24014 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Protect Identification PERMITNO.
Building Address: 2 4 014
.• —117
ners ame- one: APPLICA HON SUBMITTAL
fvt4rc --- GketJ4 �� CITY OF CUPERTINO-BUILDING DIVISION .
Contractor'sNa le.No: APPLICATION I PERMIT
k-373 E 0- BUILDING-ELECTMCALI'LUMBINGCATEGORY ORY CO. OLN
-Pitet/Englneer. Lk.Nee
QTY ELECTRICPERMFr FEE BUILDING PERMIT INFO
Address:
�� ❑ ❑
LICENSED CONTRACTORS DECLARATION PERMITISSUANCE
IhthSy.ffirmi..70 that lam Bcensed order itheBuir and Pmfeamsr9(e,andm- AI'PIlANCESRESIDENT7AL JOB DEtiCRII'UON
In ease 1.1.full
force of d ofelon3o(the8usinesaand Professions Code,and my
license Is Intali force and r.R PANELS
License Chse LION '
Date Contractor
ARCHITECTS DECLARATION 201-IODOAMPS
re0 ZO 1 understand my plans shall W used as public re red& OVER lODO AMPS SQ.FT.FLOOR AREA E/SQ.FT.
L� �j Licensed ProfessionalSIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECWLCIRCUIT/M
71o.., E Ihercby afBrmthatlam exempt fromthe Contractorb LlmnseLaw(o the
following reason.(Section 70315,Business and Professions Code:Any city or TEhgP.MECER OR POLE ST.
Py cruntywhich requiresapermitto romtmct,alter,lmprove,demolLsh,orrepalr R... ^
O�a anystmd mptl tolls ame,aborcqulreatheappBmntforsuchper tto IF—. ,4{a
E V file a signed statement that W is licensed pursuant to the pmvisiom of the TOWER DEVICES
3w Contractors Limme,Law(Chapter 9(mmmemm;with Section 7000)of Divi- SWIMMING IDOL ELECTRI
sim3oHheBualnnsand Professions Code)or that he is exempt therefrom and VALUATION
P ^I the basis for the alleged exemption. Any violation of Section 7MI5 by any `/1♦
Ilmnt for permit sub' stheapplicant to a civil nal of act comethan OUTLETSSWHCFIF_SFIXTURES (J`
app pe letpenalty
c.g fiZ'
�eyru mired donors he pr. NEW RESD6MAL ELECTR_^SQ,FT.
7 _ Y�"ae owner ll the property,or my employees with wages r thele dole STORIES TYPECONSTRUCTION
f= G rompensadon,wllldothe work endthe stratum Enm Intended or offered for
5 D sale(Sec. pply to alnowandf property Code:TheCimproves Llmme Law
whodca nor such toanrwneeofprough his o nemWildorimpmvnted thateem.and OCC.GROUP RESUNR5
whodoements am not ntelfedorwghectaow aleph owaprovidedthatsuch
improvementsarcnot Intended earodco (orsale.theowe b alder ill have TOTAL
i provemmnt L,sold withinoneyearolcomplelbn,theowner-bullderwlll have
tis Men o(proving that he did not build or improve for purpose o(sale.). QTY. PLUMBING PERMIT FEE FLODDZorE APN
�{as owner of the property,am exclusively mntrating with Iimnsed pIBiMIT ISSUANCE
cantracton to construct the project(Sec.7044,Businessand Professlam"Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon, and who contracts for such jeWims with a
cq�{p)j'pI�ctor(0hcensecipursusattothe Contratori Licerue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
mea
F am exept under Sec. B &P C for this rson
Owner pet DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
WtZRt](MANCOMPENSA ONDECLARATION RECEBrTN
❑f hereby affirm that 1 have a mtl rote of consent to self-Insure,or a FNTURFS PER TRAP SCHOOL TAX Y_ N
certificate of Worken'Compematlon lmumnm or a certified mpy thereof(Sec. RECEIPT N
3800,Lab GAS EA.SYSTEM-1 INCAOUTLETSPARK FEE Y N
Policy p RECE PT N
mCny CAS EA.SYSTEM-OVER V4(EA) BUILDING DIVISIONCertified copy is herebytehedt'EES
. GREASE/MDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Cetlfied copy V filed withh the city inspection division.
CERTIFICATE OF EJ(EMFTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissetionneed not becompleted lithe permit lsforone hundred dollars SEWER-SANITARY-STORM EA.HAFT. Date ReCCI t#
(E100)orfTR ENERGY FEE Y N
Itify that
¢ Nth
ttat In the performance thewrrk(orw <h this permit is issued, WATER HEATER W/VENT/ELEC
I shall not employ any person In any manner so u to become subject to the
Workers Compensation Laws of CallfomO. Date WATQt SYS77iM/TREATING PAID
O Z Applicant
Z O NOTICE TO APPLICANT:ILaftermakingthis CcrtBimteofF-emptton,you NEWRESOENTIALPLMB. SQFT. Date Recef t# -
should become subject to the Workers Comper see ice pmvWom of the Labor M
W~ W Code,you most forthwith comply with such provislons or this permit shallW
> deemed revoked. BUILDING FEd CONSTRUCTION LENDING AGENCY SEISMIC FEE= ZIherebyalfirmt)ut there b,a construction lendingagency forthe perform TOTAL: ELECTRIC FEEO arm ofthe work forwhichthla permit is issued(Sec.3097,Civ.C.)O Leaders Name PLUMBING FEEIL — Lerder,Addren QTY. MECHANICAL PERMIT FEEMECHANICAL FOOImtifythatlluvercadthlsappBmtb an cisaethattheabovelnformatlonismmct.I agmrto comply with all city and county ordinances and matelaws PERMITISSUANCE FEES PAID:Wrelating to building comWction,and heebyauthodzercpresentativeso(thtsZcilymenter upon the abovo-mentbned Property for Wpmion puryoses. ALTER OR ADD TU MFCH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date
against liabilities,pdgmema,mss and expenses which may In any way accrue AIR HANDLING UNIT(To 10,000 CFM)
againstsai�l Mnaequenceof thegrardleg of that permit. SUBTOTAL-
Q 31 5Z AIR HANDUNG UNIT(OVER IO,OWCFM) CONSTRUCTIONTAX
Slgruture of Apparent/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MAT(IALS DISCLOSURE
Will the applicant orfuture bu lldmg omrpant store or hand le hazardous HEATING UNIT CFO lO00D0 BTU)
notarial as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Recel
lhalalthand SafetyCedlrerg,Sftectloon25532(a)i T
NG UNIT(OVER ID0000 BTU)F-ITO 0
Will the applicant!uture building occupant use equ 1pment or d evices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
� '
which emit hazardous air contaMwnb as detlned by the Bay Area AIr
Quality Management DISMt7 R-COMP pFIPOR 100000 BT'U)
4 Yn tl��/L No
have read the ha�ddue materlaL,requlremenb under Chapter 6.95 ofR-COMP(OVER 100,OOD BTU) AUGhe Califemla Health&Safety Code,Sections 25505,25533 and 75534. 1 F1(/ 3 .tnaa_
understand that if the building does not currently have a meant,that It is myESIDENTIAL MECH._SQ
•L�Y`V�GJ
reiporoibWty to ratify the oaxupant of the requ cements which moat be mrd ^'I Y
prioriolssuan�Ca Cert ¢ateof Occupancy. V Uf i
1 31 .gt
Owner or authonaed agent
Data
TOTAL: ISSUED BY:
OFFICE COPY