24031 .APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add...:aaa� 24031
O /yi a D2
weer ams: one:
GPe '"�Z CITY OF CUPERTINO-BUILDING DIVISION
Centmem;.Name. /�pLie.N. APPLICATION I PERMIT
Q T 7 BUILDINGELEC'IRICALPLUMBINGMECHANICAL CATEGORY CONTROL N,.V Aldzr�A
M1ltect'anglinatem Lk.Na
CITY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmu
PERMIT155UANCE T� El ❑ 1:1LICENSED CONTRACTOR'S DECLARATION �]
Ihereby
tottorrm(fiohat lam Bcrn3oftheunder
usiroprovisions lChapterons9(coland APPLIANCES-RESIDENTIAL JOB DESCRIPTION
%rF
InarsaiSedlon 7000)ol Div set. (the Bugnessand Pro(mslone Code,and my 1y�
license is In full to not effect PANELS
Llan I�Lk.N�•
Date Lie.NConbor -
pp UP TO 2DO AMPS
ARCHITECrSDECLARATION 201-1000 AMPS
N CZO I understand my plans."ll be used as Public.,it.. OVER10DOAMPS SQ.PT.FLOOR AREA $/IYQ.FT.
Z� Licensed Professional S'IGNSELECTRICAL ED IN
6 OWNER•BNLDER DECLARATION SPECLILCIRCUIT/MISC E ^
Iherebya(flrm thatlameaemptfrom the Contractor's License Law for the 1{-(l
F4^qqqq following reason.(Section 7011.5,Business and Penfwions Code:An d or
� county which mqulmsa permit reconstruct,alter,Improve,demolish,orrcpair TGMP.METER OR POLE:NST. Qr
'S anystrecturc pdorto its Issuance.homilitiestheappliant lorsuch permit to Cj 319
O file a signed statement that he Is licensed pursuant to the provlsum;of the POWER DEVICES
teme
Contractor'.License Law(Chapter 9(commenclag with Section 7000)of Dlvl-
3 p�n SWIMMING POOL ELECTRIC
s the basis for
the alleged
Prolamines Any vioor latioat n
of exempt th01,5by y VALU�]�(�L
' the bash for the alleged exempllon. My vlolatlan of Section 70M1S q'any -- //11��
appllamfora perrdt.ubjectatheappllcanttoadvil pevltycenctmorethan OU7i-EP""W17C}IL"FT%'MtES �/u\
five h1,aso nerdelta,thepr. NEW RESIDENTIAL ELECTR_SQ.FT. SLOKLES (,•`,J 7lPECONSTRUCTION
�n ❑1,as owner of the property,or my employes with wags as thele sole
compensation,will do the BusinesandIkandthea Code: hnet intendda License d for
Law
sale(See apply Busbies.andf property who
Wilds or improves
Wares Law
�$ doenaapply loan owner o(p rough whonemporimprwvidedthemen,that
andwhodoeOCC.GROUP RES.UNITS
I.Prowaeuch catsam kat sten Moroffe his own L,.Ifh es,providedthateach
improvementsarcd :mended earofc for.zk.ILh ere p cider l lI haw
TOTAL:
Improvement hwld w:thinoneycarofcompletkRth.owner-budderwill M1ave
Oi,tttrdenofproving that he did not build or bnprove for purpose ofsain). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with Licensed PERMIT ISSUANCE
contractors to construct the project(See.7046,Business and Profeskm Code:
The Commerce's License Law don not apply to an owner d property who ALTER-DRAIN kVENT-WATER(EA)
build.or Improve therse, and who contra for such ptojeds with a
cgp(fatmW licensed pursuant to the Coentrador'a License Law. BAIX FIAWPROTECT.DEVICE FEE SUMMARY
El I am exempt under Sec. B k P C for this maven
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Data RECEPI'p
WORKMAN COMPENSATION DECLARATION IBX'NRES PER TRAP SCIi00L TAX Y N
1'Aercby a!(Irtn that I have a certiBate of consent to self-insure,ora RECEIPT N
3800,Lab
C.)amf Worken'Compemallonlmunnce ore nrtlfled ropythereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEF. Y_ N
3800,
Policy p RECEIPT p
CAS.EA.SYSTEM-OVER d(G)
ny ,� BUILDING DIVISION IT ES
ertllle copy 1.he d with he ed,city a' GREASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy Is(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SE}VER-SANITARY-STORM EA.200FT. _-Fa RCCCI til
(1'hls.edren need not be completed If the permit Is forms,hundred dollars
($10()orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the weak forwhich this permit is Issued,
1 shall not employ any person In any manner an An to become wb)ed to the WATER SYSTEM/TREATING
Workeac Compensationlawaof Ca B(omla.Date PAID
ZZ NOTICE 7O APPLICANT,li.Ber making this Certificate of Exemption,you NEW RESIDENTIAL FILMS. SQ.FT. Date Recef t#
HD should become.ubject to the WmkAWCompmentlon prooWmuo(the Labor TOTAL:
N Code,you moat forthwith comply with such provlalom mrthh permit shall be �.
> deemed revoked. BUILDING
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a comtmdion leadLegagency,for the perforrryELECTRIC FEE
DZ ante of the work for which this permit Is issued fi`c 3097,C:v-C3 TOTAL:
U O Lenders Name PLUMBING FEE
IL I- Lendcr's Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
1cen1(ythatl have mad this appliaBonand kalethattheaboveinlormatlw
O W
1 hcomea.I agree to complywlth all city and countyerdlnaeces and Asia laws PERMITLSSUANCE FEES PAID:
>• N relating to building comtmction,and hereby Authorize representatives o(thie
F Z city to enter upon the abowmentioned property for inspection purposes. ALTER OR ADD TO MUCH. Date RCCCI t#
(We)agree to save,indemnify an d keep barren the City of Cu pertlno
against s,judgments,cortsar expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
ago ty In con of Ilea granting o/thispe It.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
gnatureo pplk est Cantroctmr to IXFIAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllant or future building occupantstore or handle hazardous HEATING UMT(TO 100,000 BT11) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Cade Sedlon 255320)7 HEATING UNIT(OVER 100,DDO BTU) TOTAL:
n Ys No
:Ilthe applkantor lure building aavpand by theecItilpmentBay Area devices VENTILATION PAN MINGLE RESID) ISSUANCE DATE
whishcaralt,Marugement air contaminants est,ae defined by the Bay Area Air 8
Lily Mamgcment DIstdd7 BOILER-COMP O}B'OR 100,IX0 BTLD
Yn No
Moe read the haze mus materials rcqulrermats under Chapter 6.95 of BOILER-COMP(OVER 100,DDO BTU) JUL 0
the Ca life mh lialth A Safety Code,SM Tom 25505,25533 and 2:534.1 �flry
understand that If the building dos not carremly have a tenant,that it h my NEW RESIDENTIAL MECH. SQFT rlL Fr'6Y
responsibility to notify theoccupant ofthe requirement,which at be met
prior to Issuance ofa Certificate of Occupancy. My Vr LVPIZ1`1
01 )
Owner or authorized agent Data ISSUED BY:V✓✓
TOTAL„
OFFICE COPY
� o
CN. CN
N �,
8
ti
z ri
Y
� ;
Ze
� �
q H b