24332APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ect Identification
PERMIT N¢
Bulldleg Address:
4 3 3 2
N. _
one:
fVL, i"
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
c^n ecto . me: t LIc.No:
BUILDINGELECTRICALPLUMBING.MECHANICAL
CATEGORY
CONTROL N
Architect/Enginnr. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
�`�
Add— Z �-1'Oct/ Vlh
. PLUMB M�h
❑ ❑ ❑.
-
PERMITISSUANCE
LICENSED CONTRTION
under provisions me
IhthSb
that lam Licensed under Armand Cssions
APP[IANCESRESIDENI3AL
JOB DESCRIPHON
PANELS
Innnee I.Infors forceofdefelon3oflheBuslnevandPro/e.alonaCade,end my
ion7O Pm ode,an
license is In fou force and effect. -
Licenv Claes Lic.N
Date Contractor
UP TO 2DO ANTS
illi-tOWAM
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVERIOOOAMPS
SQ. Fr. FLOOR AREA
SIGNS ELECTRICAL
Licensed Professional
"
SPECIAL CIRCUIT/M15C
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cont .elm. License Law for the
-
TEMP METER OR POLE INST.
following reason.(Section 70315, Business and Professions Cade: Any city or
rountywhkhrequimapermlttomnstmd,altepimprove,de=lhh,ormpair
anystmetue prior tolls issuance, also requirealheappBont/orsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
1'
SWIMMING POOL ELECTRIC
Contractors License Law (Chapter9(Commentlng with Section 7000) of Divi.
slon3ofthe Buelnmsand Profewiom Code)ortlutheiservmptlherefmmand
TIO
the basisfor the alleged exemption. Any violation of S .tion 70X5 by any
ppucant fora permit cubjedathe applicantto a dvll penaltyof nO momthan
OUTLETS -SWITCHES -FIXTURES
a�
fivCdred dol6rs (4500).
����jjjjyy�AI
as owner of IM property, or my employees with wages as their wk
NEW RESIDENTIAL ELECTR SQ
GDNSII2UGHDN
pervmiun, will do the work and the stmeture b not intended or offered for
1c(sec 7041, B cad... and Pmfessiory Code: The Contractors License law
does not apply to an owner of property who builds or Improves thereon and
who doessuchworkhmme,1forthrough hlsownemployeeero
,pvldecithatsuch
OCC. CROUP
RFS UNITS
Improvements are not Intended proffered for Bale. If, however, lhebuliding or
TOTAL:
Improvement hwld withinoneyeamfcompletiogtheowner-builderwlll have
IfILIlurden of provingthat he did notbulld orlmprove forpurpowofsakJ.
11 L as owner of the property, am exclusively contracting with licensed
mntrsctors to Construct the project (Sec. 70K Business and Professions;
QTY, PLUMBING PERMIT FEE
HADDM�
APN
'
PERMIT ISSUANCE
The Contractor. License law don not apply to an owner of property who
or Improves thereon, and who contracts for such pTjecta with a
licensed pursuant to the Contractor's LlLaw.
cgyB(acourts) 11mxrue
LII am exempt under Sec. B & P C for this reason
ALTQt-DRAIN & VENT • WATER OWWilds
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
FD7IURES PER TRAP
I
SANITARY YY_ NRECEIPTN_�
Owner Date
WORKMAN COMPENSATION DECLARATION
[DI hemby affirm that I have a certificate of consent to self -Insure, ora
certificate of Worker.'Compensalion Insurance ora certified wpythereof(Sec.
3800, Lab C.)
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFEE Y_ N_
RECEIPT M
Polley N
C y
GAS EA. SYSTIM-OVER 4 (EA)
BUILDING DIVISION FEES
rtlfied copy Is hereby td.
�CerlBled wpybflkd withh the the city inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE7RAP
CERTIFICATE OP EXEMPTION FROM WORKERS'
PAID
EA 200FT
COMPENSATION INSURANCESEWER.SANITARY-STORM
TThlssection and not be completed Bthe permit bfur one hundred dollars
($100)orlesaJ
I certify that In the performance ofthe work for which this permit I. heated,
Date Re i t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
WATER SYSTEM/TREATING
I.hall not employ.ny person In any manner w v to become subject to the
Workers Compensation Laws of California. Date
PAID
NEW RESIDENTIAL PLMB. SQ}T.
Applicant
Date Remipt
NOTICE TO APPLICANT: I, after making this Certificate of Exemption, you
should become.ubjed to the Workers' Compensation provisions of the LaW r
TOTAL:
-
BUILDING FEE
Code, you moat forthwith comply with such provisions orchis permit shall be
deemed revoked.
- CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirrnthat there is a construction lending agency for the perform-
ance of the work /or which this permit In blued (Sec. 3097, Civ. C.)
Iandere Name -
Lender. Address
Iartl(ythat l have read thisappucatlonand statethatthe above information,^
Ia correct. I agree to complywilh all cttyand county ordinances and pate laws
TOTAL,
ELECTRICFEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
ALTERORADDTOMELH:
relating to building construction, and hereby authorue representatives of toe
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
.gal i116010es,jidgmenb, Corteand expenses which may In anywayacaue
Date Recei t#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
agai 1 id City to consequence of the gra qng o/thla permit
-
AIR HANDIdNG UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signatum of Applicant ontrs or D>< !
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZA DOUR MATERIALS DISCLOSURE
Will the applicant or future building occupant atore.1 ha^dlehavrdous
HEATING UNIT CTO 100,000BTU)
Date Redei t#
material as defined by the Cupertino MuNctpal Cada CM1apter 9.12, end the
Health and Safety Code Section 25532(a)7
C3 Yen No
Will theapplicant lir lure Wilding occupant use equipment ordevioes
HEATING UNIT (OVER 100,000 BTI)
TOT
VENTILATION pAN(SINGLE RESIO)
ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yea No
r have read the h.q..mate,ials requirements under Chapter 8.95 of
PA
BOILER -COMP OHP OR 100,DM BTU)
BOILER.COMP(OVER 100,000 BTU)
the California Health & Safety Code, Sections 25505,Z03 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to not ify the occupant of the rqubc.nte which most be met.
a'1 I
o CT
NEW RESIDENTIAL MECTL SQ.FT.
prior to issuance of a Certificate of Occupancy.
1 e
Ise
/t
M�Ti1/a
1r{I
Vla)a `
ISSUED BY:
TTS —
Owner or authorized agent Data
OFFICE COPY