24015APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Bal/eq 2d m O�
PEILMT NO.
24015
wne/rs ante: /
/��8//IP l r ha'n_ !R7,? -1'700
CITY OF CUPERTINO�BUILDINGDIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBINGMECHAMCAL
� G�
'^ l' 67—
Contractors Name: Lic.Ne:
1 1' fes- 393 q
CATEGORY
CONTROLX
Architect/Engineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERh4TISSUANCE
1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby eElton that l am licensed under provelons o(Chapter 9(commenc
IngwlthSMlo_ vielon3olthe Businessand ProlesdansCadeTarso my
h=aebinfu0 deffect
LlcenseC m Lk.a 4.S
Date Contractor fC
APPLIANCE4RESIDENIAL
JOB DESCRITDOONN
GHQ K� / ��
PANELS
XII -1000 AMPS
ARCHITECTS DECLARATION
IrJ['T��n"
OVER 1000 AMPS
SQ. PT. FLOOR AREA
$/5Q. FT.
I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
'
SI'Ff1ALCRRCIRT/hfISC
OWNER -BUILDER DECLARATION
I hereby affivnthat I am exempt from the Contractor's License law for the
TEMP MEITiR OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to mrutruct, alter, Improve, demolish, or repair
any structure poor to its Issuance, a bo requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(mmmentlng with Section 700) of DO-
gon3 ofthe Buslnessand Profe goosCods) orthat heb exempttherefromand
POWER DEVICES
SWPSM)NG POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Stolon 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not mum than
OU LETSSWITCHESFIXTURESL
gay 0-0
/ 00
NEWRESIDENTIALELECTR FT.
livered dollars ($50M
as owner of the property, or my employees with wages as their sok
STORIES
TYPE CONSTRUCTION
ompensatlon,wlll dothe work, and thestructure is not Intended or offend for
sale (Sec. 7044, Basham and Profemloru Code: The Contractors Lt.. Law
does not apply to an owner of property who Builds or Improves thereon, and
who does such work himself orthrough hlsown employees, providedthatauch
GROUT'
RIS. UNITS
Improvements arc not Intended oraffered forsale. If, however, thebullding or
Improvement bsald within oneyearofcompldlon, theowner-buRderwlll have
TO
t rden of provingthat he did ot build orimprove for purpose of sale.),
�n
I, as owner of the property, am exclusively con—ting with licensed
contractors to construct the project (See. 7064, Business and Professions Code:
QTY, PLUMBING
-PERMIT
PERMIT ISSUANCE
FLOOD ZONE
APN
I'he Contractor's License Law does not apply to an owner of property who
Wilda or Improves tharean, and who contracts for such pRojeds with a
C,,nn.t; do(s) hcensed pursuant to the Contractors License Law.
1_JI am exempt under Sec B & P C for this reason
ALTER -DRAIN & VENT -WATER (EA)
BACKFLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDEFFLS
DRAINS FLOOR ROOF, AREA, COND.
SANITARY V N_
RECET T a
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of Consent to self -Insure, or
certificate ofW.rkam Compewtlon insurance or a certified copy thereof (Sec.
3800,Lab C.)
I? Policy p ,.% /A [ l - V
Cm ryAS
FIXTURES- PER TRAP
OOL TAX Y_ N_RECI4P1 M
GAS EA.SYSTEM-1 INC.60UTLl TS
PARK FEE Y N
RFGElrr N
F.A.EA. SYSTEMOVER 4 (FA)
BUILDING DI VISION FEES
fid ropy is hefurnished.
❑d copy b filedwith thecity Impction division.
a
GREASE/NDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEM PTION FROM WOR KERS'
COMPENSATION INSURANCE
Qhlssectlon need not be completed If the permit bfor one hundred dollars
PAID
Daid! Rech IM
SEWER -SANITARY -STORM EA. 40007.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
6)I cemlth
]certifyy that In the performance of thework farwhlch this permit is (eared,
I soak[ not employ any Demon in any manner at ate to become subject to the
Workers ensa
Comption laws o(CallfombDate
WATER SYSTPM/TREATING.
Applicant
NOTICE TO MPLICAM:IL after making fhb Certificate of Exemption,aLabor
shoulddou boo....bpdto the Workers Camp provisionshis profthe Labor
Code, you must forthwith comply with each pmWbw or this permit shall be
deemed revoked.
Date Remi t�
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING FIE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the a perform
ance of the work for which this permit tasud (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
-
PLUMBING FEE
Lenders Name
sander's Address
I certllythat I have read thbappllyBonand statethat theabove Information
iscorred. l agree to comply with all city and county ordinances and state laws
QTY. MECHANICAL PERMIT . FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentloned property for inspection purposes.
(We) agree to rom
ve, Indenify an d keep harmless the City of Cupertino
ALTERORADDTOMECH.
Date Reeei tN
P
SUBTOTAL'
agaimtliabllltles, jadg na, costeand expenen Ich may In anywayacwe
ag i Id City sequenceofthe gr o o hbpenot
r
0
AIR HANDLING UNIT(TO t0,0D0CFM)
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sig tum A Isar/Contras r IDo
IXHAUSTHODD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the sppllcant or future building oovpant storeor handle hazardous
material as dc0ned by the Cupertino Municipal Code, Chapter 9.1 7, and the
Date RCCCi ISI
HEATING UNIT (OVER 100,000 BTI,
TOTAL:
Health and Safety Code Section 25534(a)7
❑ Y. M No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DA'T'E
Will the applicant orfumm Building occupant use equipment ordevices
which emit hanocious air contaminants as defined by the Bay Area Air
BOILER -COMP OHP OR 100,000 BTI)
Qua lity, Management Dist rid? -
Yea❑No
have read the huardous materials requirements under Cha pier 6.95 of
BOILER-COMP(OVIM 100,000 BTU)
the Giffomb I Imlth & Safety Code, Sectiore 25505,2M3 and 25534. I
NEW RESIDENTIAL METH. SQ.Ff
that it bray
usponsi nd that lithe the occupant oft a currently have which
ify requirements which most be met
JUL 23 1
priors Issuance of
prior to Lssuance of a Certificate of Occupancy.
aCeheocte of ccupa
n
ISSUED BY:" V'a•1 /t,111sv
Owner or autharlud agent Date
TOTAL:
OFFICE COPY