH. SQ-FT
responsibilitytu notify the occupant of the requirements which at be mot ;;I�' ! Vr vuI'LnI11VV
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL, ISSUED BY: V
OFFICE COPY