21024 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
11.11 In Prn ed Idemlfindon PERMIT NO.
Building Address: �p a /R9 VlST/{ QD Caesar-t/,vo,C'.4 9so�y� 21 024
0 R_ O — - S
�]/' M /IRI'VOY/Cli V'1R CA'Yr• one. A A
!c/f `0 CITY OF CUPERTINO-BUILDING DIVISION
c°"o-�ttm" ^e: Lie. a APPLICATION /PERMIT
BUILDINGELECTRICA4PLUMBINC-MLCHAMCAL CATEGORY CONTROL
'Archltcd/Englneer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE j� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �,J
I hereby affirm that l am licensed under provisions ofChapter9(mmmm APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith SeR1on7000)of DlWdon3 ofthe Rutlnnsand Pnefesed .Code,and my
Livens KlassI. force endeffeci. PANELS
License Class Lk.tl
Date Contractor
ARCHITEC'S DECLARATION 201-1000 AMPS xx
ne Zp I understand my plans shall be used an public records. OVERIOOOAMPS 'A„` O V 5Q.Fr.FLOOR AREA f/SQ.FF.
0
m U� j Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION \
IhercbyafOrm that lafrom the frothe Contractor's License Law fm SPECIAL C]RCl1I the /MTSC ( - f fN
QQ following reason.(Section 70015,Business and Professions Code:Any city or \ s 1
F t'� countywhich rcreconstruct,utmea permit reconstruct,alter,Improve,demolish,orrepair IEMP.METFRORPOLEIN . .'
a anystmcum prior to its lstuance,al.orequirn the applicant forsuch perndtto
file a signed statement that he is licensed Pursuant to the pmvlsions of the POWER DEVICES
%3µ Contractors License Law(Chapter 9(commencing with Section 700D)or Divi- SWIMMINGPDOLELECCRIC r
WW OJ slon3ofthe Buelneasand Pro(essioa Cmde)orthatheisewmpt(hcmfromand -''' '* ` VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any T ?/
4r
applicant for permit sub' the applicant to a civil nal of not moro/han OVILE1SSWITQF�F5I71(TN2E5
p��J five
Pn Mci+ PP penalty n b D
lu live I,as ed owner of he pr. NEW ft ENI7AL ELEC7R .FT, STORIES TYPE CONSTRUCTION
�n MI,as owner of the property,or my employees with wages as 1MIr wk
7 c mpeneat o wllldolhe wmk+ndthe etru[lure boot Intended or offered for ,a" li
n4 sale(Sec.76tq Businns and Prefeseloro Code:The Contractors Llceae Law
$ doesnotapplytoan ownerdimapenywho bulks orimprovesthercon,and OCC.CROUP RFS.UNITS
hlmselforthrough hlsownemployees,provided that such
improvements are not Intended oroffercd for sale.If,however,/hebulldingor TOTAL:
Improvement issold within oneyearofcomplalon,the owner-build erwill have
tt. L as rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntrattore to matruct the project(Sec.(Sec.7014,Business and Proft adoCode:
The Contractor's License law dove not apply to an..at o/property who ALTER-DRAIN&VENT•WATER(EA)
Wild. or Improves thereon,and who contracts for such p(ojecis with
do a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this reason
FEES
DRAINS.FLOOR ROOF,AREA,CONTI. SANITARY Y N'
Owner,, Q/ s Date _ /1 RECEIPT N
WORKMAN COMPENSATION DE CLAM ION MTURES.PERTRAP SCHOOL TAX Y N
❑Ise by e(Orm that I have a ce tificatex.raor Of consent to alrythimed or RECEIPT N
MNMoe,Labc.Worken'Compeaation ltuuranceora certlfkd ropytheremf(Sec. GAS EA.SYSTEM.1 INCAOUILEIS PARK FIE Y N
Polis lab C.)
Pellry M RDCEGAS EA.SYSTEM-OVER 4(EA) DING Df M
Com any BUILDING DI VISION FEES
�Certifed copy b filedherew th the cited.y
CREASE IINDUSIRL WASTE INTERCEPTOR PLANCIIECK FEE
Certified copy b filed with the city lapectlon division.
CERTIF1CATE OF EXhT PION FROM WORK ER S' GRE-ASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA KpFI. Date Recei t#
(Phisaess.) need not becomplaed If the permit Moamar hundred dollars
(5100)rdifythat
3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icenot thato the person
anof y
onerwork so as tobthispermitb Issued,
1 shall not employ any person in any manner m ss to become subject to the WATER SYSTEM/TREATING
' Wmrkero Compensation Laws o/Gllfornla.Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. =OFp. Date Recei t#
Z O NOTICETOAPPLICANT:lf,aftermakingthis Ceniflateof , e=n,you
ehmid become aubjvct to the Workers'Compensationpm tl ka of the Labor TOTAL:
(A Code,you=at forthwith comply with such pe,vbtone orthb permit shall be 'Vol
] dermad revoked. UUILDING FEE
W p CONSTRUCTION LENDING AGENCY EISMIC FEE . 0
CL Iherebya/@mthattherele a coatmctlon lendingagency for the perform - ELECTRIC FEE
7 Z once of the wark(or whkhthb Permit is I.."(Sec.3097,Civ.Q TOTAL:
U O Iander'e Name PLUMBING FEE
LL F Lender's Addre.. Q'TY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertifythat l havereadthisapplicattmnand state thatthe abovcmformatfmn
O W
1 is correct.lagemto comply with all cityand county and Iran.and get.law. PLIthirrissuANCE FEES PAID:
relating to building construction,and hereby kahorlu representatives of this
city to enter upon the abm
ove- entioned inspection for pection pu recent. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeei t#
'against liabilities,judgments,mks and expenses which may in any way areme AIR HANDLING UNIT(TO FLOW CFM) SUBTOTAL'
aga test 0 City In conseque2V of the granting of this permit.
_ AIR HANDLING UMT(OVER10,000CFM) CONSTRUCTION TAX
gna of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand Is harardous HEATING UNIT CFO 100,000 BTU) Date Rmci t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
IIe❑allt ad Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 gTU) TOTAL: •S
Will the applicant orfuwm building Occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurclous air contaminants as defined by the gay Area Air
Quality Management Dist 7 MOILER-COMP l00,OW BTU) PAW)
MI
Yes No [-P90
Ihread the hau oety Cole, etions 25505, underChapter 25534.1 of BOILER COMP(OVFRiW,0006TU) ��� 13 1S90
the California 1lealih k Safety Code,Sections 75505,2153]and 7:534.I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENHAL MECH. SQ.FT. s
msponululity to notify the occupant of the mqummenta which at be met
prior to Issuance of Certificate of Ocmpanry.
Qtyty ^u g�InP
,a
Owner or authorised agent Data TOTAL: ISSUED
OFFICE COPY